Mental health, ethnicity and the UK armed forces: Historical lessons for research and policy.

BACKGROUND: UK armed forces have recruited from other races and ethnicities at times of crisis. To meet diversity targets, they have also recruited indigenous groups of non-White British heritage. Considered at greater risk of mental health problems generally, these populations are likely to suffer more in combat and in transition to civilian life. Yet, there is little data on how they fare. METHODS: A scoping review was conducted of peer-reviewed studies of psychological illnesses suffered by racial and ethnic minority soldiers from World War One to the present, together with research at the National Archives, Wellcome Trust Archives and the Imperial War Museum for unpublished studies. RESULTS: British commanders and psychiatrists argued that 'martial races' were protected against post-traumatic illnesses because of an innate resilience related to a rural heritage. Consequently, low morale and breakdown were interpreted as malingering to avoid combat. Indian troops received lower levels of psychiatric care than provided for British soldiers delivered with limited cultural understanding. Inferior terms and conditions were offered to Indian soldiers with lesser opportunities for promotion. These practices, established in both World Wars, continued for Gurkha and Commonwealth soldiers recruited to meet manpower and diversity targets. Disproportionate complaints of discrimination may explain why ethnic minority status is a risk factor for mental illness. CONCLUSION: Management patterns laid down during the Imperial era continue to influence current practice for ethnic minority service personnel. Yet, armed forces can play a positive role in fostering diversity and integration to provide protective factors against mental illness.

Piloting an approach to scab control on Welsh sheep farms.

Introduction: Sheep scab caused by Psoroptes ovis, is a disease of concern to many stakeholders in Wales due to its welfare implications. There are good diagnostic tests and treatments available to deal with the disease. Even so, it remains a problem in Welsh flocks. As such a coordinated approach is required to deal with this issue in a more sustainable manner. Pilot design: Sheep scab positive 'index' farms were initially diagnosed using a skin scrape to identify P. ovis mites. Contiguous farms were identified and antibody responses used to confirm onward infestation. All infested farms were treated by either dipping with an organophosphate (OP) dip or injecting with a licensed macrocyclic lactone (ML) product depending on farmer choice. Results: Three positive 'index' farms were identified along with 12 contiguous properties. Positive serological responses were observed in seven of the 12 contiguous farms; four of which were treated by OP dip and three by an injectable ML product. Discussion: To avoid reinfestation of treated farms, dealing with disease on contiguous properties is crucial. Through the project coordinating team, three local outbreaks of scab were dealt with in a short space of time with appropriate diagnosis and treatment being carried out. Some farmers were uncooperative and strategies such as providing additional external support and veterinary involvement might alleviate these issues in the future. This coordinated approach is recommended to veterinary surgeons in the field when dealing with scab on farm.

Combat exposure and co-occurring mental health problems in UK Armed Forces personnel.

BACKGROUND: Mental disorders and alcohol misuse are often comorbid, and this comorbidity is more common in those who develop mental disorders following exposure to traumatic events. AIMS: To investigate the relationship between combat exposure and operational role (support versus combat) with mental disorders and associated comorbidity in a UK military cohort. METHODS: 4896 participants from a UK military cohort reported their operational role and frequency of exposure to combat events during deployment. Outcome measures included self-reported post-traumatic stress disorder, common mental disorder and alcohol misuse. RESULTS: Personnel reporting higher levels of combat exposure were more likely to meet criteria for two or more co-occurring mental disorders (odds ratio [OR] 3.90, 95% confidence interval [CI] 2.73-5.58). While having a combat role increased the risk of developing co-occurring disorders compared to having a support role (OR 1.67, 95% CI 1.26-2.23), this effect diminished following adjustment for variables including combat exposure (OR 0.89, 95% CI 0.62-1.27). CONCLUSIONS: Combat exposure may play a greater role in the development of comorbid mental disorders than operational role, i.e. job title. Clinicians treating military personnel should be alert to the increased risk of comorbid mental disorders and alcohol misuse among those with a history of combat exposure.

COVID-19 and the Blitz compared: mental health outcomes in the UK.

The Blitz narrative of resilience stands in contrast to the mental health risks identified as consequences of the COVID-19 pandemic. Although evidence from then-classified studies of World War 2 showed that most people managed the stress of bombing, those vulnerable and exposed to substantial trauma had lasting or severe mental illness. Studies of different towns and occupational groups identified the proportion of people killed and wounded, the percentage of housing destroyed, and the loss of paid employment as risk factors for psychological breakdown. Mothers and children suffered not only with evacuation, but also from the trauma of bombing and damage to schools. A general association between civilian physical and psychological casualties suggests that population groups with high rates of infection and mortality might be susceptible to mental illness as a result of the pandemic. Lockdown and distancing measures contrast with the wartime sense of belonging and shared identity, reinforced by community networks and social activities.

