Over the last ten years, two military campaigns have dominated the United Kingdom’s (UK) foreign policy. The operations in Afghanistan and then Iraq, although contentious, have raised a number of important questions about the country’s relationship with its armed forces. This debate has highlighted the apparent separation of the military from broader British society, between which there is increasingly little communication and consequent understanding.

One of the defining characteristics of these two conflicts, typified by the 2003 invasion of Iraq, has been the paucity of support, if not outright hostility, that the general public has shown. Arguments over whether this criticism extends beyond politicians to the military continues. The growing toll of military wounded and dead, while small in historical terms, has elicited growing questions about the function and utility of the UK’s military in general. Never far from this media spotlight has been the mental health of those presently serving in the armed forces, those who have served (veterans), as well as the wider military community.

While combat and combat support units (such as infantry and artillery) form the majority of the media’s depiction of war, supporting these offensive units are a large number of service personnel: from cooks to drivers, from mechanics to nurses. A diverse and heterogeneous population to study, the military are subject to many of the issues witnessed in society at large. Statistics suggesting high rates of homelessness, imprisonment, suicide or mental illness are frequently among the headlines. In particular, it is the diagnosis of post-traumatic stress disorder (PTSD) that has solicited considerable attention. The characteristic flashbacks and hyper-responsiveness (to the car engine that misfires) have been incorporated into the popular understanding of PTSD and the sequelae of conflict.

In this article, we give a brief background to military mental health, considering the history of post-conflict syndromes, before going on to consider the challenges posed to mental health in today’s armed forces and among ex-service personnel. Finally, we briefly scan the horizon for future challenges to good mental health in tomorrow’s military.

Historical Approaches to Military Mental Health
Many of us are familiar with the term ‘Shell Shock’ which, although initially considered a consequence of physical trauma or toxic munitions during World War I, later came to be recognised as a psychological response to combat. It was widespread; some estimates suggest that ‘shell shock’ accounted for 10% of all British battle casualties. Furthermore, both the War Office and printed press, champions of the ‘stiff upper lip’ public school mindset, were loathe to accept shell shock as an official condition.

Edwardian society deemed nervous breakdown as a threat to both male authority and traditional sex roles.1 Therefore, and not surprisingly, ‘shell shock’ is rarely mentioned as a consequence of World War II; but for this a relatively straightforward explanation exists – so severe were the social and political consequences of ‘shell shock’ following the Great War, British authorities simply banned the term. Instead, a similar constellation of symptoms were later described as ‘Post-concussional syndrome’.2

Wherever there is conflict, there is likely to remain psychological sequelae

World War I may have been a turning point in the history of warfare with increasing mechanisation, modern munitions and the horror of trench warfare. However, it was almost certainly not the first conflict to have psychological consequences for those who had fought. Since the inception of warfare it is reasonable to postulate that psychological sequelae have emerged albeit in various forms, though shaped and interpreted by the prevailing attitudes of contemporaneous medical (and more recently, psychiatric) practice.

The diagnosis of ‘irritable heart’ during the Crimean campaigns of the 1850s is among the first suggestions of medically unexplained symptoms as a consequence of warfare. Attributed to the heart, this maladie was inexplicable by contemporaneous investigation. By the time of the Boer Wars in the late nineteenth century, the diagnosis of ‘disordered action of the heart’ had become commonplace,3 though opinion was split between those who considered it to be an unexplained organic disease and those who considered it a more ‘constitutional’ affliction.

Therefore the question arises whether a post-conflict stress reaction is common to all wars, and whether the symptoms are constant in the presence of changing attitudes and diagnoses?

The view from inside: a soldier dons protective chemical weapons clothing during Operation Desert Storm. Army Image, UK MOD Crown (Copyright 2012)

‘Fast-forwarding’ to the latter twentieth century, and the campaigns in Korea, and later Vietnam, the more modern view of post-traumatic stress disorder began to coalesce. Here, the term ‘fast-forward’ is used intentionally; it alludes to televisual techniques and modern media. On the basis that the flashback, so commonly used by cinematographers, was a symptom absent among those affected veterans up until the First World War,4 the consistency of the post-conflict stress reaction has been called into question. Some have even suggested a cultural basis to today’s PTSD, with flashbacks suggested as an effect of widespread access to television and cinema flashback sequences, in contrast with the assumption that these techniques merely reflect combatants’ experiences.

