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Purpose: Structural and attitudinal barriers often hinder treatment-seeking for mental health problems among members of the Armed Forces. However, little is known about potential gender differences in structural and attitudinal barriers among members of the UK Armed Forces. The current study aimed to explore how men and women differ in terms of these barriers to care among a sample of UK Armed Forces personnel and veterans with self-reported mental health problems., Methods: Currently serving and ex-serving members of the UK Armed Forces who self-reported a mental health problem were invited to participate in a semi-structured phone interview on mental health and treatment-seeking. The final sample included 1448 participants (1229 men and 219 women). All participants reported on their current mental health, public stigma, self-stigma, and barriers to mental healthcare., Results: Overall, men and women reported similar levels of both structural and attitudinal barriers, with no significant differences detected. The highest scores for both men and women were observed in attitudinal barriers relating to self-stigma domains, which encapsulate internalised attitudes and beliefs about mental illness and treatment., Conclusions: Findings suggest that anti-stigma campaigns can be targeted simultaneously at both men and women within the Armed Forces. In particular, targeting self-stigma may be beneficial for health promotion campaigns., (© 2023. The Author(s).)

The enormous impact of mental illness on work and productivity is a global challenge, with immense costs to wider society. Now is the time for action, with new international guidelines and an emergent consensus on occupational mental healthcare. Alongside governments, organisations and employers, psychiatrists have a leading role to play.

Objectives: Research suggests that military personnel frequently delay disclosing mental health issues and illness (MHI), including substance use disorder, to supervisors. This delay causes missed opportunities for support and workplace accommodations which may help to avoid adverse occupational outcomes. The current study aims to examine disclosure-related beliefs, attitudes and needs, to create a better understanding of personnel's disclosure decision making., Design: A cross-sectional questionnaire study among military personnel with and without MHI. Beliefs, attitudes and needs regarding the (non-)disclosure decision to a supervisor were examined, including factors associated with (non-)disclosure intentions and decisions. Descriptive and regression (logistic and ordinal) analyses were performed., Setting: The study took place within the Dutch military., Participants: Military personnel with MHI (n=324) and without MHI (n=554) were participated in this study., Outcome Measure: (Non-)disclosure intentions and decisions., Results: Common beliefs and attitudes pro non-disclosure were the preference to solve one's own problems (68.3%), the preference for privacy (58.9%) and a variety of stigma-related concerns. Common beliefs and attitudes pro disclosure were that personnel wanted to be their true authentic selves (93.3%) and the desire to act responsibly towards work colleagues (84.5%). The most reported need for future disclosure (96.8%) was having a supervisor who shows an understanding for MHI. The following factors were associated both with non-disclosure intentions and decisions: higher preference for privacy (OR (95% CI))=(1.99 (1.50 to 2.65) intention , 2.05 (1.12 to 3.76) decision ) and self-management (OR (95% CI))=(1.64 (1.20 to 2.23) intention , 1.79 (1.00 to 3.20) decision ), higher stigma-related concerns (OR (95% CI))=(1.76 (1.12 to 2.77) intention , 2.21 (1.02 to 4.79) decision ) and lower quality of supervisor-employee relationship (OR (95% CI))=(0.25 (0.15 to 0.42) intention , 0.47 (0.25 to 0.87) decision )., Conclusion: To facilitate (early-)disclosure to a supervisor, creating opportunities for workplace support, interventions should focus on decreasing stigma and discrimination and align with personnels' preference for self-management. Furthermore, training is needed for supervisors on how to recognise, and effectively communicate with, personnel with MHI. Focus should also be on improving supervisor-employee relationships., Competing Interests: Competing interests: RB reports grants from The Dutch Ministry of Defence, during the conduct of the study. However, this did not influence the interpretation of the data or the decision to submit the paper for publication. EG has nothing to disclose. NG is the Royal College of Psychiatrists Lead for Trauma and the Military; however, all views expressed are his own. FL is an employee at the Ministry of Defence but this did not influence the interpretation of the data or the decision to submit the paper for publication. JvW has nothing to disclose. DvdM has nothing to disclose. ADR has nothing to disclose. EB reports grants from The Dutch Ministry of Defence, during the conduct of the study. However, this did not influence the interpretation of the data or the decision to submit the paper for publication., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The COVID-19 pandemic has once again highlighted the need for all psychiatrists to have a good understanding of the bi-directional relationship between mental health and a person's ability to function well at work. Ensuring patients are able to work should be a key treatment outcome for all psychiatrists.

