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MC 24
Memorandum from Robin Short, Martin Kinsella and David Walters
Executive Summary
1. The aim of this evidence is to provide the Defence Select Committee with an understanding of the effectiveness of mental health care provision for veterans, with particular emphasis on Post Traumatic Stress Disorder (PTSD). This evidence will also identify innovative solutions that match best practice in community mental health care for providing cost effective ways of addressing all aspects of PTSD.
2. The extent of the PTSD problem among serving personnel and veterans is considerable. Experience shows that the size of the problem is certain to increase in line with the high current tempo of operations. The result is already predictable in that limited existing resources, already over-stretched, will become completely overwhelmed. It is, therefore, essential that new approaches to dealing with PTSD should be developed as a matter of urgency, as it is clear that the current model does not provide damaged servicemen and women with the effective treatment they deserve.
3. The US military has made significant progress in de-stigmatising PTSD and now includes psychological maintenance as an integral part of post deployment activity. The lessons learned, and applied, by the US military should be carefully considered for inclusion within the British military's medical armoury. Initiatives should be put in place to enable the British armed forces to develop a coherent, seamless transition for those who choose, or are obliged, to leave the service due to their PTSD injury.
4. Programmes for dealing with PTSD in veterans should be based around current best practice for community mental healthcare and should be willing to adopt new and innovative solutions and techniques. It is essential to break free from outdated thinking and ineffective programmes. Provision of adequate support in the community for casualties, carers and family members is an essential requirement of any programme. All programmes must be outcome focused with clear, measurable cost-effectiveness criteria built into them.
Introduction Extent of PTSD
5. According to statistics from the National Centre for Post Traumatic Stress Disorder (NCPTSD), run by the United States Department of Veterans Affairs, 30.9% of male Vietnam veterans and 26.9% of female veterans developed PTSD. The prevalence of late onset PTSD is 15.2% in men and 8.1% in women. The UK does not have such a far reaching sample as this but generally accepted figures indicate the prevalence of late onset PTSD among UK veterans is 9% (source - Kings Centre for Military Health). Initial indications from Iraq suggested that 2% of regular soldiers and 4% of reservists developed PTSD. Subsequent review of the data increased these figures to 4% and 6% respectively. It now seems clear that more of our forces are likely to suffer psychological injury than physical injury as a result of combat.
6. Late onset PTSD typically manifests 12 - 15 years after the traumatic experience. This hits the most valuable cadre of our military personnel - combat experienced NCOs who provide the bulk of the operational corporate knowledge within the organisation. Many are lost to the service once the symptoms of the injury appear. During the period that it takes for the full blown symptoms to manifest, the performance of the soldier could be seriously degraded as they tend to operate in denial and adopt avoidance strategies, typically involving alcohol and drugs abuse.
7. We expect significant growth in the number of PTSD cases over the next 13 years. These are not short-term problems. PTSD is a lifetime injury. According to the 2004 NCPTSD report, 25,000 US veterans of World War Two were receiving disability benefits and 161,000 Vietnam veterans were receiving compensation for PTSD related symptoms.
Symptoms
8. The symptoms of PTSD include flashbacks, nightmares, emotional shutdown, hyper-arousal and avoidance. These frequently result in the casualty attempting to self medicate with alcohol or drugs. This reduces operational efficiency of the unit and often leads to discharge from the service for unsatisfactory performance. Self-harm, violent behaviour and suicide is common.
In Service PTSD
Failure of Policy
9. The MoD has still not published a coherent policy regarding the detection and treatment of PTSD in British service personnel. Despite convening a major conference to study the issue of PTSD as long ago as 2001, the MoD has failed to develop a policy in the interim period. Given that in four of the six intervening years our armed services have been involved in four major conflicts, the lack of a policy appears, at the very least, to represent a failure of planning. Part of the problem arises from a failure even to acknowledge the existence of PTSD. This seems odd when our major ally in all four conflicts, the USA, both acknowledges that PTSD exists, and has put plans in place to address its impact in existing and future conflicts. We believe that in its casual disregard for the mental health of our service men and women, the MoD's failure to create a comprehensive policy to deal with the effects of PTSD is wholly unacceptable.
