UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 762-ii

HOUSE OF COMMONS

ORAL EVIDENCE

TAKEN BEFORE THE

DEFENCE COMMITTEE

THE MILITARY COVENANT IN ACTION? PART 1: MILITARY CASUALTIES

WEDNESDAY 15 JUNE 2011

PROFESSOR SIMON WESSELY and DR NICOLA FEAR

Evidence heard in Public

Questions 126 - 245

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Oral Evidence

Taken before the Defence Committee

on Wednesday 15 June 2011

Members present:

Mr James Arbuthnot (Chair)

Mr Julian Brazier

Thomas Docherty

Mr Mike Hancock

Mr Dai Havard

Mrs Madeleine Moon

Penny Mordaunt

Sandra Osborne

Bob Stewart

Examination of Witnesses

Witnesses: Professor Simon Wessely, King’s College London, and Dr Nicola Fear, King’s College London, gave evidence.

Q126 Chair: Thank you both very much for coming to give evidence to us for our inquiry entitled "The Military Covenant in action? Part 1: military casualties". Might I ask you to introduce yourselves and say what you do?

Professor Wessely: I am Simon Wessely. I am a consultant psychiatrist and epidemiologist at King’s College London. I set up and look after the King’s Centre for Military Health Research. I’ve been doing that since the middle days of Gulf War syndrome and have looked, latterly, at Iraq and Afghanistan. It is a unit within King’s, and we specialise in military health. That is what I do, among other things.

Dr Fear: I am Dr Nicola Fear. I am a reader in epidemiology in the King’s Centre for Military Health Research, based at King’s College London. I have been involved in military research since 2002. I spent two years working with the Ministry of Defence before moving to King’s in 2004.

Professor Wessely: I should add that I’m the adviser in psychiatry to the Army.

Q127 Chair: Will you tell us about the King’s Centre for Military Health Research-what it does and how you ensure that the research is independent of the MOD?

Professor Wessely: Yes, sure. It is a research unit within King’s College London, so it is an academic unit. Its main purpose is to carry out research and publish it. Our main customer is the MOD, but it is not the only one. We also have funding from the US, the Medical Research Council, the ESRC and the Leverhulme Trust. Do we have funding from the Wellcome Trust? I can’t remember-no, we haven’t.

Q128 Chair: ESRC stands for what?

Professor Wessely: The Economic and Social Research Council. We also get funding from the Royal British Legion and so on. Our main projects revolve around the kind of health surveillance that began in Telic 1 in 2003. We have periodically looked at the health of 10,000 or so members of the three services, and are following them up now as they continue to deploy or as they go into veteran life. Around that are a variety of other studies, looking at stress management, different ways of managing and preventing operational stress, screening in the armed forces and lots of other things, all of which at the moment escape me but will come back in a second. We work with other colleagues around the medical school in different disciplines when we need them, like neurology, immunology and so on, when we do stuff on vaccines and forces health protection. We also have a full-time professor of history in the unit, because we are very interested in historical aspects of military health.

The relationship with the MOD has developed over the years. We have two rules. One is that everything that we do, we publish, so we have never done anything that has not been published-or at least when it has not been published, it has not been our fault; it has been because of journals. The MOD has no censorship power over the results and the papers that we publish; nor, to be fair to it, has it ever tried to exercise any. The only rule is that we do not look at special forces, so we have never had any dealings with SF. That was part of the deal. The MOD sees final copies of our papers and reports, so that it can look at them for any factual errors and so that it knows what is going to come out in the press, but as I said, it does not have any veto over it. That relationship has developed over the years and, I think, has been reasonably successful, but as I said, the right of publication is unequivocally with us at KCL, and as you can see from the reports, we do publish quite a lot, including some stuff that is favourable and some stuff that is not.

Q129 Chair: Special forces are an interesting exclusion. Do you want to tell us why they are excluded, or would you prefer not to?

Professor Wessely: It has nothing to do with preference. I don’t actually know; they just said at the start, "No SF."

Q130 Mr Havard: May I ask the question slightly differently? Do you know what, if any, special other arrangements there are to deal with-

Professor Wessely: I genuinely have not a clue.

Q131 Chair: Who pays for what you do?

Professor Wessely: At the moment, about 50% of our funding comes from the MOD. The rest, as I said, comes from a variety of sources. We have two big studies, on screening and on children of military families, which are funded by the US Department of Defense. We have other funding for work looking at veterans and service leavers from the Royal British Legion. We are looking at public attitudes to the military with funding from the Economic and Social Research Council. We have also had MRC grants. We have a big project at the moment looking at crime, violence and incarceration. What we have done is this: for all the people in our study, we have obtained their criminal record data from the Ministry of Justice to look at the impact of deployment, service and vulnerability on patterns of offending. That is funded by the Medical Research Council.

Q132 Chair: If you are doing all this research into people, presumably you have open access to the people you need to have access to within the Ministry of Defence.

Professor Wessely: Within reason, yes we do, but obviously even though you have open access, finding them is still incredibly difficult, not least because when you are dealing with serving personnel, they do have jobs to do, but we do work in theatre. We have done two studies, and we are now doing a third, of various operational mental health issues in Iraq and Afghanistan. We go out to theatre. Two or three of us are going out in two weeks’ time to Afghanistan to do that. Funnily enough, we have incredibly good access there. The problems are often when they come home and when they leave. Tracing people after they have left the armed forces is not easy. They are a young, mobile population. We are very good at it, but it is always a struggle. If you asking whether there are institutional barriers to us, no. Chair: Tracing people after they have left the armed forces is something that I think we will have to come back to during the course of the afternoon.

Q133 Mr Hancock: In two of your studies, in 2006 and 2009, your results showed no increase in the mental health problems of those being deployed, as opposed to those not being deployed. Were you surprised at that result?

Professor Wessely: Yes.

Q134 Mr Hancock: How big a core group were you looking at?

Dr Fear: In the 2006 study, we had more than 10,000 study participants. In the subsequent study, we had just under 10,000 participants-a relatively large sample size. Professor Wessely: Remember, that is regulars only. That was not the finding for reserves, but for the regulars only.

Q135 Mr Hancock: When you discovered that, where did you take that research? What happened to those fellows later on when some of them did start to develop problems? Was it that the problems did not arise as quickly as you anticipated they would?

Professor Wessely: No, it wasn’t that. Let us be clear: 3% to 4% of them did have post-traumatic stress disorder, so it was not that they were not having problems; it was that the rate had not changed between 2003 and 2009, despite the increased op tempo-that was the surprising fact. They were not free from problems; they just had not got worse with increasing numbers of deployments. There was not an increase to explain, and we cannot explain the absence of something, but we clearly think that certain issues are important, such as a shorter tour length compared with those of our US colleagues.

Q136 Chair: How does that 3% to 4% compare with the population as a whole?

Professor Wessely: No one knows the true prevalence of PTSD in the UK population, because there has never been a population-based study. We know that overall, from work that we have done using data up to the beginning of 2000, the mental health of the armed forces is very similar to that of the general population, with the exception of alcohol, but those data really date to the national service, Cold War and Northern Ireland generation. The problem is that there isn’t good population data on PTSD in the UK. We tried to get it done in a thing called the national psychiatric morbidity study, but it was not included in the way that we wanted; other studies have not looked at veterans. We think that it is probably around the same, but it might be slightly more or slightly less.

Q137 Mr Hancock: You studied a group that had not been in combat; had they never been in combat, and so possibly had spent only relatively short periods of time in the armed forces?

Professor Wessely: There are two separate things to that. Those who were in combat, which was about 25%, had higher rates of PTSD. For them, it was around 7%, which to be honest, did not surprise us. Had we not found that, it would have caused us to wonder. The other group are mainly in combat support and all the other roles, but they have deployed. The problem is that by the second study it is almost impossible to find a non-deployed control group; they barely exist. When they have not deployed at all, they are either very new or they have medical problems that mean that they are not a very good comparison anyway. I have now forgotten the first thrust of your question.

Q138 Mr Hancock: I was interested to know how that group was made up, and you have given us the answer to that. There were those who were in combat roles and those who were in support roles. For some people, just being in a support role would be stressful. You don’t have to imagine the situation; lots of people have seen a situation where there are risks everywhere. Did you not get the same sort of response from them?

Professor Wessely: For the ones who were clearly based in Bastion and Kandahar and really did not get beyond the wire, we did not see much impact of traumatic incidents. Mental health problems were more things like depression and family problems; that came out more. The further you got from the main bases, the greater the increase in traumatic symptoms, some of which are not disorders, and there was more to judge.

Q139 Mr Hancock: May I ask about going back? Prior to Iraq, British soldiers were deployed to Northern Ireland for much longer deployments, and some were there for 18 months or two years. Did you study what happened to those people on return?

Professor Wessely: No. The very first ever follow-up study on the UK armed forces was the Gulf War study. Prior to that, there had been no tradition of doing those kinds of studies. They only really begin with Vietnam and the US.

