2 Mental health of Armed Forces personnel
Background
7. In our previous inquiry into military casualties,
we found that the MoD did not have a complete understanding of
the mental health needs of serving personnel or veterans. We recommended
that the MoD identify the extent of mental health problems in
the Armed Forces, including post-traumatic stress disorder (PTSD)
and alcohol misuse. We were also concerned about the higher incidence
of mental health problems in reservists who had been deployed.
We concluded that mental health was an area we needed to follow
up with the Armed Forces and the MoD.[7]
8. In general, the mental health of the Armed Forces
is good, and it is important that the public and Parliament recognise
this fact. But, Service personnel remain particularly at risk
from certain conditions. Professor Simon Wessely, Director of
the King's Centre for Military Health Research told us:
[...] in general, the mental health of the armed
forces remains remarkably robust, all things considered in terms
of what has been going on in the last 10 years and the nature
of the post. It is important that the general public get that
fact. This is not a crisis that we are facing, a catastrophic
failure in morale or a tidal wave of problems. But […] we
know that there are particular groups who are particularly at
risk, and particular problems that are perhaps more prevalent
in the armed forces than in the rest of the population. Plus,
of course, being in the armed forces does not make you immune
from the same problems that afflict all of us.[8]
Incidence of mental health problems
9. The MoD has commissioned extensive research from
the King's Centre for Military Health Research into the impact
of deployment on the mental health of Armed Forces personnel.
The Centre has conducted two large cohort studies of some 10,000
personnel deployed to Iraq or Afghanistan and those not deployed.
The studies were reported in 2006 and 2009.[9]
The Centre has since been commissioned to undertake a further
cohort study following up these individuals, with the inclusion
of additional Armed Forces personnel to increase the sample size.
In addition to written questionnaires, this study will involve
interviewing and collecting more detailed clinical information
from a subset of the sample, 1,500 to 1,800 Armed Forces personnel.[10]
10. Professor Wessely and Professor Nicola Fear,
Director of KCMHR, told us that the cohort studies indicated a
level of common mental disorder amongst Armed Forces personnel
of some 20 per cent including 11 per cent suffering from depression
and some three to four per cent experiencing post-traumatic stress
disorder (PTSD), both in line with rates in the general population.[11]
However, personnel deployed in combat roles, reservists and individuals
whose cumulative length of deployment was 13 or more months in
any three year period exhibited higher rates of PTSD at six to
seven per cent.[12]
11. The majority of personnel who reported symptoms
of PTSD in the KCMHR studies had not asked for medical treatment
on return from conflict zones. The KCMHR is currently undertaking
research for the US Government as to the value of post-deployment
screening. Professor Wessely described it thus;
We previously showed that screening for mental
health problems before people deploy was ineffective. It basically
doesn't work. It is much more interesting to see whether screening
people when they come back, when they may have developed mental
health problems—as opposed to predicting—has more
utility. We are in the middle of the first ever such trial in
the world, doing post-deployment mental health screening of more
than 10,000 people, and that is ongoing. The results of that will
definitely have an impact on policy one way or the other.[13]
Stigma
12. We asked Professor Wessely about the problems
of stigma associated with Armed Forces personnel seeking help
for mental health problems. He said that stigma was a problem
in the general population as well as in the Armed Forces but that
the level had been reducing in the Armed Forces.[14]
Indeed, he argued that more people in the Armed Forces sought
help than in the general population—he estimated that 40
per cent of those who needed help in the Armed Forces had asked
for it compared to an estimated 25 per cent in the civilian population.[15]
He noted that the degree of stigma was dependent largely on circumstances,
explaining that the stigma associated with seeking help when in
theatre was much greater than when at home:
It is as though when people are on deployment,
they really are very task-orientated, they want to know they can
rely on their mates, so it is not the right time to be emoting
and talking about your personal problems. Then, when they come
back, it drops quite dramatically and it is a good time for talking
about these things. So it is important not to see it as an innate
quality that people have. In the military context, there are times
when you can understand that and you can see why it might be so,
so I think we have to have a more nuanced view of stigma.[16]
Treatment of regular Armed Forces
personnel
13. Armed Forces personnel can access Defence Medical
Services (DMS) mental health care support through their local
medical centre which can refer them to one of the 16 UK Defence
Community Mental Health teams (DCMH) or one of the five overseas
departments.[17] If required,
inpatient care has been provided under contract by South Staffordshire
and Shropshire Healthcare NHS Foundation Trust since 2009.[18]
Mental health support is available on operations from field mental
health teams.