Increased Operational Tempo
10. The exact numbers of Falkland's veterans with PTSD is unknown but it is an area of major concern for groups such as the Falklands Veterans Foundation and the South Atlantic Medal Association. If the 9% rate (see paragraph 5 above) is correct for this group, some 2,700 of the 30,000 who served in the campaign will have PTSD. 255 British service personnel were killed in combat. Since then over 1% (some 300, plus) of those who took part have committed suicide - i.e. more than died in the conflict itself. This baleful figure continues to increase and can be expected to rise further due to the current commemoration of the 25th anniversary of the Falklands conflict, triggering late onset PTSD in former combatants and aggravating the reaction in those already diagnosed. Experience shows that as more troops are rotated through Afghanistan and Iraq and the level of exposure to combat trauma increases, we will inevitably see more and more PTSD casualties. Marines and soldiers are 400% more likely to develop PTSD than sailors and airmen due to their repeated exposure to traumatic events.
11. In 1999 the journal of Consulting and Clinical Psychology reported that 3% of males and 8% of females in the Gulf War had PTSD on returning to the US. This doubled over the next 24 months. In 2003, the New England Journal of Medicine (NEJM) reported that 16% of those returning from Iraq had PTSD and the US Department of Defence (DoD) acknowledged that 16% had symptoms of severe depression and PTSD. The Pentagon mental health taskforce 2007 report states that the incidence of psychological trauma is rising with prolonged combat duty: 38% of regular soldiers, 31% of marines, 49% of National Guard and 43% of marine reservists had symptoms of post-traumatic stress, depression, anxiety, and other psychological problems within three months of returning from active duty.
12. The 2006 Annual Report from Combat Stress states, "With nearly 1,000 new cases referred, an increase of 25% on last year alone, the Society's resources are stretched to the limit ... since September the number of veterans referred to Combat Stress centres has almost doubled from 81 to 158. ... The rate of admission from Iraq is much faster. The worry is that it is only the bow wave of what will be coming for many years."
13. In line with the increased operational tempo of British armed forces, the level of PTSD casualties can be expected to increase significantly over the coming years; and if the US experience provides an accurate guide British PTSD casualties will number in the tens of thousands.
Impact on Morale and Retention
14. With over 100,000 soldiers having served in Afghanistan and Iraq to date, there is a risk that over 9,000 new cases of PTSD will develop among serving British troops. As things currently stand, this means that some 9,000 experienced combat soldiers will be lost to the army, which will further exacerbate the existing retention and recruiting problems. Experience suggests that many will seek early discharge to avoid the stigma of being exposed as a PTSD casualty. This leads to an unnecessary loss of 'corporate' military experience, while those who remain are put under still greater pressure. Meanwhile, an increasing burden is placed upon the NHS and social care systems, both of which are ill equipped to handle PTSD in military veterans.
15. A further worrying factor to emerge from the US experience indicates that 8-10% of females deployed to Iraq went on to develop PTSD. It has become clear that the affects of PTSD are much more pronounced and debilitating in women. This will obviously act as a de-motivator for women seeking a career in the armed forces, which will adversely affect recruiting in the female population.
Stigma
16. US Department of Defense research indicates that 60% of PTSD casualties are unlikely to request help for fear of service repercussions. Similarly research published in the NEJM 2003 found that only 23-40% would seek help. There is still a reticence among regular forces troops to acknowledge that they may need psychological support. Those who have identified that they have a serious problem are reluctant to share this information with the chain of command; so they do not present themselves for help, rather relying on self-medication and voluntary discharge as a solution. Many are oblivious to their deteriorating condition, while those around them will often be in denial, unwilling to acknowledge the potential problems within their close knit community. This increases the operational risk to the casualty and those who may rely on him or her in combat.