Q140 Mr Havard: Perhaps you help me, if not everybody else. We talk about post-traumatic stress disorder and the identification of it; it presumably has a definition, and you therefore either fall within it or you don’t. You then said something like, "Well, they’ve got these problems but they’re not disorders." Will you help us with some problems of definition? What is in post-traumatic stress disorder and what is not? How are those different things accounted for?

Professor Wessely: That is a vitally important issue. The first thing to say is that some of the symptoms of post-traumatic stress disorder are not, by themselves, abnormal. We would not say that coming back from a deployment with poor sleep, or being more irritable or a bit more angry and difficult, were signs of a disorder; that is a normal emotional reaction. My father still has nightmares involving the Royal Navy in 1944, and he is 85. You will have to trust me: he is not disordered, but that is the way it is. There is sometimes a tendency in modern culture to equate having bad memories and nightmares with having a psychiatric disorder. The best way of understanding a psychiatric disorder is that it is when it is not just that you have good or bad memories of your military service, but when that impedes your function; because of those memories, you cannot work, you cannot keep down a marriage, you start doing drugs or drink-in other words, your performance is impaired.

In cases of PTSD, everyone remembers symptoms such as flashbacks, anxiety and such things, but they forget that there is also a requirement that someone is impaired in their function. When someone is impaired in their function, they are moving towards a formal psychiatric disorder that may require treatment. Simply having memories of war is almost a sine qua non of having been deployed, and we go out of our way not to medicalise or pathologise that.

Q141 Mr Havard: That was my fear-that a lot of things that would be normal, in a sense, were being medicalised in a way that they do not need to be. Where does the definition come from?

Mr Hancock: Following on from what Dai said, if symptoms extend over a long period of time, wouldn’t you consider that?

Professor Wessely: At the risk of being personal, my father has had nightmares about the Royal Navy all his life. He has never forgotten about it, but he is not disordered and does not need treatment. The idea of him now having counselling-I don’t think you would get very far with that. One would not dream of saying that he is disturbed.

There is a very nice study from America and the Second World War that followed up very, very highly exposed combat veterans over 50 years. Nearly all of them continue to have memories-often very traumatic memories-about the war. They are also more likely to be in "Who’s Who in America" than those who have not had combat exposure. That is probably to do with a selection of reasons. You would not go around saying that those veterans had a disorder. There were some who did, however. Some committed suicide, some were murdered and some had tremendous problems with drugs and alcohol. Those people had clearly moved into psychopathology, as we would call it.

Q142 Mr Hancock: In your studies, do you find that that group does lead in some instances to the other category?

Professor Wessely: Yes, we do. We find that some people have symptoms, and then gradually develop a disorder over time-sometimes called delayed-onset post-traumatic stress disorder. It is not like cancer, where you are okay, and then suddenly get it. It is more gradual, and there comes a point where you cross a line and then fulfil the criteria, usually when you cannot function. Other people do the opposite, so there is a changeover with people who gradually improve and get better. There is a natural history to these things, which is why the overall rate is stable over time. That is because some people are getting better, and some people are getting worse, but the overall rate remains pretty static over the years.

Q143 Mr Havard: Remembering some of those things and contextualising them might be cathartic. I understand now, but I would like to know whether you think some of this is over-medicalised, or not medicalised enough. Are these definitions right as they stand at the moment for the sort of research that you are doing?

Professor Wessely: I think in the armed forces they try very hard not to over-medicalise. The TRiM system-the trauma risk management programme-in which we played a large part and did the big trial to look at its effectiveness, came out of precisely a desire not to medicalise these issues. Previously, there had been post-incident debriefing-psychological debriefing-and as soon as something bad happened, you talked about it with trained counsellors. A series of studies, including our own, then showed that not only did that not work, but it made you worse, so we moved away from that. In my view, that was inappropriate early medicalisation of something that was a normal reaction. The military are very good at that; the idea is: "Yeah, you’re shaken up or whatever, but that’s normal and should be dealt with with your mates," within the TRiM system and so on, and only if things get bad should you be referred to an RMO or a mental health professional. These things are not psychiatric disorders.

In society as a whole, it depends. I agree with you in general: I think there has been a tendency sometimes to trivialise PTSD and move away from the original conception, which came out of Vietnam and then the Falklands, of grossly abnormal situations where you are in fear of your life-situations where anyone would develop problems-to sometimes quite trivial things. We all have a collection of stupid Daily Mail stories, and I keep them as well. I find them irritating, because they demean those people who have come back with real psychiatric disorders.

Q144 Mr Havard: They devalue the coinage.

Professor Wessely: Yeah. People who trip on paving stones, and things like that. I find them annoying, to be frank.

Q145 Mrs Moon: You talked about those who had been in combat having a higher incidence-I think you said 7%. Did you find that any professions or particular roles had a higher incidence? I believe that in America, for example, they found that those involved in medical teams had a higher incidence. Did you uncover any such difference?

Professor Wessely: We did. We originally found exactly the same, and that the medics had slightly higher rates in 2003 to 2006, but for whatever reason, by the follow-up they were back with the others.

Dr Fear: Simon mentioned the medics, and that was the main sub-group that we looked at. We also looked at Marines as a separate group, and paratroopers and infantry personnel, to compare those groups. We found lower rates of PTSD among the occupational group of Marines, compared with the infantry and the paras.

Chair: Than the paras, or and the paras?

Dr Fear: Than the paras.

Mrs Moon: Could Dr Fear move the bottle of water? It is blocking the microphone.

Professor Wessely: The point from that is that the relationship is not a simple one between exposure to trauma and post-traumatic stress disorder. When Marines had high levels of exposure, but lower levels of stress, the general view, which I think is the correct one, is that it was mitigated by high esprit de corps, training, professionalism, cohesion and leadership-all things that the military is good at. It is not a linear relationship between trauma and outcome in mental health.

Q146 Penny Mordaunt: On the rare occasions when someone has a crisis episode and might cause injury to themselves or others, there have been suggestions of broader welfare factors, such as someone’s accommodation, how they are living with people, and being supervised, which have either exacerbated the situation or led to something not being picked up when earlier intervention might have prevented a tragedy. You draw out things such as leadership, trust and confidence. In this time of great change for the armed forces and change to how people are living and how units work and live together, do you think that they are detrimental factors to someone’s mental health to the ability of people looking after them to pick up problems?

Professor Wessely: I think we would be speculating on that one; I don’t really know. We know a lot about how it is managed in theatre, because we see it and look at the outcomes. In general, things are picked up very quickly there. You are in such intimate contact with people in such an abnormal situation that you quite rapidly notice, to be honest. We have not done much on accommodation changes, have we?

Dr Fear: No.

Professor Wessely: I can’t really answer that. Certainly, with the increased work load that people are under, you would think that some things get missed, but what we are seeing is an increase in people presenting now to mental health services. It is still not big-let’s not exaggerate this-but there seems to be a slow cultural change of increasing recognition and acceptance. There is a huge way to go, for sure, but if anything, I would hazard a guess that it is going slightly in the other direction. Well, I know that, but I don’t know precisely why.

Q147 Chair: So decreasing stigma?

Professor Wessely: Possibly. Let’s be clear: the majority of people with mental health problems do not present either in service or after service-only around 40% do, and 60% do not. As I say, there is a lot of undetected morbidity that we know about but no one else does, apart from the person themselves. We should also say that that is probably no different from any other occupational group. If we take a group of doctors-my wife runs a sick doctor service-it is very similar. If we took a group of MPs, I suspect it would be very similar as well. It is a much bigger social problem. Our own original, rather naive, view was that it was to do with the nature of Army culture. I think we have changed our mind; if anything, the military is now-we have some nice data on this-slightly more accepting of mental health problems than it was, and many problems with veterans begin when they leave, not when they are in service. It is not that there is a bullying military culture, and then they join the touchy-feely, cuddly NHS and everything is fine. It certainly does not work like that.

Q148 Sandra Osborne: Do people present symptoms years later? I have Combat Stress in my constituency. It sees people come forward maybe 20 years after they have left the forces. Is that because they have not come forward, or is it something that just happens?

Professor Wessely: No. I am a trustee of Combat Stress, so obviously I am familiar with what we do. Usually, 12 to 13 years is the average time it takes for people to present, but that does not mean that they are fine for 12 years and then, after going to a reunion or watching a TV programme, it all comes back to them and then they are in trouble. They have been in trouble during that time; it has just taken 12 years for them to do something about it or, more often, to be told by the wife in particular that they have to do something about it. It is not that you are fine and then suddenly go downhill. That does happen, but it is very unusual. What is not just common, but the norm, is that it takes years before you will accept it and finally admit to problems. That is the norm; hence the figure of 12 years that Combat Stress mentioned.

Q149 Mr Brazier: On the point you made about the Royal Marines being more resistant in your studies than other groups, presumably that is quite heavily related to the fact that the corps of Royal Marines developed the decompression technique ahead of everyone else. For quite a while, they were the only people going through a formal decompression process. That is right, isn’t it?

Professor Wessely: I should know, actually. I am sure you are right.