14. In 2008, the Armed Forces introduced a non-medical
response to traumatic events, starting with the Royal Marines,
called Trauma Risk Management (TRiM). TRiM is now the responsibility
of the single Services and is delivered by trained peers not mental
health professionals. The MoD told us that TRiM was judged by
commanders to contribute to operational effectiveness as it ensured
a timely and front line response to the needs of Service personnel
exposed to traumatic events.[19]
In addition, since 2009 all Armed Forces personnel undergo a mandatory
period of decompression on return from operations. Decompression
provides time for personnel to readjust before returning to family
life in the UK.[20]
INCREASED NUMBER OF PERSONNEL SEEKING
MENTAL HEALTH SUPPORT
15. The number of military personnel being treated
for mental health problems has increased as has the rate of patients
diagnosed with a mental disorder. Between 200708 and 2012-13,
the number of new cases requiring care from Defence Community
Mental Healthcare (DCMH) increased by a third (5,000 to 6,700)
and the number of patients diagnosed with a mental disorder rose
from 3,500 to 5,100 (45 per cent increase). The number of consultations
conducted by the DCMH rose despite the reduction in the size of
the Armed Forces over this period.[21]
These figures do not include those personnel being treated by
their GP. The MoD told us that the complexity and seriousness
of the cases being treated had also increased as illustrated by
the increase in the number of appointments per patient and the
rise in the number of personnel medically discharged from the
Armed Forces with a diagnosis of PTSD.[22]
16. The MoD told us that the increase in those seeking
help might be partially due to the success of anti-stigma campaigns
and TRiM, although it could also indicate an absolute increase
in levels of mental illness.[23]
The increase could also be due to personnel presenting earlier
with mental health problems than in the past. Professor Wessely
said that there had been a big drop in the length of time before
personnel sought help and that this might be a good thing. He
further said:
[...] there is no doubt that within the Defence
Medical Services and the charity sector, people are presenting
earlier than they used to. Combat Stress, for example, used to
say that it was 12 to 14 years before people would present. Now
that is certainly not the case. Now we know it may be up to two
years, so there has been a big drop in the length of time it takes
before people will either come and get help or, as happens more
often, be told to get help by their spouse or whatever.
[…] It might be a mark of the fact that
some of the stigma campaigns and the outreach programmes are having
an effect. We will have to see, and the longitudinal study that
we are doing will help to separate out these various themes, but
we should not leap to the conclusion that because the defence
services are seeing more cases, something has gone wrong in theatre.
It might well be that this is something we should be pleased about.[24]
17. Following the 2005 Strategic Defence and Security
Review, the MoD increased the number of personnel providing mental
health support by 25 including an additional 13 psychologist posts.
The total number of defence mental healthcare staff across UK
and overseas is approximately 250,[25]
and the MoD is currently looking at recruiting additional mental
health professionals and developing pilot schemes to exchange
staff with the NHS to transfer skills.[26]
18. We welcome the introduction of the Trauma
Risk Management system and the MoD's work in reducing the stigma
attached to seeking help for mental health problems. We also welcome
the fact that personnel are seeking help for mental health problems
earlier than in the past. The Armed Forces have seen a significant
increase in the number of personnel requiring treatment by the
Defence Community Mental Healthcare Teams without a proportional
increase in the number of staff. Given evidence that Service personnel
are coming for mental health support sooner than in the past and
while they are still serving, pressure on existing resources will
only increase. In response to this Report, the MoD should inform
us of its plans to deal with the increased volume of work and
tell us how quickly it can ramp up its support for personnel in
the event of any further acceleration in the number of personnel
coming forward for help.
