The mental health of military veterans in the UK.

Risk factors for poor mental health among UK veterans include demonstrating symptoms while in service, being unmarried, holding lower rank, experiencing childhood adversity and having a combat role; however, deployment to a combat zone does not appear to be associated with mental health outcomes. While presentation of late-onset, post-service difficulties may explain some of the difference between veterans and those in service, delayed-onset post-traumatic stress disorder (PTSD) appears to be partly explained by prior subthreshold PTSD, as well as other mental health difficulties. In the longer term, veterans do not appear to suffer worse mental health than equivalent civilians. This overall lack of difference, despite increased mental health difficulties in those who have recently left, suggests that veterans are not at risk of worse mental health and/or that poor mental health is a cause, rather than a consequence, of leaving service.

Around 20 000, or 10%, of the regular strength of the UK armed forces leave every year. The vast majority will qualify as veterans in the UK, as a single day’s service is the only criterion for that status. Estimates utilising the 2007 Adult Psychiatric Morbidity Survey in England (APMS) suggest that there are 3–5 million veterans in England alone (Woodhead et al, 2009).

Prevalence

It is difficult to determine the prevalence of mental health conditions among UK veterans, in part because veterans are difficult to identify and trace, as they are widely dispersed on leaving service and have no obligation to declare their veteran status. Studies of the UK armed forces which include comparisons between serving personnel and veterans provide some evidence that those who have left the services are more likely to report symptoms of common mental disorders and post-traumatic stress disorder (PTSD) than those who stay in service (Hatch et al, 2013; Jones et al, 2013); however, these samples were constructed primarily with regard to deployable and recently serving cohorts, rather that being veteran specific, and are not representative of the wider veteran population. Furthermore, as personnel are downgraded due to ill-health, it is to be expected that reports of poor health will be more common among those who have been discharged.

Despite difficulties in studying these populations, one study specific to UK veterans of the Gulf and Bosnia eras found 38% suffering from common mental disorders and 13% were identified as having a ‘post-traumatic stress reaction’ using a measure based on the Mississippi Scale for PTSD (compared with 28% and 5% respectively for those still in service) (Iversen et al, 2005a). A separate study of veterans using the APMS (n = 257, a heterogeneous veteran sample that included personnel who had left any time between 1960 and 2007, and hence many had been out of service for longer than in the previous study) found 7.6% of male veterans suffering alcohol misuse, 8.5% neurotic disorder and 2.9% PTSD (Woodhead et al, 2011). Risk factors for poor mental health among UK veterans include demonstrating symptoms while in service, as well as being unmarried, holding lower rank, experiencing childhood adversity and having a combat role. Of note, however, is that deployment to a combat zone does not appear to be associated with mental health outcomes (Iversen et al, 2005b; Jones et al, 2013). Veterans are also at risk of reduced levels of social integration compared with those still in service, in that they report less social participation outside of their work. As in other settings, reporting poor social networks is linked to poor mental health (Hatch et al, 2013).

Mental health problems may not surface until after leaving service; veterans of recent conflicts in Iraq and Afghanistan who seek help from Combat Stress, the major charitable provider of mental healthcare for veterans, average 2 years between leaving and initially presenting for care (van Hoorn et al, 2013). While presentation of late-onset, post-service difficulties may explain some of the difference between veterans and those in service, delayed-onset PTSD appears to be partly explained by prior subthreshold PTSD, as well as other mental health difficulties; furthermore, the study found that delayed-onset PTSD was not associated with leaving service (Goodwin et al, 2012).

There is also some evidence that, in the longer term, veterans do not appear to suffer worse mental health than equivalent civilians. A study using the 2007 APMS data on veterans made comparisons between veterans and age- and gender-matched civilian controls and found no significant differences between them as regards alcohol misuse, neurotic disorders or PTSD (Woodhead et al, 2011). However, it is important to note that the sample of veterans in this study was relatively small and did not include many recent service leavers.

Nonetheless, the overall lack of difference between veterans and the general population, despite increased mental health difficulties in those who have recently left compared with their equivalents still in service, suggests that veterans are not at risk of worse mental health and/or that poor mental health is a cause, rather than a consequence, of leaving service.

The role of alcohol

Alcohol appears to play an important, although complex, role in military mental health. Alcohol has traditionally been used to assist unit cohesion (Jones & Fear, 2011) and unit cohesion may protect against mental health problems (Du Preez et al, 2012). However, enhanced comradeship comes at the price of higher alcohol misuse (Du Preez et al, 2012) and the long history of alcohol use in the UK armed forces (Jones & Fear, 2011) makes effective intervention difficult. While those in service may be capable of functioning at high levels while consuming large amounts of alcohol, the functional consequences for veterans are unknown.

Service provision

Once members of the UK military leave the armed forces, their mental and physical healthcare is provided by the National Health Service (NHS). There are concerns that veterans may ‘fall between the cracks’, presenting mental health challenges that are outside the expertise of primary care but below the threshold of secondary services, which focus on severe and chronic cases (Macmanus & Wessely, 2013). Charitable providers have expanded to compensate in some regards, but the resulting myriad of providers risks confusion for those who need help. Moreover, knowledge of the veteran charitable sector is lower among younger people in the general population (Gribble et al, 2014) and so many at-risk early service leavers, who are largely young adults, are likely to be unaware of the charitable support available to them. Furthermore, fund-raising activities risk portraying veterans as victims. The latter risk has particular consequences, as the manner in which veterans perceive the outside world affects their mental health; PTSD and suicidal behaviour are associated with negative world perceptions, including rejection of civilian life (Brewin et al, 2011).

With the Armed Forces Covenant enshrined in law, it is possible that the health of UK veterans will transition away from being embedded within the civilian services provided by the NHS, and towards a model more resembling that of the US Department of Veterans Affairs; however, so far, specific veteran health provision is limited to prosthetics and mental health (Macmanus & Wessely, 2013).

Conclusion

While there is currently no definitive evidence showing that veterans are at an increased overall risk of mental health difficulties compared with civilians, poor mental health may be a factor causing personnel to leave the armed forces. With UK troops about to complete their withdrawal from the highly politicised Afghanistan conflict in the next year, it is likely that their mental health status will remain in the media spotlight as UK society grapples with the effects of significant financial cuts across all aspects of government, including defence and health.