Q150 Mr Brazier: I am pretty sure that I am right, because Royal Marine officers have told me about it. What is now happening was largely originally developed by them. My question is: do you think that reservists experience more problems on return from deployment, and why?

Professor Wessely: The answer to that is a categorical yes. We know that they have worse mental health problems. Again, let’s be clear that these figures are not like those in the USA, where one third come back with neuropsychiatric problems. For us it is about 6%, so 94% do not come back with mental health problems. Nevertheless, reservists are more vulnerable. We have had a long look at this in various ways, with various different studies and data sets. It is not to do with what happens to them in theatre. In particular, we showed that, between 2003 and now, morale and satisfaction with their role in theatre had increased from Telic 1 right through to now. It was a bit disappointing to see that that had not led to an improvement in mental health problems.

The problems are particularly to do with support and homecoming issues. Reservists are more likely to have problems with their employers; they are less likely to feel that the military is supportive; they are less likely to feel that their families are supportive; and they are more likely to have problems from their peer group. Let’s say that the reservists come back to King’s. For two days it is great, and they tell their war stories, and you start telling them about the latest NHS reform and how terrible it has been while they have been away, or whatever the current problems are. We are clear that it is to do with different homecoming experiences, different support structures and different family structures.

Q151 Mr Brazier: I have two short supplementary questions on that. One of your colleagues-I cannot remember who it was-gave testimony to a meeting of the all-party mental health group, in conjunction with the all-party reserve forces group, three or four years ago. It was a joint meeting. I think you were there, Chair. Your colleague said that there was some evidence that reservists in reservist units were less likely to have problems than those who went over as individual augmentees.

Dr Fear: Recently, we have used our data to look at whether deploying with your parent unit or as an individual augmentee impacts on mental health problems. We have looked separately at regulars and reservists. Our latest data show that there is no difference in mental health outcomes.

Q152 Mr Brazier: Interesting. The other thing I was going to ask was on the fact that mental health problems are something that emerge, as you have said, over a much longer period. You mentioned at the very beginning the difficulty of tracking people who have left the armed forces. Presumably that is a big factor. If it is difficult for the regular armed forces, it must be even more difficult for reservists.

Professor Wessely: Yes.

Q153 Mr Brazier: That might suggest that the disparity is slightly greater than it appears, because it is harder to catch up with reservists.

Professor Wessely: It is harder to catch up with reservists. I will not go through all the details, but we are fairly confident that those are the true rates and that we are not missing a big pit of morbidity that we could not find, because we can look at the influences on response rates. We think it is more that they are difficult to find. Their links with the charities and the various regimental associations are weaker. It is harder for us to get valid addresses. Plus, some of those have lost contact with the military and are not bothered any more. Those who are still serving are easier to find. I do not think that we are missing a bigger problem. We are missing, in all our studies, a very hard group to find, which includes, for example, the homeless, but it would be highly improbable that reservists were more likely to be homeless than regulars. If anything, it would be the other way round.

Q154 Mrs Moon: May I ask Dr Fear to go back to the statement that she started to make and amplify it? You talked about soloists, whether reservists or regular. You found that there was no difference between soloists who were regulars and reservists, but there was higher incidence among reservists. Are you saying that there is also higher incidence among those who go as soloists, say someone from the Navy or the RAF who is embedded in a formed regiment, where the majority are the Army and where they go back to their Navy or RAF unit without the support networks? Are you finding higher incidence among soloists from other forces as well?

Dr Fear: I would have to come back to you on that, I am afraid. I cannot remember those details off the top of my head.

Professor Wessely: We didn’t on OMNI, did we?

Dr Fear: We didn’t, no.

Professor Wessely: We did studies in theatre, and there was not any difference overall between individual augmentees and those who formed units, irrespective of whether they were reservists or regulars. I cannot remember the details either; we will have to look that one up.

Q155 Penny Mordaunt: You made the observation that if harmony guidelines were exceeded, there was an increased risk of PTSD, psychological distress and severe alcohol problems. Why was that?

Professor Wessely: We think that it is to do with expectations. It is very hard to think of any other reason because you would say, "Well, what’s the difference between six months and seven months? It’s not that much really; why would you suddenly get a doubling of alcohol problems?"

I think it is because people expect to go home on a certain date, RAF permitting. If that is denied them, they suddenly get quite demoralised and the family do too-remember that there is now instant communication between home and theatre. That would be our explanation. I should say in defence that it does not happen very often, but when it does we notice that impact. I know that the MOD has accepted those findings and tries very hard to stick as much as it possibly can with the tour length that people are given.

Q156 Penny Mordaunt: Did you notice any difference in the 2009 results for those who had multiple deployments?

Professor Wessely: No, we didn’t-in direct contrast to the USA, where there is a linear relationship between the number of deployments and mental health, obviously going up quite dramatically. Again, you might come back to the previous question about whether we were surprised by that, and I think we were. But no, there is no relationship at the moment-we have to say "at the moment"-between the number of deployments and current mental health.

Q157 Penny Mordaunt: You think that that comes back to the expectation issue. People being deployed again and again are-

Professor Wessely: The only nation that we can compare with is the US, which has a one-year deployment and then a one-year down time. As soon as they come back, they do not even have post-operational leave; they wait until they are due their leave and a year later they are back on deployment. You do not really need to do much research to know that spending all that time in a rather difficult place, where people are trying to kill you, is not very good for your mental health. The obvious explanations are sometimes the correct ones.

Chair: We will be coming back in a moment to look at the comparison between ourselves and the United States.

Q158 Mr Brazier: I have a very quick supplementary about the system that we have in Britain of sending people back for a short period of leave in the middle of deployments. I had a rather curious complaint from an officer, who said that he thought that it was bad for the families rather than good for them. His leave happened to fall at the very latest possible point. He said that he was in the absurd position of having done more than five months of a six-month position, going home-he had young children-and seeing all his family, and then going through the trauma of saying goodbye to them all again to return to operations for two and a half weeks. He said that it would have been much better for his family if he had gone straight through the six months. It is a difficult thing to study, but has anybody made that sort of remark to you?

Professor Wessely: Yes, very much so. It is a very difficult thing to study; you would have to do a randomised controlled trial, giving half of them leave and half not, and I suspect that that would not be acceptable. Our data show that R and R is popular with people. We are aware of a couple of other studies that show the opposite, and we are trying to reconcile those two data sources as we speak, so we do not know.

Things like decompression-we don’t know whether that is successful. We know that it is popular the first time around, but we do not know whether it prevents things because we do not have a group who do not decompress. One of the reasons why we are zealously pushing a randomised trial of screening, which is what we are doing at the moment, is precisely because then we can give you real answers about whether it makes a difference or not. On R and R, we are aware of both points of view and we find it a little difficult to reconcile.

Q159 Bob Stewart: As an ex-commanding officer, I think that it is extremely difficult to make people take R and R early or late. We do not need to study that; people totally understand it straight away. If they go early, they are not into the tour and if they go late, they are at the end of it.

My question is this. Having been the object of a four-month tour and six-month tours thereafter, what is your opinion-both of you-of the best length for an operational tour in an operational theatre such as Afghanistan, which is quite intensive? What length of time do you reckon is the best?

Professor Wessely: I don’t think it is for us to give you a specific answer to that because there are so many other issues beyond the area that we look at, which is the impact on health.

Bob Stewart: I am thinking of it from the point of view of mental state.

Professor Wessely: I am aware that there are many, many other equally important issues.

Bob Stewart: I accept that.

Professor Wessely: We know that the UK system seems to be working. We don’t know whether that is by luck or judgment or whether it is just because once you have a rule, you stick with it and people accept it. You could lengthen it, provided that you have managed expectations without undue problems. We are reasonably confident that the US system is not ideal, and most of our colleagues in the US would agree.

It is not just the tour length; as I am sure you know very well, it is the down time as well. You have to manage that as well, so the two are not independent. For what it is worth, my view is that we have got the balance about right, but I really caveat that by saying that we look only at the health effects, not everything else-we do not look at anything strategic or operational, and we know that there are views the other way. But at the moment, the UK seems to have the balance reasonably well. [Interruption.]

Chair: I am afraid that we now have to go and vote. We are nowhere near finished, so we will return. We will be back within 10 minutes, if possible, unless we hear news that there is to be a second vote, in which case we will be longer.

Sitting suspended for a Division in the House.

On resuming-

Q160 Mr Hancock: On the civilian side of the harmony guidelines, have you been commissioned to do any work on the reaction of the wives, girlfriends and partners of service personnel who have been affected in one way or another and what they are going through. The MOD has a duty of care to the whole family, but nothing I have read mentions any research that has been carried out about the effects of these types of deployments on the husbands of the wives who have been deployed. Have you done any work on that?

Professor Wessely: We have, yes. We did a study on the Welsh Guards, talking to the wives before, during and after deployment, and also to-it was always the husbands in that particular study. It was interesting that in general the wives were pretty resilient, but the husbands didn’t think that they were. The husbands had a tendency to say, "No, no, she’s not doing very well at all," but the wives would say, "He keeps saying that, but actually I am doing reasonably well." We have a big study now looking at children, in which we will be interviewing-well, you are the PI.