Reservists
Higher numbers of reservists
report mental health problems
19. Reservists experience higher levels of reported
mental health problems than regulars, experiencing double the
rate of PTSD post-deployment compared to regulars in all roles
and continuing to show higher rates five years after deployment.
When asked about the higher incidence of mental health problems,
Surgeon Captain Sharpley said that although reservists had a higher
rate of PTSD, they had a lower risk of alcohol misuse and, therefore,
the totality of the mental health problems of reservists were
broadly equivalent to those of regular personnel.[27]
Rear Admiral Williams told us that the culture of the command
chain needed to change to be more effective at dealing with mental
health problems, in particular to encourage personnel to seek
support. He also said that this change had to be extended to ensure
that those who work with the Reserve Forces were aware of the
problems faced by reservists on their return from deployment.[28]
20. Air Vice Marshal Murray of SSAFA said that reservists
were often isolated on return from deployment:
Young soldiers understand where to get help from;
Reservists—this goes back to the isolation point—don't
really understand, and nor do their families. They don't really
know how to hook into and how to get support from the Army, the
Air Force and the Navy, which is there if they need it, but it
is about getting into it. They are also pretty independent people
running pretty independent lives, which is a strength. But when
things go wrong, they can go horribly wrong and they are on their
own.[29]
21. In its cohort study, the KCMHR asked reservists
how they dealt with reintegration back into civilian life. Professor
Fear said that the cohort study looked at:
reintegration back into civilian life—how
they coped with socialising with their civilian friends and their
families, but also with reintegrating back into their civilian
employment. We found that those Reservists who struggled—who
had problems readjusting—were more likely to report mental
health problems across the board, particularly PTSD and common
mental disorders.[30]
22. We asked Professor Wessely what needed to be
done to improve mental health support for reservists. He stressed
that any solution had to involve informal support:
[…] The implications of what we are saying
are fairly obvious all round, but these are very difficult things
to do in reality. It is not just formal social support that you
can deliver. You could deliver increased welfare services and
provide more counsellors and more psychologists and all those
things, but the evidence shows that just as important—some
people think more important—are the informal networks that
you cannot create because they come naturally. They are about
mates being bonded together.[31]
23. In our last Report on military casualties in
December 2011, we recommended that the MoD identify the factors
leading to the difference in the rates of PTSD between reservists
and regulars. The MoD is in the process of commissioning two pieces
of research related to the mental health of reservists. The first
one will explore the factors which determine why reservists are
more at risk of mental health problems on return from combat operations
and will assess the awareness of reservists of mental healthcare
and support services. The MoD described the second project as
follows:
KCMHR research indicated that Reserves post deployment
normalisation and reintegration experiences were different to
that of their Regular counterparts. The requirement was identified
to develop a Post Operational Stress Management (POSM) programme
tailored to Reservists differing needs.
This research programme will look to provide
recommendations on the most appropriate POSM programme for improving
Reservists reintegration and normalisation experiences and as
a consequence improve their mental health outcomes.[32]
Neither of these pieces of research have yet
been formally commissioned but the MoD expect them to report in
March 2015.
24. The MoD has introduced some specific support
for demobilised reservists with mental health problems but it
is still limited. Professor Fear said:
We evaluated the Reserves mental health programme
and showed that the individuals who were going through that were
having good outcomes, so that was shown to be effective.[33]
25. The higher incidence of mental health problems
developing in reservists deployed to Iraq and Afghanistan has
been known for some considerable time. Given our earlier recommendation
in 2011 that it investigate the factors contributing to that higher
incidence, we are disappointed that the MoD is still in the process
of commissioning this research. This has meant that the MoD has
yet authoritatively to identify or to address these issues and
provide support specifically tailored for reservists. This is
of great concern to the Committee given that the importance of
identifying and addressing the particular problems facing reservists
is increased by the growing dependence on Reserve Forces in Future
Force 2020.