Background: Often, military personnel do not seek treatment for mental illness or wait until they reach a crisis point. Effective, selective, and indicated prevention is best achieved by seeking treatment early., Aims: We aimed to examine military personnel's attitudes, beliefs, and needs around seeking treatment for mental illness. We compared those who sought treatment to those who did not and those with and without the intention to seek treatment. Finally, we examined factors associated with intentions of not seeking treatment., Method: We conducted a cross-sectional questionnaire study of military personnel with (N = 324) and without (N = 554) mental illness. Descriptive and regression analyses (logistic and ordinal) were performed., Results: The majority of the personnel believed treatment was effective (91.6%); however, most preferred to solve their own problems (66.0%). For personnel with mental illness, compared to those who sought treatment, those who did not had a higher preference for self-management and found advice from others less important. For those without mental illness, those with no intention to seek treatment indicated a higher preference for self-management, stigma-related concerns, denial of symptoms, lower belief in treatment effectiveness and found it less important to be an example, compared to those with treatment-seeking intentions. A clear indication of where to seek help was the most reported need (95.7%). Regression analyses indicated that not seeking treatment was most strongly related to preference for self-management (OR(95%CI) = 4.36(2.02-9.39); no intention to seek treatment was most strongly related to a lower belief that treatment is effective (OR(95%CI) = .41(0.28-0.59) and with not having had positive earlier experiences with treatment seeking (OR(95%CI) = .34(0.22-0.52)., Conclusions: To facilitate (early) treatment seeking, interventions should align with a high preference for self-management, mental illness stigma should be targeted, and a clear indication of where to seek treatment is needed., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Military service is associated with increased risk of mental health problems. Previous reviews have pointed to under-utilization of mental health services in military populations. Building on the most recent systematic review, our narrative, critical review takes a complementary approach and considers research across the Five-Eyes nations from the past six years to update and broaden the discussion on pathways to mental healthcare in military populations. We find that at a broad population level, there is improvement in several indicators of mental health care access, with greater gains in initial engagement, time to first treatment contact, and subjective satisfaction with care, and smaller gains in objective indicators of adequacy of care. Among individual-level barriers to care-seeking, there is progress in improving recognition of need for care and reducing stigma concerns. Among organizational-level barriers, there are advances in availability of services and cultural acceptance of care-seeking. Other barriers, such as concerns around confidentiality, career impact, and deployability persist, however, and may account for some remaining unmet need. To address these barriers, new initiatives that are more evidence-based, theoretically-driven, and culturally-sensitive, are therefore needed, and must be rigorously evaluated to ensure they bring about additional improvements in pathways to care., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Background: For a small minority of personnel, military service can have a negative impact on their mental health. Yet no studies have assessed how the mental health of UK veterans (who served during the recent operations in Afghanistan or Iraq) compares to non-veterans, to determine if they are at a disadvantage. We examine the prevalence of mental disorders and alcohol misuse in UK veterans compared to non-veterans., Methods: Veteran data were taken from the third phase of the King's Centre for Military Health Research cohort study (n = 2917). These data were compared with data on non-veterans taken from two large general population surveys: 2014 Adult Psychiatric Morbidity Survey (n = 5871) and wave 6 of the UK Household Longitudinal Study (UKHLS, n = 22 760)., Results: We found that, overall, UK veterans who served at the time of recent military operations were more likely to report a significantly higher prevalence of common mental disorders (CMD) (23% v. 16%), post-traumatic stress disorder (PTSD) (8% v. 5%) and alcohol misuse (11% v. 6%) than non-veterans. Stratifying by gender showed that the negative impact of being a veteran on mental health and alcohol misuse was restricted to male veterans. Being ill or disabled was associated with a higher prevalence of CMD and PTSD for both veterans and non-veterans., Conclusion: Whilst the same sociodemographic groups within the veteran and non-veteran populations seemed to have an increased risk of mental health problems (e.g. those who were unemployed), male veterans, in particular, appear to be at a distinct disadvantage compared to those who have never served.