Dr Fear: We are looking at 600 fathers from our military cohort, and we are interviewing them about their military experiences but also their relationships with their families and in particular with their children. We are asking how they feel that they relate to their children and how their children cope with them being in the military. We are also contacting their partners, or their wives, to get their views on how the father interacts with the family and with the children. For those children who are 11 or older, we are contacting them directly to ask them about what it is like having a father in the military and how they cope-what are the pluses and minuses of being a military child? That is work in progress.

Professor Wessely: We also have work published on home-coming experiences, and on rates of marital breakdown as a result of deployment. It is a big issue.

Q161 Chair: That is continuing work-you haven’t finished that research yet.

Professor Wessely: No, we have finished the early ones. We haven’t done the family ones, but we have done the impact on marital relationships.

Mrs Moon: I am sure Bob Stewart would love to volunteer for that.

Bob Stewart: I would feel like it was a report on me, and I think I would fail. I would be at the bottom level, according to you guys. Failed in all senses. Just imagine my children commenting on me-I’ve got six of them. They would say that I’m done for.

Chair: Moving rapidly on-

Professor Wessely: Let’s hope you are not in the sample, then.

Chair: The next topic is risk-taking behaviour and alcohol misuse.

Q162 Mrs Moon: Your research shows an increase in alcohol use in those returning from deployment. That is after a period of no alcohol use while in theatre. Sometimes, one of the early indicators of mental health problems is increased alcohol use as self-medication. Is that why there is an increased alcohol use? Is it being used as self-medication to deal with the trauma of engagement in theatre?

Professor Wessely: Nicola is our resident alcoholic, so she can answer this one.

Dr Fear: The report that we recently published showed that 13% of the armed forces are reporting levels of alcohol misuse compared with, as Simon has mentioned, between 3% and 4% with PTSD. Yes, there is perhaps some co-morbidity there-people with PTSD are misusing alcohol-but, obviously, not everybody who is misusing alcohol has got PTSD. We think there is some level of co-morbidity, but we do not believe that those 13% of people are harbouring mental health problems.

Q163 Chair: How does that compare with the population as a whole?

Dr Fear: Alcohol misuse within the military is substantially higher than we would expect with the general population. Obviously, the general population comprises people of all ages, and those who are occupationally inactive. If we take all those differences into account, the latest figure for the prevalence of alcohol misuse in the general population is 6%, compared with 13% in the military.

Professor Wessely: That applies equally to men and women.

Q164 Mr Hancock: Does it apply to individual services?

Professor Wessely: Yes. The Army and Navy are the worst; the RAF is slightly better, but they are all bad.

Q165 Mr Havard: And there is no difference between men and women?

Professor Wessely: Not much. The men drink more than the women, but the women drink far more than non-military women-quite substantially so.

Q166 Mrs Moon: Among those who are ultimately diagnosed with post-traumatic stress disorder, is there usually in their medical history a period of excessive use of alcohol? Is that something that is also common in their medical histories?

Professor Wessely: Yes.

Q167 Mrs Moon: So there is a link for those who go on to have post-traumatic stress disorder, but of the 13% only 3% generally go on to do so.

Professor Wessely: Yes. Certainly, we know that alcohol increases the risk of subsequent PTSD. That is a stronger relationship than the other way around-of PTSD increasing alcohol.

Q168 Mr Hancock: But isn’t that because it leads to other problems?

Professor Wessely: Yes; there is new work now suggesting that is actually the results of common vulnerabilities to both, and that they are not completely independent factors. It is not like heart disease and cancer, which are separate things. They are related. In terms of prediction, we know that pre-service vulnerabilities, such as time in care or having a poor family history and things like that, predict both alcohol and PTSD quite strongly.

Q169 Mrs Moon: You also talk about increased risk-taking behaviour and violence.

Professor Wessely: Yes.

Q170 Mrs Moon: Alcohol abuse is also associated with increased risk-taking behaviour and violence, especially domestic violence.

Professor Wessely: Yes.

Q171 Mrs Moon: Is the common factor again the alcohol misuse?

Professor Wessely: Alcohol is associated with both accidents and domestic violence. It is not that A causes B causes C. These things tend to congregate in the same people so they have a degree of vulnerability which leads to multiple things. It is the same with early service leavers, for example. They have a range of poor outcomes. It is not just one outcome-alcohol; they are also more likely to have unstable jobs, unstable relationships, be in trouble with the law, and have debt problems and mental health problems. Those are not visited on them singly. It is a range of social adversity problems that they experience. It is quite hard to separate out the impact of one over another.

Q172 Mrs Moon: Are you going back to look at pre-military engagement issues in terms of early life experiences and how that relates to their subsequent behaviour after theatre?

Professor Wessely: Yes. We know it does. We have published on that. Pre-service adversity is the single largest risk factor for post-service adversity, but not in a way-it is important to emphasise this-that would enable you to screen out those who are going to develop problems. So these are risk factors, but they are not sufficiently good for you to be able to say, "You can join the forces. But you can’t, because we know you are going to break down because you have come from a broken home. You have not, so you can." There we know that you would be wrong more often than you would be right, which is why we have published showing that pre-deployment screening for mental health problems is singularly unsuccessful and why the MOD don’t do that.

Q173 Mrs Moon: Is there any correlation at all with any of this and physical injury?

Professor Wessely: We can say immediately that physical injury increases the risk of psychiatric disorder. We have much more on that. We have a slight problem with that because we would rather tell you off record because it is with a major journal and they get very upset if we leak the findings. There is my friend from the News of the World behind us. We can tell you privately, but we can’t do so in open session. It is not because we have anything to hide; it is just that the journal will kill the paper and we’ll be in big-

Q174 Mrs Moon: When do you expect the paper to be published?

Professor Wessely: We don’t control that. I wish we did.

Q175 Mrs Moon: How long is a piece of string?

Professor Wessely: Yes.

Q176 Mr Hancock: A paper we were sent by the MOD in answer to some questions talks about trauma risk management-TRiM. It says that TRiM has been developed to identify, manage and minimise the effects these events have on service personnel. You said that it is useless. You said that trying to screen people in advance-

Chair: That is a different issue.

Q177 Mr Hancock: Where does this come into it then?

Professor Wessely: There are two separate things. First, there has been an idea for years that it would be great if you could spot people before they develop problems and then you wouldn’t put them in harm’s way.

There is a wonderful thing in Ben Shephard’s book on the Second World War, where he found a letter in the War Office from a commander writing back to London saying, "Please stop sending me these people. They are breaking down in the brothels of Cairo. God knows what will happen when they meet the Afrika Korps."

There has always been this idea that if you could just select better, then you wouldn’t get mental health problems. That is what we studied. We showed that although you can statistically predict the risk of breakdown-so that with a large group of people you can say that one group is twice as likely to break down as another-with an individual you would be wrong four times out of five. That is before they are deployed. They have not gone into harm’s way yet.

It is really not surprising that we have found that because one of the biggest things is what on earth happens to them in theatre-and that has not happened yet. TRiM is about something that has happened and then it is about how you manage things in the field. It is a very different thing. Something bad has happened. They have now made TRiM into a verb, so to TRiM is now a verb in the Army. Horrible, isn’t it? But they talk about TRiMing. We can’t control their use of language.

That is where the system is at its best, because it is not medicalising. It is using the people within the group and culture-not people like us or even mental health people-to spot who is having difficulties, and when they are really having difficulties to help them or say, "You really do need to see the MO." That is a very different thing, intended to do very different things. TRiM is very popular and is being rolled out across the armed forces.

We did the original study in the Royal Navy of the randomised controlled trial of TRiM. Unfortunately, that did not work very well because the Navy did not do anything that year, so there was not much trauma. It was a bit of a damp squib because not much happened. It has been rolled out and has very good face validity and is popular. People seem to like it as a process, whereas they did not like some of the things that had been done before, such as the post-trauma counselling.

Q178 Chair: Was the fact that you found it impossible to do the pre-screening partly because the level of mental health issues is lower than one might expect? If it is only 10% among the whole of that at-risk population, you will still be wrong nine times out of 10. Is that essentially it?

Professor Wessely: Yes. It is not the only thing, but you are right. The more common a disorder is, the easier it is to screen. The US does screening and says that it is because it has a lot more PTSD than we do. There is still no evidence that it works, but that is one thing. You are right: screening for an unusual disorder, where your instruments are not great and where you have a big overlap between normal emotional reactions, as we were talking about, and psychiatric disorder, is always going to be a sticky wicket.

So far we have said, first of all that we are doing the trial of post-deployment screening to see if it works. However, if, for example, there was a major deterioration in the mental health of the armed forces, we would revisit that. The area where they-not we-do the screening is in the physically ill with serious injuries, where the prevalence of psychiatric problems is much higher, and therefore the chances of the system being effective are much higher. That was quite a turgid answer, but nevertheless you are absolutely right.

Q179 Chair: Not at all.

