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break free from outdated thinking and ineffective programmes.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—ie 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
(ie 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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