PTSD Strategies in the US Army
17. One of the biggest issues in dealing with PTSD in combat soldiers is the ability to detect the problem in the first place. Many casualties do not realise that they have a problem. Those who do realise that all is not well often adopt a variety of coping strategies such as avoidance activities and self medication. This could go on for years adversely affecting the individual's performance. Due to the machismo nature of the fighting soldier, and the prevalent misunderstanding that PTSD is a weakness or mental illness, few seek support or counselling.
18. The US Army has acknowledged the reality of PTSD as a combat related injury and they now build in attrition factors due to PTSD into their operational planning. Perhaps more importantly Lieutenant General Kiley (US Army Surgeon General) approved a proactive approach to de-stigmatising PTSD. This has been achieved by valuing the soldier as a fighting resource and like any tank, helicopter or aircraft this human resource needs careful maintenance after an operational
patrol. The first element of the maintenance routine, referred to by the US military as a "reset" mission, is an all-encompassing medical assessment which includes psychological testing. Once the testing is complete the soldier is prescribed a comprehensive maintenance plan, including psychological counselling where necessary. This approach creates the understanding that PTSD is a combat injury. It also provides a regular opportunity to conduct a formal assessment of the mental health of the soldier; so early detection of PTSD, and effective intervention, is much more likely to take place. In our view a similar preventative strategy should be adopted for UK fighting forces.
Resettlement
19. By definition, PTSD does not exist until 28 days after the traumatic incident. There is a risk of causing more problems by well meaning, but unnecessary intervention during this period. But, outside this window, the earlier PTSD is detected the easier it is to treat. If PTSD screening was provided better access to medical support on discharge. This would go some way to averting the view held by many veterans that they were dumped by the system. Meanwhile, it would enable delivery of a more coherent support system. Such screening would also offer an opportunity to reduce the number of experienced soldiers seeking early voluntary release as part of a strategy to avoid dealing with their PTSD symptoms.
20. PTSD resilience training could be offered as a pre-release training course to service personnel. This would have several benefits: it would show the MoD demonstrating a proper regard for the welfare of its fighting forces; it would also reduce the burden on the NHS and service charities because the PTSD problem would be addressed during its early stages before degenerating into complex PTSD. Moreover, this approach could actually reduce the number of experienced people leaving the armed forces, since following the successful completion of a PTSD resilience training course, they may feel able to continue in military service. These training courses would be designed to help protect existing servicemen and women, and veterans, from the effects of PTSD. We believe that these courses should be funded from Ministry of Defence resources and delivered by the MoD in partnership with voluntary sector and specialist providers.
Societal Problems Prison
21. No precise figures exist on the numbers of ex-servicemen in UK prisons. According to the National Ex-Services Association as many as 7% of the total prison population in the UK is made up of veterans. Many of these prisoners are serving life sentences for murder, some committed while suffering from PTSD flashbacks. This is broadly consistent with US experience where 50% of Vietnam PTSD casualties have been arrested or jailed at least once, 34.2% more than once, while of those brought to trial, some 11.5% were convicted of the charges against them.
22. The UK prison population has just passed 80,000; so as many as 5,600 inmates could be veterans. If we take the conservative 9% figure for the rate of PTSD, then a minimum of 504 veterans are incarcerated as a result of their medical condition. A similarly conservative estimate for keeping someone in prison is £37,500 per annum. So we find that the taxpayer is spending almost £19 million every year to lock up British veterans simply because they cannot get effective diagnosis and treatment for their injury. If we assume that the average time in prison is 3 years, each incarcerated veteran costs the country £112,500. We firmly believe that this money could be better spent on funding a comprehensive programme of community support and training for PTSD casualties, which would reduce the strain on the prison system, the NHS, MoD and Treasury.
