Memorandum from Robin Short, Martin Kinsella
and David J Walters
In oral evidence to the Defence Select Committee's[36]
inquiry into Recruitment and Retention in the Armed Forces, a
statement was a made which suggests the existence of a much higher
level of PTSD than has previously been admitted by MoD officials.
We believe that the loss of personnel as a consequence of mental
health problems will have a significant impact on the long-term
retention of military personnel.
Mr Jenkins, in the course of a question directed
to Professor Strachan, made the following statement: "We
recently found in our report on the Annual Report and Accounts
that the failure of the Army and the RAF to achieve their Harmony
Guidelines was unacceptable, so what can the Armed Forces do to
improve observance of the Harmony Guidelines?"
Professor Strachan replied, "They can do
very little while they are under the operational pressures they
are under. One of the absurdities of the report is the expectation
that Harmony Guidelines can be sustained".
And Professor Dandeker added, "On Harmony
Guidelines, I think there is some important contextual information
that needs to be remembered, which is that something between 13
and 20% of personnel are in breach of Harmony Guidelines ....
The second point is that the Harmony Guidelines, so far as our
own research is concerned, show that if you keep personnel within
them their mental health does not suffer. It does suffer if you
go over those guidelines, so I think the point to recall is that
the great majority are within the Harmony Guidelines. I think
that the Harmony Guidelines have been well constructed because
the evidence suggests that if you stay within them they do not
suffer; if you go beyond them there is a 20-50% likelihood that
they will suffer in terms of PTSD."
From the evidence offered by these two experts,
we see that:
— The army and RAF have failed to meet
harmony guidelines.
— There is little likelihood of achieving
them with the present operational tempo.
— 13-20% of personnel are in breach
of the harmony guidelines.
— 20-50% of those in breach of the
guidelines suffer in terms of PTSD.
According to the MoD factsheets 7,800 personnel
are deployed in Afghanistan[37]
and a further 4,000 in Iraq[38],
amounting to a total of 11,800 personnel currently employed in
theatre.
Army harmony guidelines state that individuals
should not exceed 415 days of separated service in any period
of 30 months. At unit level, tour intervals should be no less
than 24 months. So soldiers can be deployed for a maximum of 5.5
months out of every 12. This means that 25,745 troops will need
to be deployed each year to ensure that the harmony guidelines
are not exceeded.
Based upon Professor Dandeker's evidence, it
is possible to calculate the minimum and maximum rates of PTSD
that can be expected to arise from a required annual commitment
of 25,475 service personnel deployed to Afghanistan and Iraq.
— The minimum in breach of harmony
guidelines is 13%, which equates to 3,347 soldiers.
— The maximum is 20%, equating to 5,149
soldiers.
— From this group, between 20% and
50% will suffer in terms of PTSD.
— So, the minimum number of British
service personnel who can be expected to develop PTSD each year
is 669, while the maximum is 2,575.
In other words, at least 2.6% of British troops
will develop PTSD, and in the worst case 10%. If we take the average
of the maximum and minimum values, 6.3% of personnel deployed
to Afghanistan and Iraq can be expected to develop PTSD. That
equates to 1,605 new cases each year.
This figure is higher than the Kings College
study[39]
cited in the Journal of the Royal Society of Medicine, which states
that in a survey of 1,198 service personnel deployed in peacekeeping
operations between 1991 and 2000, 3.6-5.5% developed PTSD. According
to the NHS National Clinical Practice Guidelines for PTSD[40]
"the risk of developing PTSD after a traumatic event is 8.1%
for men and 20.4% for women".
The US National Centre for PTSD reports "Numerous
studies have since observed a dose-response relationship between
trauma severity and PTSD"[41]
and the American Journal of Psychiatry states "History of
any previous exposure to traumatic events was associated with
a greater risk of PTSD from the index trauma. Multiple previous
events had a stronger effect than a single previous event"[42].
So, the greater the exposure to traumatic events, the greater
the risk of developing PTSD. With 270 British fatalities since
2002 and the high intensity of the operations in Iraq and Afghanistan,
the exposure to human death and life threatening experiences is
much higher than would be experienced in a peacekeeping operation.
Although we are not aware of any research into
the root cause of premature voluntary release from the services,
there is a strong indication from amongst the PTSD casualties
we have contacted that the onset of PTSD symptoms prompts them
to leave the service, or at least not re-engage to complete a
full career. Given military training, it is reasonable to deduce
that a decision to seek voluntary release is derived from a sense
of failure, or shame, when service personnel realise they are
unable to self-manage their symptoms (generally through alcohol
and other substance abuse); these feelings are exacerbated by
the knowledge that they cannot fulfil their operational obligations
to their comrades.