Objectives: While most UK military personnel transition successfully into civilian life, some experience unemployment and disability, which may be partly attributable to in-service factors. This study aims to determine the degree to which in-service mental health problems impact on postservice benefit claims., Methods: Using data from a cohort of 5598 recent leavers from regular service in the UK Armed Forces linked with data from the Department for Work and Pensions, we assessed associations between in-service mental health and postservice benefit claims, and the population attributable fraction (PAF) of benefit claims related to in-service mental health. An analysis with postservice mental ill health as mediator was performed to determine the degree to which the observed effects were a consequence of persistent illness, as opposed to remitted., Results: Mental illness occurring in-service predicted both unemployment and disability claims, partly mediated by postservice health (23%-52% total effects mediated), but alcohol misuse did not. Common mental disorder (CMD) (PAF 0.07, 95% CI: 0.02 to 0.11) and probable post-traumatic stress disorder (PTSD) (PAF 0.05, 95% CI 0.01 to 0.09) contributed to unemployment claims. Probable PTSD was the largest contributor to disability claims (PAF 0.25, 95% CI 0.13 to 0.36), with a smaller contribution from CMD (PAF 0.16, 95% CI 0.03 to 0.27)., Conclusions: In-service mental ill health gives rise to benefit claims. These effects are only partly mediated by postservice mental health, implying that in-service (or pre-service) mental issues have carry-over effects into civilian life even if remitted. Better prevention and treatment of in-service PTSD symptoms may well reduce postservice disability claims., Competing Interests: Competing interests: RJR and HB report grants from ministry of defence and grants from Forces in Mind Trust during the conduct of the study. NG reports personal fees from King’s College London, during the conduct of the study, and is the Royal College of Psychiatrists Lead for Military and Veterans Health and also a trustee for two military charities. He was not required to act in any particular way by these organisations in relation to the paper. NTF and SW have nothing to disclose., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Healthcare workers (HCWs) are vulnerable to developing mental ill-health. Prior research has shown those in managerial or supervisory positions have pivotal roles in creating a healthy work environment, as well as recognizing and supporting HCWs with mental health symptoms to improve occupational outcomes and reduce sickness absence., Aims: To evaluate the effectiveness of active listening skills training (REACTMH) for UK healthcare managers., Methods: Managers of HCWs were voluntarily enrolled on a REACTMH active listening skills training package. Attendees anonymously completed questionnaires before and immediately after attending the 1-h remote training session and again 1 month later. The questionnaire asked about confidence in recognizing, conversing with and supporting distressed colleagues as well as perceived usefulness and importance of the training and how often they had used the taught active listening skills., Results: Fifty-eight healthcare managers enrolled onto the REACTMH programme in July 2020 and 32 (55%) completed the 1-month follow-up. Just less than half reported feeling confident in being able to identify, speak to and support potentially distressed staff before the training; significantly more (>80%) reported feeling confident 1 month afterwards (P < 0.001). Around three-quarters of attendees reported the REACTMH programme as highly useful, highly important and said they had frequently used the learned skills., Conclusions: A brief active listening skills training package was associated with significant improvements healthcare manager's confidence in recognizing, speaking with and supporting HCWs with suspected mental health conditions. Further research is needed to investigate the longer term effectiveness and acceptability of REACTMH training., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Staff working in intensive care units (ICUs) have faced significant challenges during the COVID-19 pandemic which have the potential to adversely affect their mental health., Aims: To identify the rates of probable mental health disorder in staff working in ICUs in nine English hospitals during June and July 2020., Methods: An anonymized brief web-based survey comprising standardized questionnaires examining depression, anxiety symptoms, symptoms of post-traumatic stress disorder (PTSD), well-being and alcohol use was administered to staff., Results: Seven hundred and nine participants completed the surveys comprising 291 (41%) doctors, 344 (49%) nurses and 74 (10%) other healthcare staff. Over half (59%) reported good well-being; however, 45% met the threshold for probable clinical significance on at least one of the following measures: severe depression (6%), PTSD (40%), severe anxiety (11%) or problem drinking (7%). Thirteen per cent of respondents reported frequent thoughts of being better off dead, or of hurting themselves in the past 2 weeks. Within the sample used in this study, we found that doctors reported better mental health than nurses across a range of measures., Conclusions: We found substantial rates of probable mental health disorders, and thoughts of self-harm, amongst ICU staff; these difficulties were especially prevalent in nurses. Whilst further work is needed to better understand the real level of clinical need amongst ICU staff, these results indicate the need for a national strategy to protect the mental health, and decrease the risk of functional impairment, of ICU staff whilst they carry out their essential work during COVID-19., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Recently, the UK Armed Forces have revised the ground close combat role to include women., Aims: To assess the potential mental health impact of this initiative we examined gender differences in deployment patterns, work strain, occupational factors, mental health, alcohol use and help-seeking following operational deployment., Methods: The study was a secondary analysis of self-report survey data; 8799 men (88%) and 1185 women (12%) provided data. A sub-sample (47%, n = 4659) provided data concerning post-deployment help-seeking. The latter consisted of 408 women (8.8%) and 4251 men (91%)., Results: With the exception of alcohol misuse, which was significantly lower for