23. "Vets in Prison" conducted their own research among inmates at several prisons and found that the ex-services population was 9.8%. A former Captain in the British army surveyed the inmates in his prison and found that 10.85% of the population were ex-military. Of the 80 inmates on his particular wing, 12 were ex-soldiers, most serving life sentences. Of the 12 soldiers in this survey, 6 had attained the rank of sergeant or above. Many had been decorated for gallantry.
24. Even more telling is that when the "Vets in Prison" survey is analysed by service over 95% of the inmates were former army personnel, compared to just over 4% being former navy or air force. Yet only 55% of our total armed forces are army personnel. The army is experiencing a much higher level of active combat than the air force and navy, resulting in a greatly increased probability that soldiers will develop PTSD. Jimmy Johnson, founder of "Vets in Prison" conducted a poll of the inmates on his wing. Eleven of the 120 were ex-services, with ten of the eleven being ex-army. All of these veterans were serving life sentences for murder and none had been screened for PTSD before their trial. Without treatment for PTSD these inmates will be released untreated back into society, with the same problem that caused them to murder; or they will never be released because there is no acknowledged effective treatment that can be used to rehabilitate them. With no opportunity for rehabilitation, these men will be left to rot in jail for the rest of their lives. Can such an outcome be right for those who have risked their lives in the service of their country?
Family breakdown
24. The impact of PTSD goes far beyond the individual casualty. Due to the constant risk of violent outburst and substance abuse, family breakdown and divorce is common. A conservative estimate is that 10 people (parents, spouse, siblings, children, friends and co-workers) are directly impacted by every PTSD casualty. Citing Vietnam figures: 40% of veterans have been divorced at least once, with 10% experiencing two or more divorces; 14.1% had serious marital problems and 23.1% have high levels of parenting problems.
25. The US National Centre for Post Traumatic Stress Disorder estimates lifetime prevalence of alcohol abuse or dependence is 39.2%, and the estimate for current alcohol abuse or dependence is 11.2%. The estimated lifetime prevalence of drug abuse or dependence among male combat veterans is 5.7%, and the estimate for current drug abuse or dependence is 1.8%. As the veteran's condition worsens they often find themselves unable to find or keep work, resulting in homelessness and criminality.
Homelessness
26. In the late 1990s a survey found that 25% of those sleeping rough in London were ex-services. More recently it was report that this figure had fallen to 6%. However, PoppyScotland, in conjunction with Veterans Scotland and the Glasgow Homeless Partnership, during October 2006 conducted a four-week survey of all the users of their hostels and day centres. This survey found that overall 12% of the homeless were ex-military. Of these, 69% had spent less than 5 years in the military, though 4% had over 22 years service. Of this homeless group 28% had approached service institutions for support, while 69% did not know what support was available to them. This leaves a large number of veterans with no effective support, and with an increasing sense of abandonment.
27. Research by the New Policy Institute and Crisis, the homelessness charity, has estimated that there are between 310,000 and 380,000 single homeless people in the UK at any one time. Taking a conservative estimate of the number of homeless as being 300,000 and the PoppyScotland figures as being representative of the national situation, this means on any given night more than 36,000 British veterans are homeless.
Proposing effective responses What Doesn't Work?
28. Currently serving, and former, military personnel are confronted by stigmatisation within the military, lack of identification on release, short term support by the MoD, difficulty in accessing social services and health support, unavailability of effective service by the NHS, long waiting lists and disjointed service provision by a variety of organisations. Frequently NHS therapists do not understand the experience and mind-set of a military veteran. Military PTSD casualties placed in NHS programmes typically do not do well because their experience is set at such a pitch that it re-traumatises the civilian casualties, with whom veterans are being treated, which has a disruptive impact on the therapeutic environment.