The impact of moral injury on the wellbeing of UK military veterans.

BACKGROUND: Experiences of potentially morally injurious events (PMIEs) have been found to negatively impact the mental health of US personnel/veterans, yet little is known about the effect of PMIEs on the mental health of the UK Armed Forces (AF). This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of UK AF veterans. METHOD: Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an online questionnaire to 204 UK veterans. Subjects were classified as having experienced a morally injurious event (n = 66), a non-morally injurious traumatic event (n = 57), a 'mixed' event (n = 31), or no event (n = 50). RESULTS: Potentially morally injurious experiences were associated with adverse mental health outcomes, including likely anxiety disorders and suicidal ideation, compared to those who reported no event exposure. The likelihood of meeting criteria for probable PTSD was greatest in those who had experienced a non-morally injurious trauma. No statistically significant association between alcohol misuse and experiencing a PMIE or traumatic event was observed. CONCLUSIONS: The results provide preliminary evidence that potentially morally injurious experiences are associated with adverse mental health outcomes in UK AF veterans. Further work is needed to better understand the interplay between morally injurious events and threat-based trauma in order to design effective pathways for prevention and intervention for people exposed to highly challenging events.

What factors are truly associated with risk for radicalisation? A secondary data analysis within a UK sample.

Radicalisation and extremist violence are of increasing concern internationally. The unconventional, decentralised, and transnational nature of modern terrorism involves an active process of radicalisation requiring national security responses to reflect findings from recent empirical research. This study aims to identify factors that relate to extremist attitudes and potential vulnerability to radicalisation in order to inform preventative action. A cross-sectional survey was conducted of a representative population sample of men and women aged 18-45 of Muslim heritage recruited by quota sampling in two English cities. Logistic regressions were performed on a seven-item dichotomised measure based on our previously developed scale of 'sympathy for terrorist acts'. Scores representing 'non-condemnation of these acts' were deemed to represent risk for radicalisation. Thirteen respondents had a positive score on the sympathy for terrorism measure (2.4%), 39 scored zero (6.41%) and the remainder (91.4%) had a negative score representing condemnation of terrorist acts. There was a significant association between sympathy for terrorism and belonging to the local or global Muslim community, anxiety, and support for the use of defensive violence. Gender, religious identity, country of birth, belief in Sharia law, the importance of religion in life, and mosque attendance were all not associated with sympathy for terrorism. The results contribute to an understanding of the radicalisation process and have potential value in developing preventative public health interventions.

Delivering treatment to morally injured UK military personnel and Veterans: The clinician experience.

This study explored the experiences of clinicians in providing treatment in cases of military-related moral injury (MI). Qualitative interviews were carried out with 15 clinicians. Clinicians found patients experienced particular maladaptive appraisals following MI, which were considered different from the responses experienced after threat-based trauma. To address MI-related distress, clinicians utilized a range of treatment approaches. Several difficulties in providing care to patients following MI were described, including the impact of providing treatment on the clinicians own mental health. This study provides detailed insight into the approaches currently used to identify and treat UK Veterans with MI-related psychological problems. These findings highlight the need to evaluate the effectiveness of the treatments currently provided for MI-related psychological problems and suggest developing best practice guidance may improve clinician confidence in delivering care to those adversely impacted by MI.

The psychology of protecting the UK public against external threat: COVID-19 and the Blitz compared.

The COVID-19 pandemic and the World War 2 aerial bombing campaign against the UK between 1939 and 1945 both exposed the civilian population to a sustained threat. Risk, whether from exposure to viral load or the density of the bombing, led to a range of protective measures and behavioural regulations being implemented. The V1 and V2 missiles used in summer and autumn, 1944, functioned as a second wave of bombing, arriving after people believed the danger had passed. Adherence to lockdown and a reluctance to return to work after the lifting of lockdown during the COVID-19 pandemic in the UK were mirrored in the preference for using home-based bomb shelters during the air raids. Heightened sensitivity to risk, or a so-called deep shelter mentality, did not materialise even during the second wave of bomb attacks and some deep bomb shelters were closed because of low occupancy. The most popular protective measures were those that reflected people's preferences, and not necessarily those that provided the greatest safety. As with the COVID-19 pandemic, the public drove government policy as much as they followed it.

Assessing risks of violent extremism in depressive disorders: Developing and validating a new measure of Sympathies for Violent Protest and Terrorism.

