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Summary Background Concerns have been raised about the psychological effect of continued combat exposure and of repeated deployments. We examined the consequences of deployment to Iraq and Afghanistan on the mental health of UK armed forces from 2003 to 2009, the effect of multiple deployments, and time since return from deployment. Methods We reassessed the prevalence of probable mental disorders in participants of our previous study (2003–05). We also studied two new randomly chosen samples: those with recent deployment to Afghanistan, and those who had joined the UK armed forces since April, 2003, to ensure that the final sample continued to be representative of the UK armed forces. Between November, 2007, and September, 2009, participants completed a questionnaire about their deployment experiences and health outcomes. Findings 9990 (56%) participants completed the study questionnaire (8278 regulars, 1712 reservists). The prevalence of probable post-traumatic stress disorder was 4·0% (95% CI 3·5–4·5; n=376), 19·7% (18·7–20·6; n=1908) for symptoms of common mental disorders, and 13·0% (12·2–13·8; n=1323) for alcohol misuse. Deployment to Iraq or Afghanistan was significantly associated with alcohol misuse for regulars (odds ratio 1·22, 95% CI 1·02–1·46) and with probable post-traumatic stress disorder for reservists (2·83, 1·23–6·51). Regular personnel in combat roles were more likely than were those in support roles to report probable post-traumatic stress disorder (1·87, 1·26–2·78). There was no association with number of deployments for any outcome. There was some evidence for a small increase in the reporting of probable post-traumatic stress disorder with time since return from deployment in regulars (1·13, 1·03–1·24). Interpretation Symptoms of common mental disorders and alcohol misuse remain the most frequently reported mental disorders in UK armed forces personnel, whereas the prevalence of probable post-traumatic stress disorder was low. These findings show the importance of continued health surveillance of UK military personnel. Funding UK Ministry of Defence.

The Lancet (British edition), 2010-05, Vol.375 (9728), p.1783-1797

What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study

Summary Background The effectiveness of post-deployment screening for mental disorders has not been assessed in a randomised controlled trial. We aimed to assess whether post-deployment screening for post-traumatic stress disorder (PTSD), depression, anxiety, or alcohol misuse was effective. We defined screening as the presumptive identification of a previously unrecognised disorder using tests to distinguish those who probably had the disorder from those who probably did not so that those people with a probable disorder could be referred appropriately, and assessed effectiveness and consequences for help-seeking by the odds ratio at follow-up between those receiving tailored help-seeking advice and those who received general mental health advice. Methods We did a cluster randomised controlled trial among Royal Marines and Army personnel in the UK military after deployment to Afghanistan. Platoons were randomly assigned (1:1 initially, then 2:1) by stratified block randomisation with randomly varying block sizes of two and four to the screening group, which received tailored help-seeking advice, or the control group, which received general mental health advice. Initial assessment took place 6–12 weeks after deployment; follow-up assessments were done 10–24 months later. Follow-up measures were the PTSD Checklist–Civilian Version, Patient Health Questionnaire-9, Generalised Anxiety Disorder-7 scale, Alcohol Use Disorder Identification Test (AUDIT), and self-reported help-seeking from clinical and welfare providers comparing those receiving tailored advice and those receiving only general advice. All participants and all investigators other than the person who analysed the data were masked to allocation. The primary outcomes were PTSD, depression or generalised anxiety disorder, and alcohol misuse at follow-up. A key secondary outcome was assessment of whether post-deployment screening followed by tailored advice would modify help-seeking behaviour. Comparisons were made between screening and control groups, with primary analyses by intention to treat. This trial is registered with the ISRCTN Registry, number ISRCTN19965528. Findings Between Oct 24, 2011, and Oct 31, 2014, 434 platoons comprising 10 190 personnel were included: 274 (6350 personnel) in the screening group and 160 (3840 personnel) in the control group. 5577 (88%) of 6350 personnel received screening and 3996 (63%) completed follow-up, whereas 3149 (82%) of 3840 received the control questionnaire and 2369 (62%) completed follow-up. 1958 (35%) of 5577 personnel in the screening group declined to see the tailored advice, but those with PTSD (83%) or anxiety or depression (84%) were more likely than non-cases (64%) to view the advice (both p<0·0001). At follow-up, there were no significant differences in prevalence between groups for PTSD (adjusted odds ratio 0·92, 95% CI 0·75–1·14), depression or anxiety (0·91, 0·71–1·16), alcohol misuse (0·88, 0·73–1·06), or seeking support for mental disorders (0·92, 0·78–1·08). Interpretation Post-deployment screening for mental disorders based on tailored advice was not effective at reducing prevalence of mental health disorders nor did it increase help-seeking. Countries that have implemented post-deployment screening programmes for mental disorders should consider monitoring the outcomes of their programmes. Funding The US Army Medical Research and Materiel Command–Military Operational Medicine Research Program (USAMRMC–MOMRP).