women, women reported significantly more common mental disorder symptoms, subjective depression and self-harm. Women were significantly more likely to seek help from healthcare providers. Men were significantly more likely to have deployed operationally and for longer cumulative periods. Subjective work strain, but not job control, was significantly lower for women whose military careers were significantly shorter. Post-traumatic stress disorder (PTSD) symptom intensity was similar to men., Conclusions: With the exception of PTSD and alcohol misuse, UK military women experience more mental health-related problems than military men. This finding was not related to the more arduous aspects of military service as women served for shorter times, deployed less and for shorter cumulative periods and were less likely to report work-related stress., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Veterinary professionals are at increased risk of suicide and mental health difficulties compared to the general population. Vetlife Health Support (VHS) is a mental health case management service for veterinarians with mental health difficulties., Aims: To evaluate the VHS case management service from the service user's perspective., Methods: Service users (n = 98) completed questionnaires assessing their experience with VHS and current mental health status using the Kessler-6 Scale. A sub-sample was interviewed and the data qualitatively analysed (n = 14)., Results: The results show that 97% (n = 95) reported a positive experience with VHS and 98% (n = 96) reported VHS staff respected and listened to them. Participants reported significant improvements in relationships with others after VHS (P < 0.001) and were significantly more likely to be in receipt of formal mental health care after VHS than before (P < 0.01). The main emergent themes from the qualitative interviews were (i) positive communication between clinician and service users, (ii) veterinary-specific mental health services were regarded as important to understanding service users' circumstances, (iii) knowing someone is supporting them positively impacted wellbeing and (iv) confusion with discharge status., Conclusions: Most participants reported positive experiences with VHS. Quantitatively, data showed that participants reported significant improvements in relationships and access to formal mental health care after contact with VHS. Interviews with service users revealed that they felt speaking to a mental health professional with veterinary-specific knowledge was beneficial for their wellbeing. Further evaluation assessing whether VHS leads to a measurable impact on psychological wellbeing is recommended., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Individuals who conduct disaster relief work overseas are exposed to a variety of traumatic events that can cause distress and trigger psychological illnesses. Identification of which disaster relief workers may be at risk of experiencing psychological distress or mental health disorders is frequently carried out through pre-employment or pre-deployment psychological screening. The primary objective of our review was to assess the evidence for pre-employment and pre-deployment psychological screening of relief workers who work in disaster situations. We aimed to identify specific pre-employment and pre-deployment characteristics that predict impaired wellbeing of an individual following engaging in disaster-related work., Methods: A combined list of search terms was composed relating to disaster-related occupations, screening methods, psychological disorders, and study design. The databases used were PsycINFO, MEDLINE, EMBASE, and GlobalHealth. We included studies that used cross-sectional or longitudinal study designs; were published in the English language in peer-reviewed academic journals; reported on the association between pre-employment and pre-deployment features and post-deployment psychological disorders or distress; considered any occupational groups responding to a specified, discrete crisis; and used at least one validated measure of distress or disorder. We extracted data on the author; year of publication; disaster description; country of study; study design; population sample; disorder(s) outcome and the measures used; and results., Results: Sixty-two, high-quality studies were included in the review. Forty-one potential predictors were identified. Of these, only volunteer status and previous history of mental illness and life stressors emerged as reliable predictors of distress or disorder., Conclusion: The results suggest that whilst it is attractive to screen for pre-employment and pre-deployment indicators of resilience, the evidence base for doing so is weak. At best, this sort of screening can only weakly suggest vulnerability and at worst may result in discrimination. Until better evidence about its usefulness becomes available, employers should exercise caution over its use.

Background: Previous studies have found that perceptions of mental health related stigma can negatively impact help-seeking, particularly in military samples. Moreover, perceptions of stigma and barriers to care can vary between individuals with different psychiatric disorders. The aim of this study was to examine whether perceptions of stigma and barriers to care differed in a UK military sample between those with and without a current likely mental health diagnosis., Method: Structured telephone interviews were carried out with 1432 service personnel and veterans who reported recent subjective mental ill health in the last 3 years. Participants completed self-reported measures relating to perceived stigma, barriers to care and psychological wellbeing., Results: Those meeting criteria for probable common mental disorders (CMD) and PTSD were significantly more likely to report concerns relating to perceived and internalised stigma and barriers to care compared to participants without a likely mental disorder. Compared to individuals with likely CMD and alcohol misuse, those with probable PTSD reported higher levels of stigma-related concerns and barriers to care - although this difference was not significantly different., Conclusions: These results indicate that perceptions of stigma continue to exist in UK serving personnel and military veterans with current probable mental disorders. Efforts to address particular concerns (e.g. being seen as weak; difficulty accessing appointments) may be worthwhile and, ultimately, lead to improvements in military personnel and veteran wellbeing.