This then leads to a vicious circle—more
personnel leave the service, which requires more frequent deployments
for those who remain, placing more personnel outside the harmony
guidelines and increasing their exposure to traumatic events.
This in turn increases the probability of developing PTSD. So
more choose to leave the service; thus the cycle continues.
Whether the actual figure for those with PTSD
amounts to 3.6%, 5.5%, 6.3% or 8.1%, the lowest figure is still
much higher than the 1:3,000 (0.033%) of personnel diagnosed as
suffering from PTSD during the second quarter of 2007, according
to statistics provided by the Defence Analytical Service Agency.
We believe that the DFSA figure lacks credibility because it does
not include data on PTSD identified in those who have left the
armed forces. As has been indicated above, there is strong anecdotal
evidence to suggest that servicemen and women will seek voluntary
release rather than admit they have PTSD symptoms. In other words,
the true level of PTSD is not picked up in DFSA statistics because
sufferers leave the armed forces before such a diagnosis can be
made.
In evidence to the Defence Select Committee's
recent inquiry into Medical Care for the Armed Forces, we stated[43]
that military personnel tend to present with PTSD 10-15 years
after the exposure. A recent article in The Times[44]
on trauma suffered by war-zone journalists stated that there is
an average of seven years between the traumatic event and the
onset of PTSD. After six years of intense operations in Iraq and
Afghanistan, Professor Dandeker's figures suggest that the real
number of service personnel and veterans becoming PTSD casualties
is already in the region of 9,630 and rising at a rate of over
1,500 each year. Even if we assume a 50% margin for error, and
that only 4,815 personnel have actually suffered from PTSD, the
consequent loss of trained servicemen and women is having a significant,
detrimental affect both on retention and on the operational capability
of the armed forces. If these 4,815 personnel had been provided
with effective support and treatment for their PTSD the MoD would
not now have to acknowledge:
— That the British infantry is 1,280
men short of full fighting strength.
— That operational battalions were
deployed with a shortfall of up to 100 soldiers.
— That the predicted trained strength
of 99,300 is under the required level of 101,855 (a shortfall
of 2,555, which is less than the number lost to PTSD).
As has been previously identified[45]
there is neither the capacity nor capability within the MoD or
NHS to handle the 10,000 new PTSD cases which can be expected
to occur over the next five years[46].
Ongoing failure to address the real level of PTSD experienced
by our service personnel will only place an ever-increasing number
outside the harmony guidelines, increasing susceptibility to becoming
PTSD casualties and further damaging retention and recruitment
in the armed forces.
We believe, therefore, that the MoD needs to
acknowledge the real rate of PTSD, as identified by Professor
Dandeker, which will certainly have a negative impact on the number
of Armed Forces personnel available for active service. The statistics
supplied here clearly demonstrate that a failure on the part of
the MoD adequately to deal with the forthcoming PTSD bow wave
will have a significant adverse affect on the retention of military
personnel.
3 May 2008
36 http://www.publications.parliament.uk/pa/cm200708/cmselect/cmdfence/uc424-i/uc42402.htm
Question 22 Back
37
http://www.mod.uk/DefenceInternet/FactSheets/OperationsFactsheets/OperationsInAfghanistanBritishForces.htm Back
38
http://www.mod.uk/DefenceInternet/Templates/Factsheet.aspx?NRMODE=Published&NRNODEGUID=%7bF0BB1DF1-A9C7-4E17-96E7-B3301B06E45F%7d&
NRORIGINALURL=%2fDefenceInternet%2fFactSheets%2fOperationsFactsheets%2fOperations
InIraqFactsandFigures%2ehtm&NRCACHEHINT=Guestmc2 Back
39
http://jrsm.rsmjournals.com/cgi/content/full/101/2/78?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&titleabstract=PTSD&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT Back
40
National Clinical Practice Guideline Number 26 ISBN 1-904671-25-X Back
41
http://www.ncptsd.va.gov/ncmain/nc_archives/rsch_qtly/V11N3.pdf?opm=1&rr=rr201&srt=d&echorr=true Back
42
http://ajp.psychiatryonline.org/cgi/content/full/156/6/902 Back
43
http://www.publications.parliament.uk/pa/cm200708/cmselect/cmdfence/327/327we27.htm
Para 6 Back
44
http://www.timesonline.co.uk/tol/sitesearch.do?x=0&y=0&query=PTSD+Catherine+&hitsperpage=10&nextOffset=0&offset=0&leftStartIndex=
1&leftEndIndex=10&submitStatus=searchFormSubmitted&mode=simple§ionId=674
Para 22 Back
45
http://www.publications.parliament.uk/pa/cm200708/cmselect/cmdfence/327/327we27.htm
Para 28 Back
46
http://www.publications.parliament.uk/pa/cm200708/cmselect/cmdfence/327/7061201.htm
Questions 48 and 96 Back
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