The Lancet (British edition), 2017-04, Vol.389 (10077), p.1410-1423

Post-deployment screening for mental disorders and tailored advice about help-seeking in the UK military: a cluster randomised controlled trial

Summary Background Violent offending by veterans of the Iraq and Afghanistan conflicts is a cause for concern and there is much public debate about the proportion of ex-military personnel in the criminal justice system for violent offences. Although the psychological effects of conflict are well documented, the potential legacy of violent offending has yet to be ascertained. We describe our use of criminal records to investigate the effect of deployment, combat, and post-deployment mental health problems on violent offending among military personnel relative to pre-existing risk factors. Methods In this cohort study, we linked data from 13 856 randomly selected, serving and ex-serving UK military personnel with national criminal records stored on the Ministry of Justice Police National Computer database. We describe offending during the lifetime of the participants and assess the risk factors for violent offending. Findings 2139 (weighted 17·0%) of 12 359 male UK military personnel had a criminal record for any offence during their lifetime. Violent offenders (1369 [11·0%]) were the most prevalent offender types; prevalence was highest in men aged 30 years or younger (521 [20·6%] of 2728) and fell with age (164 [4·7%] of 3027 at age >45 years). Deployment was not independently associated with increased risk of violent offending, but serving in a combat role conferred an additional risk, even after adjustment for confounders (violent offending in 137 [6·3%] of 2178 men deployed in a combat role vs 140 (2·4%) of 5797 deployed in a non-combat role; adjusted hazard ratio 1·53, 95% CI 1·15–2·03; p=0·003). Increased exposure to traumatic events during deployment also increased risk of violent offending (violent offending in 104 [4·1%] of 2753 men with exposure to two to four traumatic events vs 56 [1·6%] of 2944 with zero to one traumatic event, 1·77, 1·21–2·58, p=0·003; and violent offending in 122 [5·1%] of 2582 men with exposure to five to 16 traumatic events, 1·65, 1·12–2·40, p=0·01; test for trend, p=0·032). Violent offending was strongly associated with post-deployment alcohol misuse (violent offending in 120 [9·0%] of 1363 men with alcohol misuse vs 155 [2·3%] of 6768 with no alcohol misuse; 2·16, 1·62–2·90; p<0·0001), post-traumatic stress disorder (violent offending in 25 [8·6%] of 344 men with post-traumatic stress disorder vs 221 [3·0%] of 7256 with no symptoms of post-traumatic stress disorder; 2·20, 1·36–3·55; p=0·001), and high levels of self-reported aggressive behaviour (violent offending in 56 [6·7%] of 856 men with an aggression score of six to 16 vs 22 [1·2%] of 1685 with an aggression score of zero; 2·47, 1·37–4·46; p=0·003). Of the post-traumatic stress disorder symptoms, the hyperarousal cluster was most strongly associated with violent offending (2·01, 1·50–2·70; p<0·0001). Interpretation Alcohol misuse and aggressive behaviour might be appropriate targets for interventions, but any action must be evidence based. Post-traumatic stress disorder, though less prevalent, is also a risk factor for violence, especially hyperarousal symptoms, so if diagnosed it should be appropriately treated and associated risk monitored. Funding Medical Research Council and the UK Ministry of Defence.

The Lancet (British edition), 2013-03, Vol.381 (9870), p.907-917

Violent offending by UK military personnel deployed to Iraq and Afghanistan: a data linkage cohort study

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What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study

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Post-deployment screening for mental disorders and tailored advice about help-seeking in the UK military: a cluster randomised controlled trial

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Violent offending by UK military personnel deployed to Iraq and Afghanistan: a data linkage cohort study

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