OBJECTIVE: Clinicians are tasked with assessing the relationship between violence and mental illness. Yet, there is now a legal expectation in some countries that public services, including health professionals, assess risk of violent extremism - with few available measures. We previously developed a new measure of Sympathies for Radicalisation, using items that measure Sympathies for Violent Protest and Terrorism. In this paper, we present the detailed psychometric properties of a reduced item measure of Sympathies for Violent Protest and Terrorism. We use data from two studies to test replication and then validity against outcomes of self-reported violence and convictions in the entire sample and in those with depressive symptoms. METHODS: Data from two cross-sectional neighbourhood surveys, consisting of Pakistani and Bangladeshi adults (survey 1, n = 608) and White British and Pakistani adults (survey 2, n = 618), were used to undertake confirmatory factor analysis of Sympathies for Radicalisation and produce a short measure of Sympathies for Violent Protest and Terrorism. Survey 2 data were used to test the Sympathies for Violent Protest and Terrorism's convergent validity to classify presence/absence of violence and convictions in the whole sample and for subgroups by depressive disorder. RESULTS: The seven-item measure's structure was a consistent measure of extremist attitudes across the two surveys. A threshold score of zero to classify violence was optimal (specificity = 89.7%; area under the curve = 0.75), but sensitivity to a risk of violence was poor (34.5%). The short version Sympathies for Radicalisation was a better classifier of violence in respondents with depression, dysthymia or both (area under the curve = 0.78) than respondents with neither (area under the curve = 0.69; ß = 0.62, 95% confidence interval = [-0.67, 1.92]; standard error = 0.66). CONCLUSION: The seven-item measure of Sympathies for Violent Protest and Terrorism is an accessible and valid measure for clinical assessments and helpfully identifies low risk of violence. It enables clinicians to conduct detailed assessments of people endorsing one or more of the items, although further research is needed.

Moral injury in a context of trauma.

Moral injury, characterised by guilt, shame and self-condemnation, is conceptualised either as an adjunct to post-traumatic stress disorder or as a new syndrome. Studies of symptoms and potentially morally injurious events have produced a possible definition and informed the design of rating scales. The current challenge remains the design of effective interventions. Because moral injury relates to ethical behaviour, the meaning attached to events and perceptions of the self, moral philosophy and spirituality could contribute to the design of treatments.

Patients behind the front lines: the exchange of mentally-ill patients in the 1948 Arab-Israeli War.

The British Mandate in Palestine ended abruptly in 1948. The British departure engendered a complex situation which affected all areas of life, and the country's health system was no exception. Gradual transition of the infrastructure was almost impossible owing to the ineffectiveness of the committee appointed by the United Nations. The situation was further complicated by the outbreak of the Arab-Israeli War. We relate for the first time the story of 75 Jewish patients who were left in a former British mental hospital in Bethlehem - deep behind the front lines. Despite the hostilities, there were complex negotiations about relocating those patients. This episode sheds light on the Jewish and Arab relationship as it pertained to mental institutions during and immediately after the British Mandate.

The impact of trauma exposure and moral injury on UK military veterans: a qualitative study.

Background: Exposure to a potentially morally injurious event (PMIE) has been found to be associated with a range of adverse mental health outcomes. However, how the psychological consequences following PMIEs compare to those encountered after a traumatic, but not a PMIE, remain poorly understood. Objective: The aim was to qualitatively explore UK military veterans' responses to experiences of trauma and moral injury and the impact of such events on psychological wellbeing. Method: Thirty male veterans who reported exposure to traumatic and/or morally injurious events were recruited. Semi-structured qualitative interviews were conducted, and data were analysed using thematic analysis. Results: Six veterans described exposure to a non-morally injurious traumatic event, 15 reported experiencing a PMIE, and 9 described exposure to a 'mixed' event which was simultaneously morally injurious and traumatic. Veterans who encountered a PMIE described experiencing moral dissonance, or a clash between concurrently held sets of values (e.g. military values versus civilian values), which provoked considerable psychological distress. Veterans' cognitions and responses were found to differ following a PMIE compared to a traumatic, but not PMIE, which could have negative implications for daily functioning. Several risk and protective factors for experiencing distress following a PMIE were described. Conclusions: This study provides some of the first evidence that events experienced by UK veterans can simultaneously be morally injurious and traumatic or life-threatening as well as highlighting the process by which moral injury may occur in UK veterans. These findings illustrate the need to examine effective pathways for prevention and intervention for veterans who have experienced a morally injurious event.