Professor Wessely: It is very difficult to screen for unusual problems unless you have an incredibly good test, such as for cervical cancer. In psychiatry we do not have measures that good.

Q180 Chair: But you say you are doing a trial into post-deployment.

Professor Wessely: We are doing a trial into post-deployment screening as we speak.

Q181 Chair: How is that going? Or is that again subject to the News of the World?

Professor Wessely: We are just starting it; it will be two years before we have a result. That is funded by the US, because in the US it is policy to screen. Now in the US they are wondering whether it was a good policy, but of course once you make something policy you can’t study it. Because it is not policy in the UK, we are able to do a randomised trial.

Q182 Chair: Could you say that again?

Professor Wessely: If it is policy, everyone gets it, because it is policy. In the US, everyone gets screened. Therefore, you have no way of knowing if it is working. You have no idea; you just can’t tell.

Q183 Mrs Moon: No control group.

Professor Wessely: Yes. It could be making people worse; it could be making people better. You cannot say. It might look better because the war is finishing, or it might look worse. We do not know. In the UK, because it is not policy, we are doing a study and we can properly not screen half the people and screen the other half, and later see which group did better. We genuinely do not know whether it will be useless, good or bad.

Q184 Chair: Why would that be of much use to the US, if it has such different deployment policies?

Professor Wessely: It is just that they would like some evidence.

Mr Hancock: Maybe they should change their policy.

Q185 Chair: So they would get some evidence-not ideal evidence, but some.

Professor Wessely: It would give UK evidence. As the US does not have that evidence at all, it is funding it, and it does not do so out of charity.

Q186 Chair: What about mental health issues emerging in those who have left the armed forces altogether, as opposed to those who have recently deployed? Are you getting evidence of that causing mental health issues?

Professor Wessely: We are looking at that at the moment. In the latest follow-up study with the Royal British Legion, we had a lot more service leavers than we had before. I half said it earlier, but we know that it is not so much deployment, but the early service leavers group which seems to be over-represented in most of the outcomes. It is those who served for less than four years, and often leave for health reasons or whatever, who are clearly the most vulnerable. They seem to be the most likely to have poor outcomes across the board. In general, the longer you serve, the better you do.

Q187 Chair: Or is that a self-selecting sample?

Professor Wessely: Of course it is. Obviously, the longer you serve, the more robust you are and the more you integrate with the Army and the armed forces, the greater social support you have and the greater rewards you get. There is an interesting dilemma: the way things are set up at the moment is that the more you give, the more you get. As I am sure you know, those who serve 25 years get very generous resettlement and, as we have shown in our data, they rapidly walk into jobs and do very well. They get the most reward, whereas those who have not been in for very long get the least, but are the most needy. Having stated the dilemma, obviously that is nothing to do with us, but it is a policy issue. But that is the problem.

Chair: Yes, I can see that.

Q188 Mrs Moon: Can I clarify your comment about the early leavers? Is that Nav Patel’s work from Manchester to which you referred?

Professor Wessely: That is in it as well. He has looked specifically at suicide, and we are looking at deliberate self-harm. All of it triangulates-sorry, that is a horrible word; I hate it. All of it is compatible with what I have just said.

Q189 Mr Hancock: Just to follow on, the early leavers really do have a problem. One of the biggest problems is that most of them leave with a lot of debt because they have got into financial difficulty. A lot of service personnel who leave within two to four years leave with horrendous debts hanging round their necks. They cannot get jobs. What studies have you done to see what can be done better within the services to prevent young service personnel from getting into serious trouble, which inevitably lead to the other problems that you have talked about?

Professor Wessely: We are doing a report on debt for the Legion at the moment, but I do not think that we have looked at what interventions can be made.

Dr Fear: We are looking at resettlement, and people who have gone through the resettlement process. That obviously does not apply to early service leavers. They miss out on that, but we are looking at that as an intervention. We have no other plans on the way to look at what can be done for the early service leavers group.

Q190 Mr Hancock: For early leavers, debt is a bigger problem than alcohol or anything else.

Professor Wessely: They all go together, but you are right: debt is a huge problem.

Q191 Mr Hancock: Debt is the biggest problem. I see it all the time in my constituency.

Professor Wessely: It is important that we stick within the limits of our competence. If the armed forces started to do something on debt, we would be in an excellent position to evaluate it. But it is not for us to tell it what to do. It is its Army.

Q192 Mr Havard: Before I ask about what you do with the people who have been identified with the problem, can I just follow up on something? Andrew Murrison did a study with which you would be familiar. He recommended that people who leave-both reservists and regulars-are followed up after 12 months. That would be presumably in the context of their mental and other health issues, but you seem to suggest that there is a follow-up that is broader than that. Is any work being done about that?

Professor Wessely: Murrison has been implemented, and it will be interesting to see what impact it has. We are not implementing it, obviously.

Q193 Mr Havard: No, but do you do any work around it?

Professor Wessely: Well, it will come up naturally if we are in a position to continue the study that we are doing at the moment and look in another two or three years’ time at what has happened. Obviously we are a slightly interested party, so let us assume that we do. Yes, we would be able to see if it has made a difference or not. At the moment, we do not know. It is a difficult thing to implement. It is a lot easier to say than it is to do, based on our own experiences. Andrew knows very well that the problem is that the ones you most need and who need you are always, by definition, the ones who are an absolute sod to find. As for the ones you find really easily-why? Because they are married and have jobs. We could talk about that until the cows come home-it is always the problem.

Q194 Mr Havard: Is the Ministry effective in identifying those people who have mental health problems and difficulties because of operations? What are the barriers to doing that? What is your assessment of how good the process is?

Professor Wessely: We know a lot about this issue. The main, biggest barrier remains stigma. People do not come forward because they are worried about what their mates will think of them and the impact that it will have on their career. It is not that they do not know that services are available; we have shown that they do know, but they choose not to access them. The biggest single problem is reluctance to come forward because of stigma. The sad thing is that the people who have the problems are the ones who feel the most stigma. Those who are fine say, "It’s perfectly okay-it’s all totally acceptable. That doesn’t really matter." But the ones who have problems with depression, PTSD or drinking feel acutely that coming forward would end their careers. They think, "People would think that I was useless and I would be discriminated against." That is the biggest barrier.

Q195 Mr Havard: So it is not that the Department is not doing the right things to try and identify people, but that people are selecting for themselves not to use the services.

Professor Wessely: You cannot force people to have treatment-unless they go psychotic, but that is not the issue in the military. They must want to have treatments. You can do things to make services more attractive, and the military have done well by switching to community mental health teams and bringing in a much more modern version of mental health, which is good. You can put the mental health teams where the trouble is with field mental health teams, which we have shown to be very effective. They get good results and treat people quickly in theatre with no waiting list or anything like that. Not sending people home is a good policy and is a standard doctrine that teams try to follow as much as they can. They do pretty well on that and in theatre they do very well.

It is a difficult problem and the truth is that there is not an organisation on the planet that has solved the problem of stigma. I go back to what I said: it is a big problem for doctors, Members of Parliament-everyone. The military do well; they do not have waiting lists. As I say, we have shown that folks in the military know more about how to get treatment than those who are not in it. They are better informed now, but they still do not do it.

Q196 Mr Havard: You said that when people are identified it happens in theatre. We visited Headley Court recently and it was a similar experience, because people were still in work-they were in a job. Is that very important? The people there, even those with physical injuries and, maybe, associated mental health problems, were arguing that it was important that they were still part of the military-that they were in work and part of things.

Professor Wessely: The importance of that was established in 1917. People should be kept in uniform, as close as possible to their mates with an expectation that they will return to decent service-that has been the doctrine since 1917. No study that we have ever done suggests that that is the wrong way of doing things.

Q197 Mr Havard: So that is endorsed by your studies, essentially.

Professor Wessely: Absolutely, yes. It is sometimes more difficult to do than people think it is. There are issues, particularly around firearms and suicide risk, which are really difficult to deal with. There is no easy answer to that. But that is the policy, and certainly our evidence suggests that it is the right one.

Q198 Chair: Is that why there is such difficulty with reservists?

Professor Wessely: Not in theatre, no; but when they come back, yes. I go back to what we were saying. We have shown an association between PTSD and not feeling supported by the military. Reservists are more likely to feel that they have been left and that they and their families have not been supported in the way that regulars are. Having made that finding, it is hard to know what to do about it, because it is difficult. That is part of the picture-homecoming experiences, social support, military support and support to families are important for mental health in theatre and after it.

Q199 Mr Havard: I was going to ask you about the effectiveness of the treatment, and so on. You are saying that advising and preparing families is very important, so it is not just about the treatment of the individual. What are your observations about the preparedness, and the advice and support that families receive as part of the process?

Professor Wessely: There are two issues. We know that many of the mental health problems that present in theatre are a reflection of what is going on at home. We also know that where the person in theatre feels that the family is not being supported, their own mental health is worse, and they are more likely to develop traumatic stress symptoms. It is not just a matter of being kind to families; we would suggest, and the data suggest, that it is an operational requirement to have good support and welfare for families of reserves and regulars, because that will improve mental health in theatre.