Alcohol misuse
26. The MoD told us that KCMHR research "found
that the misuse of alcohol in the military is substantially higher
than that seen in the civilian population, particularly among
16 to 19 year olds, with males drinking over twice the hazardous
levels and females over three times".[34]
In addition, Professor Fear told us that male NCOs and Officers
are more likely to die from alcohol-related causes than other
occupational groups within the general population.[35]
27. The MoD described its policy on alcohol consumption
as shown in Box 1 below. It stressed that it had breathalysing
and discipline procedures for personnel with safety critical duties.Box
1: MoD policy on alcohol consumption
| While social drinking can play a part in developing group cohesion within the military culture, the MOD recognise the benefits of this must be balanced against misuse which could be hazardous to the individual, families or colleagues and ultimately operational capability. Therefore the MOD strategy has a twin track approach of education (routine awareness campaigns and health fairs) and regulation (for example discipline procedures and breathalysing for those on safety critical duties), with medical and welfare support for those who require it, including intervention and rehabilitation programmes. The strategy works on the principle that alcohol misuse is preventable and recoverable, and even those who are alcohol dependent can be helped.
The single Services are responsible for delivering through-life alcohol prevention programmes designed to raise awareness of the dangers of excessive alcohol misuse, including how to drink within safe limits; additional training is also provided for those in command positions. Each Service approaches the through-life framework principle in accordance with their needs, resulting in variations in programme delivery. For example the Royal Navy delivers lectures every one or three years, dependent on age, while the Army runs health fairs and bespoke alcohol presentations. The single Services all take a firm stance against misuse and manage it through a process of counselling, administrative and disciplinary action. They promote, through awareness campaigns and education, the sensible use of alcohol in accordance with government guidelines, in order to develop a culture of positive attitude and behaviour towards health and wellbeing. Their aim is to rehabilitate individuals as quickly as possible so that they remain operationally effective. Responsibility for a successful rehabilitation lies with both the individual and the support services. Nevertheless, there are those individuals who, despite chain of command and medical support, combined with an extensive treatment and rehabilitation programme, cannot be rehabilitated; in these rare instances, these individuals are discharged from the Services.
|
Source: Ministry of Defence[36]
28. In our previous Report on military casualties,
we expressed concerns that it was unclear whether the MoD regarded
the misuse of alcohol as part of a pattern of reprehensible behaviour
which required discouragement or a manifestation of stress which
required treatment or a combination of both.[37]
We recommended that the MoD carry out a study into what was driving
the misuse and abuse of alcohol and what more could be done to
change behaviour.[38]
29. In October 2012, the MoD commissioned research
to explain the high rates of alcohol consumption in the Armed
Forces and the disparity in consumption between military and civilian
populations and to recommend improvements in the management and
prevention of alcohol misuse in the Armed Forces. This study concluded
in August 2014 and confirmed the findings of the KCMHR research
that hazardous levels of alcohol consumption are the norm in the
Armed Forces, regardless of Service or gender. The study reached
some other worrying conclusions, in particular, that alcohol misuse
continues to rise and is associated with criminal offences and
violent behaviour causing problems to families and communities.
It also pointed to an "attitudinal and cultural ambiguity
regarding alcohol, it is considered by many to be a positive catalyst
of group cohesion and to help Armed Forces personnel deal with
the aftermath of deployment".[39]
30. The study made recommendations under the categories
of prevention, intervention and treatment. The recommendations
included limiting the availability of alcohol on Armed Forces
premises and increasing its price; education of personnel; intervention
for those with recognised alcohol problems; and better treatment
options including the employment of alcohol misuse specialists.