Background : Little is known about gender differences in mental health, related help-seeking behavior and social support in UK military personnel. Methods : 1714 UK military serving personnel and ex-service veterans were randomly selected if, in a cohort study, they endorsed experiencing a subjective stress, emotional, alcohol or mental health problem in the previous three years. Following exclusions, the final sample size was 1448 (participation rate 84.5%; women n = 219). Structured telephone interviews assessed anxiety, depression, PTSD symptoms, alcohol use, help-seeking and social support occurring both currently and in the past three years. Outcomes were assessed using weighted unadjusted and adjusted logistic regression analyses. Results : Mental health problems assessed at interview were broadly similar for men and women; for both genders, levels of social support were high. One-fifth of respondents screened positive for probable mental disorder or alcohol misuse; although rates of mental disorder symptoms did not differ by gender, women were significantly less likely than men to report alcohol misuse. Women were significantly more likely to have sought help from formal medical sources but significantly less likely to access informal support such as friends, family or unit welfare sources; reasons for seeking formal medical support were similar for men and women except for problem recognition and acting on advice from others, which were both significantly more common among women. Conclusion : For military personnel with a history of mental ill-health, women should make greater use of informal support networks while for men, engagement with formal medical help sources should be encouraged.

Background: While it is known that some UK Armed Forces (UK AF) personnel and veterans experience physical and mental health problems, the possible future healthcare needs of military veterans are unknown., Aims: To estimate the number of military personnel who may experience physical and/or psychological health problems associated with their military service., Methods: Data were obtained via Freedom of Information requests to several sources, including Defence Statistics. Raw data from research studies were also used where available. Data were analysed using meta-analytic methods to determine the rate of physical, mental or comorbid health problems in AF personnel., Results: Musculoskeletal problems were the predominant reason for medical discharge from service. In terms of mental health, meta-analyses estimated that veteran reservists (part-time military members) previously deployed to operational areas had the highest proportion of general health problems (35%), previously deployed veteran regulars (those in full time military employment) and veteran reservists had the highest proportion of post-traumatic stress disorder (9%), and regular personnel with a deployment history had the highest proportion of alcohol problems (14%). Overall, our findings suggest that at least 67515 veterans are likely to suffer from mental and/or physical health problems at some point as a result of their service between 2001 and 2014., Conclusions: The results of this study highlight that the difficulties personnel may face are largely musculoskeletal or mental health-related. These findings may help with planning the provision of future physical and mental health care and support for those who serve in the UK AF.

Background: Military service can be a traumatic experience and cause mental health problems in a minority of personnel, such as post-traumatic stress disorder (PTSD), which is linked to negative long-term outcomes. As a result, PTSD has received significant research attention. However, post-traumatic growth (PTG) is a newer construct, with comparatively little known about its presentation and development., Aims: To qualitatively examine the experience of (PTG) in military and ex-military personnel., Methods: A qualitative systematic search of electronic databases was conducted, with studies assessed for methodological quality and data analysed using thematic analysis. Nine qualitative studies, carried out between 2011 and 2016, met the inclusion criteria with 195 participants in total, including both military and ex-military personnel., Results: Six themes were identified: appreciation for life, re-evaluating sense of purpose, improvement of personal human traits, bonding and connecting with others, integrating into society, and being proud of heritage and feeling valuable to society., Conclusions: The results of this review illustrate that military personnel may experience PTG due to deployment-related trauma exposure, and the presentation of PTG in this population is not dissimilar to that of civilians. This study highlights the need for additional research to quantify the long-term psychological impact of PTG and whether a focus on PTG may be helpful in psychological treatment for (ex-) military personnel.