Q200 Mr Havard: I saw a report yesterday from America, where schemes are being run out of Walter Reed for families of people who are returning to try to help them deal with these questions. There was a debate about whether such schemes could continue to be financed and be made universal across the whole United States. There was a discussion about their intrinsic value or otherwise. Do you think particular things should be done?

Professor Wessely: Again, I am not going to go down the route of telling them what to do. What I can say is that where families feel better supported, mental health in theatre and post-theatre improves. It is worth looking at whether we can improve the support.

Q201 Mr Havard: But this was a scheme to help the partners to understand the problem that they were going to confront specifically in relation to mental health.

Professor Wessely: That is a specific question, and you would need to do a trial on that; you would need to know whether it made a difference or not. You are asking a very specific question, and I do not know the answer to it. I know that they are doing that, but they are doing lots of things, and one hopes they are evaluating them to see whether they made a difference or not. What we can say is that this is an important issue, which the MOD should be looking at.

Q202 Mr Havard: We visited Walter Reed recently. The US does brain scans, because they see a relationship with head injuries of various sorts, such as mild traumatic brain injury; they argue there is a causal relationship. You seem somewhat sceptical about that. Could you say what you feel about that? Is it useful to do such things?

Professor Wessely: All I can say is what we find. Let us put to one side traumatic brain injury-people with major head injuries. We are looking at something called mild traumatic brain injury, which we call concussion, because that is what it is. The rate of concussion in the UK, if we use exactly the same methodology and criteria as the US-the US is running at 20% to 24% in all the studies they do-is running at about 2% to 4%. Either we have thicker skulls, which seems unlikely, or there is some cultural difference here, and we would suggest it is possibly the latter. We get concussion, but although we are fighting the same war and taking the same risks, and although we have the same casualties now and face the same IEDs and all that, it seems to be a smaller problem for us. It is there-I am not saying it isn’t-but it seems to be a much more major issue in the US.

Q203 Mr Havard: Yes, it’s playing football with their helmets on-they shouldn’t. Anyway, that is a different argument. Can you tell us what you think about the general process of the treatment? Is it effective? Are there barriers? If so, what are they?

Professor Wessely: I have said what the main barrier is: it is getting people into treatment-that is the biggest barrier. The data we have from the field mental health teams suggest that treatment is effective. As for the data from secondary care, by that time, it is a harder problem, and the outcomes are not so good, at least not until two years ago.

Q204 Mr Havard: And there are no problems with relationships with the NHS?

Professor Wessely: Yes, there are some.

Q205 Mr Havard: And is it a devolved format?

Professor Wessely: That is too complicated. [Laughter.] No, genuinely, we have not looked at that.

Q206 Mr Havard: That is beyond your pay grade.

Professor Wessely: We could look at it. We did try to in Scotland and Wales, but we did not get very far.

Dr Fear: We did not get very far with that.

Professor Wessely: We tried with the Cardiff unit and Johnny Bisson, but I cannot remember what the problem was.

Q207 Mr Havard: I think there is a real issue here about a uniformity of approach from a central Department, such as the MOD, and the delivery agencies, which are becoming much more differentiated. We have to deal with that relationship, even you cannot particularly help us with it today.

Professor Wessely: We should have my wife here. She is the chairman of the College of GPs. When she starts talking-

Chair: I am going to move on. Madeleine Moon.

Q208 Mrs Moon: There are two separate things. I visited the specialist unit that has been developed to look at post-traumatic stress disorder. I asked about medical notes being passed between the military and health service providers and about the compatibility of their systems, because they cannot read across. That is a major issue in the States. Is that a major issue in the UK as well, that is impacting on people being able to get acknowledgement of their service in the military, and acknowledgement and awareness of the injuries that they may have received in the military, and just a read-across?

Professor Wessely: Yes, it is an issue, still. It is a very well known issue. I think it is proving quite hard to deal with technically, both within and without the military; and without going into the saga of electronic patient records, they are certainly not proving as effective as we would like them to. I think you would have to ask the Surgeon General specifically what progress they are making. I know they are acutely aware of it, and we know it is a problem.

Q209 Mrs Moon: I understand that the MOD is looking at eye movement desensitisation and reprocessing as one of the major therapies that it wants to use. How widely available is that going to be for people who have left the military? It may well be generally available within the military, but given that a lot of people who are getting post-traumatic stress disorder get it post-service, how widely available is that going to be?

Professor Wessely: Evidence-based psychological treatments are not widely available, whether you are ex-forces or not ex-forces. The big issue there is whether or not improving access to psychological therapies will pick those up. We will just have to see. That is what it is supposed to do. At the moment it remains the case, and our study shows, that even with those who have left the services, the majority of those who have mental health problems are not getting good treatment.

Q210 Mrs Moon: This is a fairly new therapy.

Professor Wessely: It is a fairly new study as well; but to be fair IAPT is still being rolled out and developed. In five years’ time we will have a much better handle on whether or not that has done what it is supposed to do. It is supposed to pick up these kinds of problems. I think it will always be a bit difficult, because I think ex-service populations are difficult. They are not that great at psychologisation; they have a lot of comorbidity-particularly the ones in trouble. I do not think that that alone will solve this problem and I think that a lot of people will need quite complex care over a long period of time. I do not think it will be a quick fix.

Q211 Mrs Moon: Is there a risk that, if you like, the diagnosis of choice will be post-traumatic stress disorder, rather than, say, bipolar disorder or some other mental health diagnosis-as an easier diagnosis to live with, as being something that is a result of service?

Professor Wessely: Well, it is a risk. One would hope that any decent service appreciates the necessity to make the appropriate diagnosis. I do not see any evidence that IAPT would not do that. I am much more worried about the growth in the voluntary sector beyond the good brands. There is a huge number of organisations springing up, who contact us on a regular basis, where I have more reservations about issues of clinical governance, diagnostic practice, outcomes, audit and all those kinds of things. I do not think the problem is going to lie with NHS services or RBL, Combat Stress or the big brands like them; but I think there is an issue with some of the other things that are happening.

Q212 Chair: We are just about to come back to the comparisons with the United States, with Mike Hancock. I should like to open by saying I am astonished by the difference that you report in relation to concussion-24% in the United States and 2% to 4% here. Are you using the same tests?

Professor Wessely: Yes.

Dr Fear: Yes.

Professor Wessely: We said that together, so we must be.

Q213 Mr Havard: Is it something to do with an equipment difference? Is it a different deployment process?

Chair: How can you extract this?

Professor Wessely: It is a diagnosis that they are making in a lot of people. The symptoms are very common. The symptoms of this are fatigue, headache, feeling dizzy. These are very common symptoms that a lot of people have, and a lot of the armed forces have. In the UK the tendency is not to attribute it to head injury, and the US now there is a tendency to attribute it to head injury. Remember, neither of us have got good data on actual exposure in theatre, so the diagnosis is made retrospectively when people come home. "Do you have these symptoms?" "Yes." "Were you exposed to blast?" "Yes, I was." A lot of people, both here and in the States, therefore think that a lot of misdiagnosis is going on.

Q214 Mrs Moon: It might be helpful if I say that when we went to the specialist unit they said that it was virtually impossible to have served in theatre without having a mild traumatic brain injury.

Professor Wessely: That is exactly my point, isn’t it? Exposure is very common.

Now we are getting to difficult territory, but there are two things. First, we don’t like the term "traumatic brain injury", because it is a scary term. I have been concussed and I bet you have. My kid certainly has playing sport. When you get a call from the school saying that your kid has concussion, you don’t call in a helicopter and everything. You pick him up at the end of the day. But if you had heard that he has a traumatic brain injury, you probably would. The name is a misnomer and it was a mistake. A lot of the US think that, too. We have stuck with "concussion", which is less scary. We know that the label has an important effect on outcome. It is not a neutral thing, and we know that it impacts on outcome.

Q215 Mr Hancock: It probably leads to other things, because the person feels that they have something that is probably serious.

Professor Wessely: You are absolutely right.

Q216 Mr Hancock: Before I ask a question about the comparison, I want to go back to your point about the importance of people who have injuries remaining in the service. With the services being reduced, the capacity for the armed forces to hold on to people will be dramatically reduced. I remember asking this question of the then Chief of the Defence Staff two years ago, and he said that the armed forces were already coming close to the point at which they simply could not allow the situation to go on. What is the advice that you are giving them?

Professor Wessely: We are not going to give advice on that. They know the issue. It is not that they are stupid and don’t know the issue; they do know the issue.

Mr Hancock: They are doing well, really.

Professor Wessely: What will happen is that more people with mental health problems will be discharged who might have done better in service than out of service. There is a much bigger picture there than for us.

Q217 Mr Hancock: They will probably realise that the stigma attached to that will travel out of the services with them.

Professor Wessely: Possibly.

Q218 Mr Hancock: Can we go back to the differences between the mental health outcomes here compared with the United States?