In addition, the study made overarching recommendations on the
need to develop a clear alcohol policy highlighting clearly key
approaches and responsibilities and a major campaign to ensure
all officers are committed to reducing alcohol consumption across
the Armed Forces.[40]
31. We questioned the charities as to whether some
Armed Forces personnel were resorting to alcohol to help them
with mental health problems, Bryn Parry, co-founder of Help For
Heroes, said:
What we are seeing is that all those who have
had some life-changing injuries, so that they can no longer do
the job that they wanted to do, are presenting with some mental
condition. They have concerns. They are not sleeping, they have
anxieties or depression, and they are turning to alcohol and so
on.[41]
32. We welcome the MoD's acceptance of our previous
conclusion that it needed to recognise the seriousness of the
problem of alcohol consumption in the Armed Forces and that it
has strengthened its response to the problem. However, we remain
concerned that the MoD's response has not had any noticeable impact
on the level of excessive and binge drinking in the Armed Forces.
We are not convinced that sufficient focus has been given to dealing
with the problem at every level of the chain of command. We also
question whether the MoD has examined whether excess alcohol consumption
may, in some Service personnel, be masking other mental health
problems.
33. We are disappointed that the MoD took well
over a year to commission research into the drivers of excessive
alcohol consumption. The conclusions of the study are very worrying.
Clearly, urgent action is needed to tackle the harm caused by
the abuse of alcohol to both Armed Forces personnel and their
families. In its response to this Report, the MoD should tell
us how it intends to implement the study's recommendations and
in what time frame.
34. The MoD should determine a comprehensive strategy
and plan to tackle alcohol misuse, identifying how it intends
to change the culture within the Armed Forces and identifying
practical measures to reduce consumption including, if necessary,
reviewing pricing policies and availability of alcohol on bases.
The plan should incorporate the recommendations of the study on
excessive alcohol consumption. It should also include performance
measures which will indicate whether the plan is working in reducing
excessive alcohol consumption.
Violence
35. The KCMHR has undertaken research on offending
behaviour, linking data on Armed Forces personnel from its longitudinal
cohort study to criminal records. The results showed that those
who are serving or have served in the Armed Forces have a lower
overall offending rate than the general population. Professor
Wessely said:
[…] those who served in the forces have
an overall offending rate that is lower than the general population.
When you think about the fact that, as is known, the forces recruit
some people from very disadvantaged backgrounds—some of
whom already have criminal offences, and they may well have gone
on to acquire more—that tends to speak to the idea that,
overall, offending goes down when you join the forces.[42]
However, rates for violent offending are higher.
Lifetime violent offending (ranging from threats of violence to
serious physical assault or worse) was more common among male
Service personnel—11 per cent compared to 8.7 per cent in
the general population. A pre-Service history of violence, younger
age and lower rank were the strongest risk factors for violent
offending. Men who were deployed to Iraq or Afghanistan with direct
combat exposure were 53 per cent more likely to commit a violent
offence than men who served in a non-combat role on operations.
Witnessing traumatic events on deployment also increased the risk
of violent offending. Alcohol misuse, PTSD, and high levels of
self-reported aggressive behaviour on return from deployment were
also found to be strong predictors of subsequent violent offending.
[43]
36. Professor Wessely said that rates of violent
offending were higher in those who had been deployed:
The exception is violence, and it is clear that
that goes up. It is particularly clear that that goes up in the
obvious groups—those who have previously offended, etc.,
with social deprivation and so on—but equally it goes up
in those who have been in combat. So, for those in the teeth arms—in
the infantry arms—who have been deployed and been in combat,
it goes up. Remember that generally in life violent offending
goes down. That is a specific deployment effect and it is massively
compounded by alcohol and somewhat compounded by PTSD. If you
are asking me honestly, I would say that the most significant
negative effect of military service is in the rates of violence,
but overall rates of offending are lower and overall there are
fewer veterans in prison than you would expect from their size
in the population. So it is a very specific effect.[44]
37. Increases in violent offending behaviour are
linked to deployment in combat roles and subsequent misuse of
alcohol and other risk taking behaviour. The MoD should identify
those most at risk of such offending and put in place measures
to assist these personnel to manage the aftermath of deployment
in combat roles better.