Modern Warfare and Military Health
Flashbacks are a relatively frequent feature among those presenting and who served in the 1991 Gulf War. It was from this conflict that the notion of a Gulf War syndrome emerged and caught the public’s attention.

Epidemiological studies in both US and UK service personnel failed to identify a unique constellation of symptoms, although deployed veterans appear to have reported symptoms of all types more frequently than similar service personnel who did not deploy to the Persian Gulf.5 While not a syndrome, the morbidity exhibited by some has led to the limited acceptance of the diagnosis by the UK Ministry of Defence (MoD) for the payment of war pensions.

With these experiences still at the forefront of the military discourse, following the invasion of Iraq in 2003, the MoD funded a cohort study based at King’s College London.

Designed as a prospective cohort for both surveillance and research, more than 10,000 personnel were enrolled into the cohort with subsequent additional enrolments since, most recently to include personnel serving in Afghanistan. Results so far have shown no discernible specific effects of the Iraq War beyond those experienced by personnel who did not deploy.6 As such an Iraq or Afghanistan War Syndrome is deemed unlikely.

While much of the research historically has been on regular personnel, specific investigation into the risks that reserve personnel (those who have a principal occupation outside the armed forces) are exposed to has also been undertaken.

Despite the robust psychology of most reservists, research has identified specific issues to which reservists are less resilient than regular personnel. While PTSD is rare among reservists, the prevalence rises with deployment more markedly than among regular soldiers. In response, post-deployment mental health care, previously provided for regular personnel, has been extended to cover this group.

Studies have consistently identified a separate problem and one that could be considered as endemic in military culture: that of alcohol misuse

More broadly though, additional resources and mental health programmes have been instituted across the services, of which the Trauma and Risk Management (TRiM) programme is an example. Piloted in the Royal Marines and now adopted by a range of organisations (including the BBC), TRiM provides training for individuals throughout the organisation to recognise mental health problems among their peers following a traumatic incident, and signpost them onwards to mental health services if appropriate.

In line with the public’s interest in PTSD, considerable efforts have been made both in the UK and US to establish the prevalence of PTSD in serving and ex-personnel. Despite frequent portrayals of PTSD as the stigmata of war-fighting, the estimated prevalence of PTSD among UK service personnel is between 4.0 and 7.0%, and varies, with higher prevalence among combat units than non-combat units. When this burden is compared against the general population this prevalence is high, however in the context of other common mental illnesses it remains relatively uncommon.

The burden of psychological disease in the military, like society more widely, is predominantly caused by neurotic disorders such as depression and anxiety.7 In the apparent search for PTSD, studies have consistently identified a separate problem and one that could be considered as endemic in military culture: that of alcohol misuse. In an analysis of mental health diagnoses, alcohol misuse was almost as common as anxiety, depression and PTSD combined. It is likely that the widespread availability and low cost of alcohol in military establishments plays a part in what is a broadly cultural issue, though quite how one might go about addressing it remains unclear.

Prevalence of PTSD rises sharply amongst deployed reservists, perhaps unprepared for the realities of war. Hamish Burke, UK MOD Crown (Copyright 2012)

The Health of Veterans
The UK’s military numbers some 230,000 regular personnel, supported by a further 175,000 reservists. However, the military covenant (the implicit agreement made between a nation and its military) extends in time beyond those currently in service. Defined as any individual who has served in the UK forces as a regular, reservist or national serviceman, there are approximately 4.6 million veterans, who with their dependents total some 9 million individuals. There are efforts underway to establish the effect of military service on this group, for whom the transition back into civilian society can be challenging.

Homelessness among veterans hit the headlines in 1994 when a report suggested that a quarter of homeless people in London had spent time in the armed forces. Disputed at the time, a more comprehensive study published by the University of York in 2008 estimated that veterans formed approximately 6% of the homeless in London, this group comprising individuals sleeping rough, but with the majority residing in temporary hostels. Accepting that further resources were needed for those exiting the services, and with re-settlement allowances being based on years of service, the MoD has made extra provision for leavers, and in particular for those who leave earlier.