Professor Wessely: That’s a tricky one, isn’t it? At first sight, the US has more PTSD than we do. Well, not at first sight, but they have more PTSD than we do. There are various reasons for that, some of which are rather obvious. For the first few years, 2003 to 2005, they had higher rates of combat exposure. That has not been the case since 2005-06, but it certainly accounts for some of the original differences. Their force structures are different. They have three times as many reservists. Given that reservists on both sides of the Atlantic are a little more vulnerable, the more reservists you have, the greater the impact on overall PTSD will be.

We have talked about age, too. The Americans are younger than the UK forces, which is an important issue. Then you have tour length, which is a very big issue. It is impossible to study, because we have one tour length and they have another, but most people think that that has a big impact.

Then you have the other issue, which is really difficult. The American rates are going up. When you come back from theatre you have a certain rate, then six months or 12 months later it has increased, often dramatically. Our rates are not doing that. They have gone up by maybe 1% over some years. What is the reason for that? Well, it is very hard to say. We find it difficult to think that it is going to be about what happened in Iraq and Afghanistan, because things are very similar there.

Q219 Mr Hancock: Is their ability to hold on to people after they have come back and been diagnosed with a psychological disorder greater than ours? Or is it the fact that they are very well compensated if they leave the service with a medical condition?

Professor Wessely: I do not know the answer to that. We are trying very hard to co-operate with Walter Reed in particular, because if we were to share data sets some of the answers might become clearer. At the moment we do not know. I do not know the answer to your question on retention.

Q220 Mr Hancock: We have just had 6,000 American service personnel in my city, and I talked to some of them. Some pilots who had been flying in the Navy were saying that if you left the service early with a medical disability, your compensation package was quite considerable. The guy in charge of the air wing on the carrier said that a number of his pilots were leaving, but what they did not imagine was the difficulty of getting civilian jobs when going out with this medical complaint that they had claimed. But it was the financial package that led many of them to seek medical advice, so they could get out of the service with a greatly increased package.

Professor Wessely: I am aware of that. I do not know whether that is the explanation. We know there are differences between the US and the UK in how you can access health care after you have left the services. We can speculate that that is an issue. We think it might be, but it is difficult to prove. It would be great to randomly allocate people to serving in the British or American armed forces. That would be a wonderful study. Again, that is unlikely to go through. We wonder whether those are issues, and we wonder if access to health care, particularly after two or five years, is impacting on this, and that is a very big issue for an American service family.

Q221 Mrs Moon: At the unit that I visited, the focus was on treating and working with the whole family. They brought the whole family to the unit for two weeks of intensive therapy. They set about writing a care plan, which was then sent back to the unit, and the person would be discharged to the unit only if the unit could carry out that care plan. Are we working on a whole family treatment plan, or are we working exclusively with the serving personnel?

Professor Wessely: I think you have to ask the uniformed services that. I am not aware of that. In general, they are aware of family issues, but I do not think there is a set-up like you have just mentioned. This was the US you were talking about?

Mrs Moon: Yes.

Professor Wessely: You would have to ask them, but I do not think so.

Q222 Mr Havard: That is partly why I asked you the question earlier about preparing, advising and enabling the family to deal with the problem. On the situation in the US, I saw a report last night. It seems 86,000 military people have come back with PTSD. But then the military chiefs seem to be saying, "That could be an underestimation. There could be 800,000." That was the figure on CBS last night. This seems to me much more to do with the socialised medicine process that they have if you have been in the military than anything else. What are the comparators? Is any of this stuff that we are seeing in America of general relevance to us in making policy decisions?

Professor Wessely: You are asking us to go a bit beyond our competence. I think it is a mistake to assume that what happens in America will inevitably happen here. I know some people say that. We should not necessarily use the Americans as an example of what we should be doing. They have unbelievable strengths, as anyone who has been out there and met them knows-their medical care, support for the forces, support for families. There is a huge amount that we can learn-I wish we did-and I wish we had one tenth of their research dollars. But that does not mean that everything is working over there. Our circumstances are different.

Q223 Mr Havard: Is it not the case that they are looking in the totality, including their veteran community? What you are studying are the people in active service.

Professor Wessely: We study the veteran community as well. We have no equivalent of veterans administration, but we do not need an equivalent. They need a veterans administration because these are people who would otherwise not get health care. They really would not get it, because they come from a stratum of society that does not get it. We do not have that system, so we need to interpret carefully what the US are finding, and we should not assume it will happen over here.

Q224 Mr Hancock: The military covenant is supposed to give that through life care, not just to the armed forces personnel but to the family. That is part of the commitment. We heard evidence from the three services’ welfare organisations; three ladies came and presented their case. They actually answered Madeleine’s question about whether there was a continuity of care to the family as well as to the service personnel, and they said that the plans were being developed so that the family was involved. They were involved as well, particularly with soldiers who were not coming back to the UK. In Germany, in particular, where it started off, there was a great deal of the sort of support that Madeleine was talking about.

Professor Wessely: That is in-service.

Mr Hancock: Yes.

Professor Wessely: I thought we were talking about ex-service now. Of course a huge amount goes on for families; we have said that. That is why we have highlighted the problem of reservists, where there is a difference and less is done, and of veterans. Much of the support networks that you described do not extend so much to veterans-at least not to the ones in trouble, funnily enough. The ones who are well have tremendous networks, as I am sure you know.

Q225 Mrs Moon: Carrying on with the issue of a veterans agency ethos, the Sheffield university study looked at people with mental health problems who have served in the military. Six pilots have been running. The study that looked at that said that one of the priorities that people said they were looking for in turning to the health service was people who had military background and an understanding of military service. They said that they felt more at ease discussing the problems that they were experiencing and more able to be honest and open about them if they were talking to people who had also served. Have you found the same sort of desire? Is that productive in helping to achieve a positive outcome?

Professor Wessely: We don’t know whether it will achieve a positive outcome. We know that a lot of people would prefer that, and we certainly know that a lot has to be said for assessment to be done by people who are militarily informed. I do not think that you can insist that they are ex-service personnel, because there just will not be enough, particularly in mental health, but it is clearly very important that they are informed. However, we should not forget that there are other service personnel who do not want you to know that they have been in the forces, and that is also their right. I am slightly nervous about policies such as all notes should be flagged that you have been in the forces, because quite a lot of people do not want you to know. You hear about the ones who do want you to know, but you do not hear about the ones who do not. Assessment, in particular, by military-sensitive people who basically understand the language and also like them is very important. I do not think you need to be treated by people who have been in the forces, but I think for assessments, yes, that’s a good idea.

Q226 Bob Stewart: When we look at the United States and the United Kingdom, I seem to recall that a long time ago, I looked at a study of resistance to interrogation in the Korean War, which you probably read when you were a student. It came out that Turkish prisoners of war did not give in. British prisoners of war did a bit, but Americans did most of all. I cannot remember the percentages. Do you think that there is an element of-I am not sure that this is politically correct to say-greater mental resilience in the UK than the US, or even Turkey? Is there anything from a societal point of view, from where they have been brought up and that sort of thing?

Professor Wessely: No. I don’t.

Bob Stewart: I’ll take that as a no.

Professor Wessely: I like to tease Americans by saying that it is about the essential superiority of the British character. It is great fun.

Bob Stewart: I did not mean that.

Professor Wessely: To be serious, when you meet the Americans, they are exactly the same. I think it has to do with the different systems, particular of health care. People will behave differently in different circumstances. Do I think that they are fundamentally more or less resilient than UK forces? I don’t at all, and there is no evidence that they are. I just mentioned reserves and combat exposure. When you equalise those, the rates and the differences between our nations become much smaller. I think that nearly all of it is explained, first of all, by rather boring demographic things, and secondly, by the impact of different health-care systems. Do I think that we are fundamentally more resilient? No, I don’t.

Q227 Bob Stewart: How much does the branch of service and leadership within that branch have an impact?

Professor Wessely: Of course it does. The US did the original study showing the importance of good and poor leadership, and we replicated those studies. Where there is poor leadership in both militaries, we have worse mental health, and where there is good leadership, you have better mental health. The same factors that impact on US units impact on ours. If you compared a poorly led US unit with a well-led British unit, you would conclude that we were much tougher. If you did it the other way round, you would conclude the opposite.

Q228 Bob Stewart: My own observation, in command, was that those people who tended to have problems, such as PTSD, which we did not recognise at the time, were those people who were in isolation-drivers of trucks in convoys-much more than the basic section in the front line that really went through it, with serious casualties and horrific things to do. Those people tended not to have PTSD as much as the guys who were on their own or isolated.

Professor Wessely: I am completely with you on that one. First, what we, and others, have shown is that the particular jobs you are mentioning are those where you have very little control over what is happening to you. It is like bomber pilots in the Second World War, where you have a much greater sense of danger and there is nothing that you can do to mitigate it, even if it is an illusory mitigation.

The second point is that we and others have shown that the issue is not the really bad things that happen, because we are dealing with professional soldiers; we are not dealing with a conscript Army. For most of them, that’s the job. It is errors of omission and commission: either when the side lets them down, which is why friendly fire is so psychologically damaging-it is one thing being shot by the Taliban; being shot by your own side is completely psychologically different-or when you let the side down and you feel, rightly or wrongly, that you did not behave as you should have done.