Domestic violence
38. Domestic violence has a profound effect on families.
The MoD told us that the Armed Forces do not tolerate domestic
violence. It also said:
Service personnel who are themselves experiencing
violence and Service family members who are victims of violence
have a comprehensive range of sources of help and information
including single-Service welfare providers, welfare and personnel
staff, Families' Federations and help-lines.[45]
The MoD wrote to us about the detailed policies on
responding to domestic violence and supporting the victims of
domestic violence led by each of the three Services.[46]
39. The research on violent offending discussed above
did not separately identify domestic violence although Professor
Wessely said that he thought domestic violence was also likely
to be higher than the general population.[47]
The KCMHR is currently undertaking a study of over one thousand
children of military fathers on the impact of military life. Professor
Fear described it thus:
[…]. We have got over 600 fathers who have
been recruited into our study, so we have collected information
from them on their health and well-being and on their family structure,
their relationship with their partner or ex-partners and children
and their view on the social, emotional and behavioural development
of their own children.
Through the fathers, we have access to the mother
or mothers of their children, and we ask the mother the same questions
about their mental health and well-being, their relationship with
the father and the children and their views on the children's
development from an emotional and social perspective. For those
children who are 11 and older, we have contacted them directly
and collected information from them, asking them, "What's
it like having a father in the Military—the good things
and not-so-good things?" We also ask them the same questions
about their own development.[48]
This study has yet to report.
40. We asked the MoD what it was doing to track incidents
of domestic violence. It told us that it had "seen no evidence
that suggests domestic violence is a greater problem with the
Service community than in the civilian community".[49]
The MoD has limited information on the number and nature of incidents
of domestic violence in the Armed Forces, and, in particular,
in the Reserve Forces nor does it know how many of these incidents
happen as a result of deployment in combat roles.[50]
41. The MoD needs to understand better the links
between deployment on combat operations, alcohol misuse and domestic
violence. The MoD must be more proactive at all levels and should
re-examine its policies on domestic violence and develop plans
to intervene to prevent domestic violence or, at least, reduce
the incidence of domestic violence by Armed Forces personnel.
These plans should deal with both regulars and reservists.
7 Defence Committee Report The Armed Forces Covenant in Action? Part 1: Military Casualties Seventh Report 2010-12, HC 762 Back
8
Q1 Back
9
King's Centre for Military Health Research: A fifteenth year report, September 2010 Back
10
Q52 Back
11
Q52 Back
12
Q3 Back
13
Q40 Back
14
Q19 Back
15
Q20 Back
16
Q19 Back
17
MoD (MIL0027) page 2 Back
18
MoD and Department of Health (MIL038) Back
19
MoD (MIL0027) page 6 Back
20
MoD (MIL0027) page 6 Back
21
MoD and Department of Health (MIL038) Back
22
MoD and Department of Health (MIL038) Back
23
MoD and Department of Health (MIL038) Back
24
Q53 Back
25
MoD and Department of Health (MIL038) Back
26
MoD and Department of Health (MIL038) Back
27
Q167 Back
28
Q167 Back
29
Q124 Back
30
Q10 Back
31
Q14 Back
32
MoD and Department of Health (MIL038) Back
33
Q40 Back
34
MoD (MIL0027) page 4 Back
35
Q57 Back
36
MoD (MIL0027) page 4 Back
37
Defence Committee Report The Armed Forces Covenant in Action? Part 1: Military Casualties Seventh Report 2010-12, HC 762
Back
38
Defence Committee Report The Armed Forces Covenant in Action? Part 1: Military Casualties Seventh Report 2010-12, HC 762 Back
39
MoD further evidence (MIL045) Back
40
MoD further evidence (MIL045) Back
41
Q115 Back
42
Q66 Back
43
King's Centre for Military Health Research paper UK military personnel
at risk of violent offending March 2013 Back
44
Q66 Back
45
MoD further evidence (MIL041) page 4 Back
46
MoD further evidence (MIL041) page 5 Back
47
Q77 Back
48
Q76 Back
49
MoD further evidence (MIL041) page 4 Back
50
MoD further evidence (MIL041) Back
|