Another persistent headline is that veterans fill up the criminal justice system, accounting for up to 10% of those imprisoned. Again these statistics are almost certainly an over-estimate, and more recent and robust statistics estimate that veterans form 3.5% of the prison population, which on a numbers basis would make veterans under-represented when compared to the general population. The picture is similar within the probation service. However, these statistics belie the fact that on a breakdown of offences, veterans are more likely to be convicted of violent and sexual crimes than the general population.

These comparisons must be expressed with a number of caveats. The fact that the military population draws frequently on less affluent communities might suggest that comparisons suggesting equivalence of outcome with the general population would underscore the benefits of military life. Whilst this may be the case for many, at a population level one must also consider the process of screening and selection that takes place at recruitment, along with assured access to employment, amenities and healthcare. As such, drawing direct comparisons between service personnel and the general population is always fraught with limitations.

These troubling statistics aside, for the vast majority of veterans military service is a very positive experience. For a small minority military life remains more than challenging, and for these individuals (frequently early service leavers) the transition back to civilian life can be daunting. It is this cohort of individuals for whom research is ongoing, and who appear to be at heightened risk for a range of poorer outcomes.

The Future
The future represents a broad range of challenges for promoting, protecting and managing mental health within the military.

In the short-term, and while fatalities for on-going operations remain low (in historical terms), the low fatality rate masks a growing number who endure horrific injuries but who, due to advances in front-line and field-hospital trauma care, now survive.

Living with significant disability both physically and mentally adds recurring pressures to healthcare budgets. Avoiding the downgrading of the status of mental health services and funding in light of acute surgical and medical care will remain critical. Ensuring that mental health remains high on the political and military agenda is necessary. Furthermore, as early service leavers are increasingly recognised as at risk of a multitude of sociological problems, improving their preparation and resettlement is vital in preserving the military covenant.

In the medium-term the increased frequency of deployment (or operational tempo) presents a challenge to mental health. While the evidence suggests that some variation in the length of tour has no major effects on mental health (providing that stand down periods are scheduled appropriately), the issue of over-stretch may present hazards as troops spend increasing proportion of service time in theatre. With operations in Iraq concluded, and a conclusion to the conflict in Afghanistan in sight, the recent interventions in what has become known as the Arab Spring demonstrate that conflict cannot be accurately anticipated. This, in the context of declining regular numbers, makes the operational tempo of the future highly uncertain, but unlikely to be relaxed.

Longer-term, the reduction in troop numbers also renders many military support services vulnerable as economies of scale are lost. The closure of the UK’s last military hospital in 2007 is one example of how infrastructure can cease to be viable. While these changes offer the opportunity for the military to better integrate with civilian society, to what extent this may have been achieved is unclear.

Moreover, the consequences of a smaller military include the potential for further divergence of society from the military as fewer people have direct contact with those in service. Increasing the number of reservists who can bridge that gap effectively is an additional benefit of increasing reserves, but this in turn requires a reshaping of services to ensure that reservists have access both theoretically and practically to high quality mental health services which can effectively manage the consequences of conflict.

The military is famed for its technological innovation. The advent of unmanned aerial vehicles, frequently referred to as ‘drones’, herald a new era of technological warfare. The implications of this on mental health are unclear. The recent debate over whether pilots situated in a home base controlling drones in theatre should receive medals is an example of the changing nature of warfare that will no doubt in some way levy a psychological toll. The Millennium Cohort is a US cohort study aiming to assess some of these challenges over time, and which has so far recruited in excess of 250,000 personnel.8

The role and importance of good mental health in the armed forces and within the veterans’ community has advanced tremendously since the early twentieth century, and even since the Gulf War of 1991. Wherever there is conflict, there is likely to remain psychological sequelae. Identifying and managing these in a non-stigmatising way in the future will remain central to ensuring a healthy navy, army and airforce, and a secure United Kingdom.