Antecedentes: La exposición a un potencial evento moralmente perjudicial (PMIE por sus siglas en inglés) se ha asociado con un rango de resultados adversos en salud mental. Sin embargo, como las consecuencias psicológicas seguidas de PMIEs comparadas a aquellas encontradas después de un evento traumático, pero no un PMIE, permanece pobremente comprendido.Objetivo: El objetivo fue explorar cualitativamenbte las respuestas a experiencias de trauma y daño moral de veteranos militares del Reino Unido y el impacto de tales eventos en el bienestar psicológico.Método: Se reclutaron treinta veteranos varones que reportaron exposición a eventos traumáticos y/o moralmente perjudiciales. Se condujeron entrevistas cualitativas semiestructuradas, y los datos fueron analizados usando análisis temáticos.Resultados: Seis veteranos describieron exposición a eventos traumáticos no moralmente perjudiciales, quince reportaron haber experimentado un PMIE, y nueve describieron exposición a un evento 'mixto' el cual fue simultáneamente moralmente perjudicial y traumático. Los veteranos que encontraron una PMIE describieron experimentar disonancia moral, o un choque entre conjuntos de valores mantenidos simultáneamente (ej. Valores militares versus valores civiles), los cuales provocaron sufrimiento psicológico considerable. Se encontraron que las respuestas y cogniciones de los veteranos diferían después de un PMIE comparada con un evento traumático, pero no el PMIE, el cual podría tener implicancias negativas para el funcionamiento diario. Se describieron varios factores de riesgo y protectores por la experimentación de sufrimiento seguido a un PMIE.Conclusiones: este estudio provee algunas de las primeras evidencias que los eventos experimentados por los veteranos del Reino Unido pueden ser simultáneamente moralmente perjudiciales y traumáticos o de amenaza vital así como tambien enfatizar el proceso por el cual el daño moral puede ocurrir en los veteranos del Reino Unido. Estos hallazgos enfatizan la necesidad de examinar las vías efectivas para la prevención e intervención a veteranos que han experimentado un evento moral perjudicial.

Hurst Rehabilitated: the treatment of functional motor disorders by Arthur Hurst during the First World War.

Arthur Hurst was a British First World War physician, best known for his films of shell shock, 'War Neuroses'. He has often been portrayed an innovative pioneer of somewhat mysterious 'suggestion' techniques for functional motor disorders but also as an ambitious clinician who exaggerated the effectiveness of his treatments and failed to address psychological factors. His use of suggestion, persuasion and re-education together with occupational therapy, for chronic or severe cases of shell shock stirred controversy at the time because of the dramatic nature of some of his treatment responses and lack of outcome data. In part, this was a turf war between neurologists and psychiatrists for a dominant therapeutic model. A re-evaluation of his publications and new research into soldiers treated at Seale Hayne in Devon show that Hurst pioneered multidisciplinary and empathetic treatments for functional motor disorders with good short-term outcomes, though insufficient data survives to assess longer term outcomes.

Extremism and common mental illness: cross-sectional community survey of White British and Pakistani men and women living in England.

BACKGROUND: Mental illnesses may explain vulnerability to develop extremist beliefs that can lead to violent protest and terrorism. Yet there is little evidence. AIMS: To investigate the relationship between mental illnesses and extremist beliefs. METHOD: Population survey of 618 White British and Pakistani people in England. Extremism was assessed by an established measure of sympathies for violent protest and terrorism (SVPT). Respondents with any positive scores (showing sympathies) were compared with those with all negative scores. We calculated associations between extremist sympathies and ICD-10 diagnoses of depression and dysthymia, and symptoms of anxiety, personality difficulties, autism and post-traumatic stress. Also considered were demographics, life events, social assets, political engagement and criminal convictions. RESULTS: SVPT were more common in those with major depression with dysthymia (risk ratio 4.07, 95% CI 1.37-12.05, P = 0.01), symptoms of anxiety (risk ratio 1.09, 95% CI 1.03-1.15, P = 0.002) or post-traumatic stress (risk ratio 1.03, 95% CI 1.01-1.05, P = 0.003). At greater risk of SVPT were: young adults (<21 versus ≥21: risk ratio 3.05, 95% CI 1.31-7.06, P = 0.01), White British people (versus Pakistani people: risk ratio 2.24, 95% CI 1.25-4.02, P = 0.007) and those with criminal convictions (risk ratio 2.23, 95% CI 1.01-4.95, P = 0.048). No associations were found with life events, social assets and political engagement. CONCLUSION: Depression, dysthymia and symptoms of anxiety and post-traumatic stress are associated with extremist sympathies.

From Allostatic Load to Allostatic State-An Endogenous Sympathetic Strategy to Deal With Chronic Anxiety and Stress?