29. With the looming size of the problem over the next decade we can be sure that existing methodologies and resources, which are selective in whom they accept for treatment, will not meet the needs of this growing high-risk population. Paying almost £600 per day for personnel to stay at the Priory is a luxury veterans cannot afford. What is needed is a radical approach using latest best practice in mental health care and charitable outreach to present a coherent solution that starts in service and is provided to the soldier/veteran through the transition into civilian life.
What Does Work?
30. It has been widely acknowledged that the voluntary, or third, sector does better than government in certain areas, and that the charity sector has an important role to play as a service provider working in partnership with the MoD. It has also been acknowledged that military personnel and veterans should be treated in a way that respects their unique needs and experiences. P3 is a leading UK charity (UK Charity of the Year 2005 and 2007 Sunday Times No.1 in the Top 100 Best Companies list) specialising in client groups who find themselves socially excluded.
31. In a speech made in November 2006, Derek Twigg, the Minister for Veterans argued that community-based mental health services should provide the model for service personnel. Meanwhile, the British Medical Journal has reported that a patient-centred and flexible approach to mental health care is the most desirable route to recovery. A community initiative, the Doncaster programme, provided support workers from within the community to deliver local mental health support. Much of this treatment was delivered via the telephone. Clients reported that they greatly appreciated the low-intensity nature of case management assisted recovery and support workers were extremely popular. This programme was considered to be a clear public policy success. Similarly, the Expert Patients Programme is a lay-led self-management programme specifically developed for people living with long-term conditions. The aim of the programme is to support people to increase their confidence, improve their quality of life and better manage their condition. A stress management company, Help Me Overcome, has developed a new training programme for PTSD casualties teaching them how to self-manage their symptoms. The pilot programme achieved better than a 70% success rate for those who attended the training (i.e. being symptom free or able to self-manage any emergent issues). It is now being reviewed by various US veterans support groups and the Dutch veteran's hospital.
Veterans
32. P3, in conjunction with Help Me Overcome, has created a comprehensive training programme, which will provide outreach and training services for veterans suffering from PTSD. The objective of the programme is to teach ex-military PTSD casualties how to manage their symptoms and be rehabilitated into society as effective members of the workforce. The training programme will be military focused with the trainers and field workers either being graduates of the
programme, military veterans or experienced field workers who have developed expertise in working with an ex-military clientele.
33. This 28 day programme consists of a 3 day residential phase followed by 4 weeks of follow up coaching. After the initial programme has been completed the recovering PTSD casualty is then provided with ongoing support using P3's existing infrastructure to rehabilitate and rejoin society as a productive individual. It is expected that rehabilitation would be achieved within one year. This provides the most cost effective initial intervention with the one year programme costing about half of the average cost of a typical stay at the Priory.
34. The aim of this programme would not be to duplicate existing service provision but rather to fill an unmet need. In particular, it will seek to provide effective treatment for those PTSD casualties who are currently abusing alcohol and drugs, a group other care providers in this sector tend to avoid. It will be provided nationally in partnership with associated providers.
Support groups
35. Evidence from the pilot programme and best practice in community mental healthcare indicate that the provision of an open, accessible and inclusive support network is essential for the long term effectiveness of the programme. Trainees can support each other, allowing them to gain a sense of self worth. Also carers, family members and children all need support, and possibly their own counselling, to help them overcome any emotional trauma caused by the PTSD casualty. The online support group provided for PTSD trainees is proving to be a very valuable resource to the graduates of the training, their carers and other PTSD casualties looking for answers. As the population of PTSD trainees grows, physical support groups will be established which will act as self-administered groups adhering to the "7 Commitments" (similar to the very effective Alcoholics Anonymous 12 step programme).
Complex Cases
36. There are many cases of complex PTSD in veterans where the co-morbidity of other issues makes it particularly difficult to treat them. Combat Stress, for example, is very selective in deciding which cases to accept because of quite reasonable concerns about potential disruption of its therapeutic environment. Consequently, Combat Stress only accepts 65% of referrals as clients, leaving a considerable number of veterans with no effective help in dealing with their symptoms. This means that there is now a major gap in tackling PTSD casualties, with a significant number of veterans falling through it.