Background: Little is known about the prevalence of mental health outcomes in UK personnel at the end of the British involvement in the Iraq and Afghanistan conflicts.AimsWe examined the prevalence of mental disorders and alcohol misuse, whether this differed between serving and ex-serving regular personnel and by deployment status., Method: This is the third phase of a military cohort study (2014-2016; n = 8093). The sample was based on participants from previous phases (2004-2006 and 2007-2009) and a new randomly selected sample of those who had joined the UK armed forces since 2009., Results: The prevalence was 6.2% for probable post-traumatic stress disorder, 21.9% for common mental disorders and 10.0% for alcohol misuse. Deployment to Iraq or Afghanistan and a combat role during deployment were associated with significantly worse mental health outcomes and alcohol misuse in ex-serving regular personnel but not in currently serving regular personnel., Conclusions: The findings highlight an increasing prevalence of post-traumatic stress disorder and a lowering prevalence of alcohol misuse compared with our previous findings and stresses the importance of continued surveillance during service and beyond., Declaration of Interest: All authors are based at King's College London which, for the purpose of this study and other military-related studies, receives funding from the UK Ministry of Defence (MoD). S.A.M.S., M.J., L.H., D.P., S.M. and R.J.R. salaries were totally or partially paid by the UK MoD. The UK MoD provides support to the Academic Department of Military Mental Health, and the salaries of N.J., N.G. and N.T.F. are covered totally or partly by this contribution. D.Mu. is employed by Combat Stress, a national UK charity that provides clinical mental health services to veterans. D.MacM. is the lead consultant for an NHS Veteran Mental Health Service. N.G. is the Royal College of Psychiatrists' Lead for Military and Veterans' Health, a trustee of Walking with the Wounded, and an independent director at the Forces in Mind Trust; however, he was not directed by these organisations in any way in relation to his contribution to this paper. N.J. is a full-time member of the armed forces seconded to King's College London. N.T.F. reports grants from the US Department of Defense and the UK MoD, is a trustee (unpaid) of The Warrior Programme and an independent advisor to the Independent Group Advising on the Release of Data (IGARD). S.W. is a trustee (unpaid) of Combat Stress and Honorary Civilian Consultant Advisor in Psychiatry for the British Army (unpaid). S.W. is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King's College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University. The views expressed are those of the author(s) and not necessarily those of the National Health Service, the NIHR, the Department of Health, Public Health England or the UK MoD.

Background: Fitness to undertake operational deployment is a key requirement of military service., Aim: To assess individual deployment fitness at a single point from one month to eight years following discharge from mental healthcare., Method: Survival analyses assessed levels of deployability; the predictive effects of key covariates upon time to being classified as non-deployable were examined using univariate and multivariate Cox proportional hazards regression procedures., Results: A total of 1405 individuals provided study data. 437 individuals (31.1%) were non-deployable or discharged from service during follow-up. 17.2% were non-deployable in the first year following mental healthcare; the proportion did not rise above this level until year seven when it was 19.1% and then 30.6% in year eight. Risk factors for being classified as non-deployable were female sex, receipt of intermediate duration therapy, management by the multidisciplinary team and previous referral to mental health services. Previous deployment was significantly associated with reduced risk. Overall, the levels of non-deployability appeared to be no higher than those found among the wider military services., Conclusion: Non-deployable status among mental healthcare recipients was broadly similar to that found among the wider UK military; risk factors for non-deployability could be amenable to targeted relapse prevention measures.

Background: Military research suggests a significant association between leadership, cohesion, mental health stigmatisation and perceived barriers to care (stigma/BTC)., Aim: Most studies are cross sectional, therefore longitudinal data were used to examine the association of leadership and cohesion with stigma/BTC., Method: Military personnel provided measures of leadership, cohesion, stigma/BTC, mental health awareness and willingness to discuss mental health following deployment (n = 2510) and 4-6 months later (n = 1636)., Results: At follow-up, baseline leadership and cohesion were significantly associated with stigma/BTC; baseline cohesion alone was significantly associated with awareness of and willingness to discuss mental health at follow-up. Over time, changes in perceived leadership and cohesion were significantly associated with corresponding changes in stigma/BTC levels. Stigma/BTC content was similar in both surveys; fear of being viewed as weak and being treated differently by leaders was most frequently endorsed while thinking less of a help-seeking team member and unawareness of potential help sources were least common., Conclusion: Effective leadership and cohesion building may help to reduce stigma/BTC in military personnel. Mental health awareness and promoting the discussion of mental health matters may represent core elements of supportive leader behaviour. Perceptions of weakness and fears of being treated differently represent a focus for stigma/BTC reduction.

A recent quantitative review in the area of stigma and help seeking in the armed forces has questioned the association between these factors (Sharp et al. 2015). To date, the contribution of qualitative literature in this area has largely been ignored, despite the value this research brings to the understanding of complex social constructs such as stigma. The aim of the current systematic review of qualitative studies was to identify appropriate literature, assess the quality and synthesize findings across studies regarding evidence of stigma-related barriers and facilitators to help seeking for mental health issues within the armed forces. A multi-database text word search incorporating searches of PsycINFO, MEDLINE, Social Policy and Practice, Social Work Abstracts, EMBASE, ERIC and EBM Review databases between 1980 and April 2015 was conducted. Literature was quality assessed using the Critical Appraisal Skills Programme tool. Thematic synthesis was conducted across the literature. The review identified eight studies with 1012 participants meeting the inclusion criteria. Five overarching themes were identified across the literature: (1) non-disclosure; (2) individual beliefs about mental health; (3) anticipated and personal experience of stigma; (4) career concerns; and (5) factors influencing stigma. The findings from the current systematic review found that unlike inconsistent findings in the quantitative literature, there was substantial evidence of a negative relationship between stigma and help seeking for mental health difficulties within the armed forces. The study advocates for refinement of measures to accurately capture the complexity of stigma and help seeking in future quantitative studies.