The concepts of allostatic load and overload, i. e., a dramatic increase in the allostatic load that predisposes to disease, have been extensively described in the literature. Here, we show that rats engaging in active offensive response (AOR) behavioral strategies to chronic predator scent stress (PSS) display less anxiety behavior and lower plasma cortisol levels vs. rats engaging in passive defensive response (PDR) behavioral strategies to chronic PSS. In the same chronic PSS paradigm, AOR rats also have higher lactate and lower glutamate levels in amygdala but not in control-region hippocampus vs. PDR rats. The implications of these findings for regulation of allostatic and stress responses, and post-traumatic stress disorder (PTSD) are discussed.

The return of the traumatized army veteran: a qualitative study of UK ex-servicemen in the aftermath of war, 1945 to 2000.

The challenge of transition from service to civilian life is explored through the experiences of a sample of 225 UK army veterans between 1945 and 2000. All subjects had a war pension for a psychological disorder, and most had served overseas in combat roles. Statements about issues of adjustment and health were analyzed by the constant comparison method. Although 20 themes were identified, three ('anxiety, nerves and depression', 'enduring illness attributed to combat exposure', and 'illness interferes with the ability to find or keep employment') accounted for 46% of the total and were reported by between 53% and 86% of subjects. Consistency was observed in the ranking of themes over time. In content, they replicate those reported by veterans of recent conflicts, suggesting that the core issues of transition have an enduring quality. Most statements (66%) date from the 1940s, a time when the application process for a pension required the veteran to provide an explanation for his illness. A rise in the number of statements during the 1980s and 1990s reflected wider cultural acceptance of post-traumatic illness and veteran population entering retirement with time to reflect on defining experiences.

The symptomatology of psychological trauma in the aftermath of war (1945-1980): UK army veterans, civilians and emergency responders.

BACKGROUND: UK veterans suffering from a psychological or psychiatric illness as a consequence of service in the Second World War were entitled to a war pension. Their case files, which include regular medical assessments, are a valuable resource to investigate the nature, distribution and duration of symptoms. METHODS: A standardised form was used to collect data from pension records of a random sample of 500 UK army veterans from the first presentation in the 1940s until 1980. Data were also gathered from 50 civilians and 54 emergency responders with a pension for post-traumatic illness following air-raids. RESULTS: The 10 most common symptoms reported by veterans were anxiety, depression, sleep problems, headache, irritability/anger, tremor/shaking, difficulty completing tasks, poor concentration, repeated fears and avoidance of social contact. Nine of the 10 were widely distributed across the veteran population when symptoms were ranked by the number of subjects who reported them. Nine symptoms persisted significantly longer in the veteran sample than in emergency responders. These included seven of the most common symptoms, together with two others: muscle pain and restlessness. The persistence of these symptoms in the veteran group suggests a post-traumatic illness linked to lengthy overseas service in combat units. CONCLUSIONS: The nature and duration of symptoms exhibited by veterans may be associated with their experience of heightened risks. Exposure to severe or prolonged trauma seems to be associated with chronic multi-symptom illness, symptoms of post-traumatic stress and somatic expressions of pain that may delay or complicate the recovery process.

Combat Experiences and their Relationship to Post-Traumatic Stress Disorder Symptom Clusters in UK Military Personnel Deployed to Afghanistan.

The association of post-traumatic stress disorder (PTSD) symptom clusters with combat and other operational experiences among United Kingdom Armed Forces (UK AF) personnel who deployed to Afghanistan in 2009 were examined. Previous studies suggest that the risk of developing PTSD rises as combat exposure levels increase. To date, no UK research has investigated how specific classes of combat and operational experiences relate to PTSD symptom clusters. The current study was a secondary analysis of data derived from a two-arm cluster, randomized-controlled trial of a postdeployment operational stress-reduction intervention in deployed UK AF personnel. 2510 UK AF personnel provided combat exposure data and completed the PTSD checklist (civilian version) immediately post-deployment while 1635 of the original cohort completed further followed-up measures four to six months later. A 14-item combat experience scale was explored using principle component analysis, which yielded three main categories of experience: (1) violent combat, (2) proximity to wounding or death and (3) encountering explosive devices. The association of combat experience classes to PTSD 5-factor "dysphoric arousal" model (re-experiencing, avoidance, numbing, dysphoric-arousal and anxious-arousal symptoms) was assessed. Greater exposure to violent combat was predictive of re-experiencing and numbing symptoms, while proximity to wounding or death experiences were predictive of re-experiencing and anxious-arousal symptoms. Explosive device exposure was predictive of anxious-arousal symptoms. The present study suggests that categories of combat experience differentially impact on PTSD symptom clusters and may have relevance for clinicians treating military personnel following deployment.