Those are the issues that differentiate everyone who gets the various emotions that we have talked about, which are normal, from the smaller number who get a psychiatric disorder. It is errors of omission and commission. It is misleading to think that it is merely seeing bad things-no, people are pretty tough and resilient in both militaries about that. It is where the rules were violated or you did not behave as you think, in retrospect, you should have done.

Chair: Moving on now to the final area of questioning-further research.

Q229 Mr Havard: This is where you can make your pitch, and rightly so. What are the most pressing parts of real research, because research gives us some precision, but there is still a lot of supposition in a number of these questions? Despite what you have done already, which you have outlined, what are the most pressing questions that should be being researched, and can you do them in the same way?

Professor Wessely: The biggest issue for us is that it is still early days. The war is continuing, and we don’t know what is going to happen. A lot of the concern is for what will happen to people at five, 10 or even 15 years, and we don’t know. Will we see a change in the patterns? We don’t know. Will some of the assumptions that we have made continue? We don’t know. Will there be an impact of some of the good things that are going on? Will they actually make a difference? We don’t know.

Obviously, we are interested parties here-I am sure you will have taken that-but I think that it is really important to get evidence on the effectiveness of interventions and to follow trends. People talk about a time bomb or a tidal wave. We have not seen that yet, but is that because it is far too early? I cannot tell you the answer to that. It is important to continue to collect good, accurate data on the impact of Iraq, Afghanistan and current operations. Having done so since 2003 has made a substantial difference in a lot of areas. We would not have had the Reserves mental health programmes if we had not shown increased vulnerability. We would not have all the various other things that have gone on, nor would we know the real balance of problems, like the importance of alcohol, so that is important.

It is also important to know the effectiveness of interventions; this would not be us. We are assuming that the kind of treatments that work in the NHS, and in NICE, good randomised controlled trials done by my colleagues at the Maudsley, are appropriate in the armed forces, and we do not actually know that. We are assuming EMDR is appropriate, because it works in civilian settings. We do not know if it works in military settings, and it is important that we look on the ground to see whether these treatments are working. We are making an assumption.

Q230 Mr Havard: I was just about to ask you that. Earlier on, you said that there is a number of groups and organisations coming forward with their own style of interventions and processes, which are very different one from another. We are trying to evaluate which ones we should look at and see how they compare and so on. There are agreed methodologies in the college or wherever it is, but then there are other things. You seemed to suggest earlier that you had some sort of role in helping the MOD to decide that. Was that the case, or was that some role you fulfilled with the Royal College of Psychiatrists, or what? What is the mumbo jumbo and what is the useful stuff?

Professor Wessely: This is just a general duty on professionals. I am a boring psychiatric academic. I believe in evidence, I believe in randomised controlled trials, and I believe in NICE guidelines. I think that that is the way forward. People should know what is effective. We cannot stop people having non-effective treatments-of course we can’t. They should at least know. I worry that at the moment people are getting treatments where there is no evidence that they work, and they do not know that.

Q231 Mr Havard: So what should be the process of validation?

Professor Wessely: Please God, we are not advocating greater regulation. In the talking therapies market it is like trying to regulate water. It cannot be done. Information can be regulated, however. People need to know, when they are using treatments, that there is long-term evidence of effectiveness, good governance, good outcomes, good audit and good clinical practice. They need to know that, and they need to know where there isn’t that.

Q232 Mr Havard: You are saying that this is an important area that the MOD needs to turn its attention to, as much as anyone else, to decide what is effective.

Professor Wessely: That is slightly harsh.

Q233 Mr Havard: I’m putting words in your mouth-sorry.

Professor Wessely: The MOD can and does regulate within service. It is very good at that, actually. Most of its practitioners have been well trained and the treatments that they offer are validated. They do not do non-validated treatments. It is not a problem in service. It is for those who have left.

Q234 Mr Havard: And the funding of this necessary research for the Ministry of Defence.

Professor Wessely: I repeat: I do not think that it should come from the MOD, because that would be unfair. I happen to think that the duty is on those who offer treatments to have shown that they are effective. They always say, "Oh, we can’t do that", but we do it, so they can do it. It is hard, but you can do it. That is me speaking personally.

Q235 Mr Havard: So this is a responsibility for the National Health Service.

Professor Wessely: No. It is a responsibility for people offering treatments. If they are not well accepted or well validated already, they have a duty to show that those treatments are safe and effective.

Q236 Mr Hancock: Just one question. I am interested as to whether this is a question that you ask, or will consider asking. Do you ever ask returning soldiers whether they feel what they have done was fulfilling and rewarding for them? Soldiers who gave an awful lot in Iraq maybe feel disillusioned that their efforts were not rewarded by the outcome. How important is that for the future of the work that you will have to do to help soldiers?

Dr Fear: We have asked, in our latest survey, whether the people who went to Iraq and Afghanistan felt that the mission was beneficial to the citizens in either Iraq or Afghanistan and how they feel that the British public have viewed their role in that mission. We ask whether they feel that the public have been supportive. We also ask them about the attitudes of the public towards them since they have been home. We have not looked at the data yet, but, as Simon mentioned at the beginning of this session, we have recently had some money from the ESRC to look at public attitudes towards the military.

We are also going to ask the general population what their views are on the mission, on the success of the mission and on service personnel who have served on those missions. We will then be able to compare the data to look at how the soldiers’ attitudes and the population’s attitudes compare. Obviously, from the soldiers’ perspective, we can look at how that impacts on their readjustment into life back in the UK and at subsequent mental health problems.

Q237 Mr Hancock: I think the public perception would be that the military are top of the tree, if you asked people for their views. I am interested in the young soldier who saw friends die and who comes back. What end result and effect does that have on him?

Professor Wessely: We are interested in that as well. We ask those questions. I am afraid that time alone will tell what the impact of that issue is. If you are asking whether we have asked those questions, yes we have. Most actually still see it in very professional ways, and they feel that, okay, things may have gone to hell in handcart, but they did well. That seems to be very important. Again, it comes back to whether they behaved professionally.

Q238 Mrs Moon: Two things. One is that I have found this session extremely interesting and very informative, so thank you. I just wonder whether we could set up a system where a copy of your research is automatically sent to the Clerk when it is published, so that we are kept abreast of your research and findings, and also whether we could perhaps ask for a private conversation between yourself and one of our Clerks in relation to the issue of physical injury, so that we could know those findings on a confidential basis.

Professor Wessely: On the second one, yes, that is fine. On the first one, we give our research first of all-

Q239 Mrs Moon: When it is in the public domain.

Professor Wessely: Of course. That is absolutely fine. I am sure that we can do that.

Q240 Chair: Final question. We have to produce a report at some stage. Do you have any suggestions for recommendations that we might like to make to the Ministry of Defence?

Professor Wessely: No.

Q241 Mr Havard: That is going to be part of our confidential discussion, is it?

Professor Wessely: To be honest, we are very conscious about the limits of what we do. It is not for us to tell them how to run the armed forces. We produce evidence and then some they incorporate and some they do not. As I have said, it has been very satisfying, because they do listen to what we say. They do not always act in the way that we might think that they should act, but they often have reasons that are well beyond the areas that we are considering, so we do not tell them what to do.

Q242 Mr Havard: That is fair. You are part of their evidential base for making decisions.

Professor Wessely: Absolutely. We would be upset if they did not read what we did.

Q243 Mr Havard: I respect that. Could I ask you a slightly different question? Are there things that we should have asked you about that we have been neglectful in asking you about, which would help us in making the decisions?

Professor Wessely: No. I think you have covered the waterfront pretty well, to be honest.

Dr Fear: No.

Professor Wessely: One area that really intrigues us is communication between families and serving personnel. That is an issue where we have had a glib assumption that more is always better, which is something that I am wondering about. We see in our studies that the impact of bad news from home can be quite profound, and now it is so unregulated and so fast that I do not know whether people are considering that.

Q244 Bob Stewart: A telephone call that goes wrong between a wife and a husband can be pretty dangerous.

Professor Wessely: Nothing is private out there, and you can hear conversations with people almost trying to sort out the washing machine and so on. We know that too little communication has a terrible effect on morale, but should we wonder whether you can have too much as well? That is an area that we have to explore.

Q245 Mr Havard: I visited one of the submarines recently, along with others. Their view of how they have to deal with communications, which bits of it are useful to them and whether delays and so on are detrimental, is interesting. They have a particular view-they are in a very different position from someone on the ground in Helmand, but there are some comparative groups that you might be able to study in relation to that, are there not?

Professor Wessely: Yes. It is possible. There is an area of debate to be had, so this can be thought about in a little more depth. What is the right level of communication? Certainly, the biggest impact on mental health in theatre is not what is going on in theatre; it is events at home. We are very clear about that.

Chair: Thank you very much for that fascinating evidence.

Prepared 16th June 2011