37. In 1989, a residential home was established at Ty Gwyn, Llandudno, whose mission was to provide care for the more difficult complex PTSD casualties. It had become apparent that the respite care provided elsewhere had often proved inadequate. Indeed, at one point Ty Gwyn held a contract from Combat Stress to take the latter's more demanding clients because the clinical care offered by Combat Stress was not designed to cope with more difficult cases of PTSD.
38. Ty Gywn adopted the position that it would accept all ex-military PTSD casualties and provide full clinical care - where necessary to complete a thorough detoxification (for drugs or alcohol) before dealing with the PTSD symptoms. When this facility was forced to close due to lack of funding from the NHS over 1,500 veterans with complex PTSD were left without any effective support. Many of these had not been referred to Combat Stress, while others had found the level of respite care provided by Combat Stress ineffective for treating their condition. The majority of those who completed a recent PTSD resilience training course had been residents with Combat Stress, but were still experiencing full blown PTSD symptoms when they entered the programme.
39. The closure of Ty Gwyn provides the clearest possible example of the failure of policy with regard to moving the treatment of military personnel into the NHS and away from specialist military facilities. In the case of those with complex PTSD, whose psychiatrist had recommended that they should receive care at Ty Gwyn, all too often the casualty's local PCT refused to sanction the necessary funding on the grounds that they were already paying for local psychiatric and psychology services. They saw no reason to provide the specialist intervention available to the very difficult cases accepted by Ty Gwyn and therefore blocked both referrals and funding. With Ty Gwyn's closure those casualties rejected by Combat Stress were left to fend for themselves, since they had already been failed by the conventional psychiatric services.
Recommendations
40. A residential facility providing a more supportive environment for complex PTSD cases should be established and referrals to it encouraged. This would allow casualties to safely detoxify, which would provide the highest probability of success during the delivery of a comprehensive training programme designed to help complex PTSD casualties. This facility would provide short-term residential programmes, typically four weeks, for detoxification and PTSD resilience training.
41. As this model of service delivery becomes established it would also provide an opportunity to create specialist training expertise which would be made available to the MoD for inclusion as an in-service programme. This expertise could be deployed so as to offer protection against developing PTSD among serving personnel.
Conclusions
42. The extent of the problem of PTSD among serving personnel and veterans is already considerable and can be expected to continue to increase with the current tempo of operations. It is quite clear that the currently available approaches are inadequate for dealing with PTSD. It is also clear that existing treatment facilities, already overstretched, will be unable to cope with the increased demand for the services they provide. Accordingly, it is imperative that new models and innovative solutions are fully examined now for efficacy in dealing with the predicted demand.
43. The US military has made significant progress in de-stigmatising PTSD and already includes psychological maintenance as an integral part of post deployment activity. The lessons learned, and applied by the US military should be considered for inclusion within the British military approach to PTSD. Any such initiatives among British forces should be developed so as to provide a coherent, seamless transition for those who chose to leave the service due to their injury.
44. Programmes for dealing with PTSD in veterans should be based around current best practice for community mental healthcare and should demonstrate a willingness to adopt new and innovative solutions and techniques. It is essential that outdated thinking and ineffective programmes should be ditched in favour of those that can prove their effectiveness. All programmes must be outcome-focused with clear, measurable cost-effectiveness criteria designed into them.
45. Our armed forces and veterans deserve nothing less than proper care for injuries they have sustained while fighting for their country. Without a comprehensive policy designed to ensure the mental health of our armed forces, including programmes to deal with the more difficult PTSD cases, it is clear that our servicemen and women are being badly let down. As the number of casualties presenting with symptoms of PTSD increases with the raised tempo of operations, such a failure of policy can only be viewed as shameful.
28 June 2007
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