Background: The effectiveness of post-deployment screening for mental disorders has not been assessed in a randomised controlled trial. We aimed to assess whether post-deployment screening for post-traumatic stress disorder (PTSD), depression, anxiety, or alcohol misuse was effective. We defined screening as the presumptive identification of a previously unrecognised disorder using tests to distinguish those who probably had the disorder from those who probably did not so that those people with a probable disorder could be referred appropriately, and assessed effectiveness and consequences for help-seeking by the odds ratio at follow-up between those receiving tailored help-seeking advice and those who received general mental health advice., Methods: We did a cluster randomised controlled trial among Royal Marines and Army personnel in the UK military after deployment to Afghanistan. Platoons were randomly assigned (1:1 initially, then 2:1) by stratified block randomisation with randomly varying block sizes of two and four to the screening group, which received tailored help-seeking advice, or the control group, which received general mental health advice. Initial assessment took place 6-12 weeks after deployment; follow-up assessments were done 10-24 months later. Follow-up measures were the PTSD Checklist-Civilian Version, Patient Health Questionnaire-9, Generalised Anxiety Disorder-7 scale, Alcohol Use Disorder Identification Test (AUDIT), and self-reported help-seeking from clinical and welfare providers comparing those receiving tailored advice and those receiving only general advice. All participants and all investigators other than the person who analysed the data were masked to allocation. The primary outcomes were PTSD, depression or generalised anxiety disorder, and alcohol misuse at follow-up. A key secondary outcome was assessment of whether post-deployment screening followed by tailored advice would modify help-seeking behaviour. Comparisons were made between screening and control groups, with primary analyses by intention to treat. This trial is registered with the ISRCTN Registry, number ISRCTN19965528., Findings: Between Oct 24, 2011, and Oct 31, 2014, 434 platoons comprising 10 190 personnel were included: 274 (6350 personnel) in the screening group and 160 (3840 personnel) in the control group. 5577 (88%) of 6350 personnel received screening and 3996 (63%) completed follow-up, whereas 3149 (82%) of 3840 received the control questionnaire and 2369 (62%) completed follow-up. 1958 (35%) of 5577 personnel in the screening group declined to see the tailored advice, but those with PTSD (83%) or anxiety or depression (84%) were more likely than non-cases (64%) to view the advice (both p<0·0001). At follow-up, there were no significant differences in prevalence between groups for PTSD (adjusted odds ratio 0·92, 95% CI 0·75-1·14), depression or anxiety (0·91, 0·71-1·16), alcohol misuse (0·88, 0·73-1·06), or seeking support for mental disorders (0·92, 0·78-1·08)., Interpretation: Post-deployment screening for mental disorders based on tailored advice was not effective at reducing prevalence of mental health disorders nor did it increase help-seeking. Countries that have implemented post-deployment screening programmes for mental disorders should consider monitoring the outcomes of their programmes., Funding: The US Army Medical Research and Materiel Command-Military Operational Medicine Research Program (USAMRMC-MOMRP)., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: TRiM (Trauma Risk Management) has been shown to improve mental health and attitudes towards mental health in high-risk occupational groups; however, there has been no research into how TRiM might work for railway workers., Aims: To assess whether attending a TRiM training course alters mental health and attitudes to mental health-related help-seeking in railway workers., Methods: Workers completed a survey assessing mental health and attitudes towards mental health and help-seeking, before and after a 2-day TRiM course; follow-up questionnaires were administered 4 months post-course., Results: Fifty railway employees completed the questionnaires. Post-course scores for cohesion and mental health peer literacy (i.e. feeling able to recognize and discuss mental health symptoms with colleagues) and some aspects of stigma significantly improved, while there were non-significant improvements in common mental disorder and post-traumatic stress symptoms. The response rate for completing follow-up surveys was small (n = 8) but results from these subjects suggested mental health peer literacy scores remained significantly improved., Conclusions: This study provides a useful insight into attitudes of railway workers regarding stigma and their confidence in discussing trauma-related mental health. Significant improvements in cohesion and mental health peer literacy along with the general improvement in scores post-TRiM course provide some evidence of the potential benefits of TRiM training in railway workers. Follow-up results have limited reliability due to the small number of responders but suggest possible long-term benefits of attending a TRiM course. Further research is required to confirm this finding., (© The Author 2015. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objectives: To establish the level of psychological symptoms and the risk factors for possible decreased mental health among deployed UK maritime forces., Methods: A survey was completed by deployed Royal Navy (RN) personnel which measured the prevalence of common mental disorder (CMD), post-traumatic stress disorder (PTSD) and potential alcohol misuse. Military and operational characteristics were also measured including exposure to potentially traumatic events, problems occurring at home during the deployment, unit cohesion, leadership and morale. Associations between variables of interest were identified using binary logistic regression to generate ORs and 95% CIs adjusted for a range of potential confounding variables., Results: In total, 41.2% (n=572/1387) of respondents reported probable CMD, 7.8% (n=109/1389) probable PTSD and 17.4% (n=242/1387) potentially harmful alcohol use. Lower morale, cohesion, leadership and problems at home were associated with CMD; lower morale, leadership, problems at home and exposure to potentially traumatic events were associated with probable PTSD; working in ships with a smaller crew size was associated with potentially harmful alcohol use., Conclusions: CMD and PTSD were more frequently reported in the maritime environment than during recent land-based deployments. Rates of potentially harmful alcohol use have reduced but remain higher than the wider military. Experiencing problems at home and exposure to potentially traumatic events were associated with experiencing poorer mental health; higher morale, cohesion and better leadership with fewer psychological symptoms., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Introduction: UK military research suggests that there is a significant link between current psychological symptoms, mental health stigmatisation and perceived barriers to care (stigma/BTC). Few studies have explored the construct of stigma/BTC in depth amongst deployed UK military personnel., Method: Three survey datasets containing a stigma/BTC scale obtained during UK deployments to Iraq and Afghanistan were combined (n=3405 personnel). Principal component analysis was used to identify the key components of stigma/BTC. The relationship between psychological symptoms, the stigma/BTC components and help seeking were examined., Results: Two components were identified: 'potential loss of personal military credibility and trust' (stigma Component 1, five items, 49.4% total model variance) and 'negative perceptions of mental health services and barriers to help seeking' (Component 2, six items, 11.2% total model variance). Component 1 was endorsed by 37.8% and Component 2 by 9.4% of personnel. Component 1 was associated with both assessed and subjective mental health, medical appointments and admission to hospital. Stigma Component 2 was associated with subjective and assessed mental health but not with medical appointments. Neither component was associated with help-seeking for subjective psycho-social problems., Conclusions: Potential loss of credibility and trust appeared to be associated with help-seeking for medical reasons but not for help-seeking for subjective psychosocial problems. Those experiencing psychological symptoms appeared to minimise the effects of stigma by seeking out a socially acceptable route into care, such as the medical consultation, whereas those who experienced a subjective mental health problem appeared willing to seek help from any source., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Introduction: The relationship between mental health symptoms, stigmatising beliefs about mental health and help seeking is complex and poorly understood., Method: 1636 UK Armed Forces personnel provided study data immediately after deployment (T1) and approximately 6 months later (T2). Stigmatising beliefs were assessed using an eight-item scale previously used in studies of UK military personnel. Symptoms of probable common mental disorder, probable post-traumatic stress disorder and subjective stressful, emotional, relationship and family problems were evaluated at T1 and T2. Help seeking during deployment was assessed at T1 and post-deployment help seeking at T2. Alcohol use and subjective alcohol problems were assessed at T2 only., Results: Reporting a probable mental health disorder or potentially harmful alcohol use following deployment was both significantly associated with higher levels of stigmatising beliefs. The reported degree of stigma was associated with changes in mental health symptom levels; compared to those who were never classified as a probable mental health disorder case, recovered cases experienced significantly lower levels of stigmatisation, whereas new onset cases reported significantly higher levels., Conclusion: The way that individuals report mental health stigmatisation is not static; rather stigma fluctuates in proportion to the frequency and severity of psychological symptoms. These results suggest that public health stigma-reduction strategies which aim to promote engagement with mental health services should be focused towards people who are experiencing worsening mental health. Our results suggest that willing volunteers who have recovered from a mental-ill-health episode may be well placed to assist in the delivery of such a strategy.

Introduction: Clinical assessment is an essential but potentially time-consuming component of mental healthcare provision. The Threshold Assessment Grid (TAG) is a brief structured assessment tool which is applied to written referrals with the aim of identifying the severity of mental illness and suitability for further psychological treatment by assessing perceived risk, safety concerns and clinical factors., Method: The TAG criteria were used to structure a brief TAG-triage face-to-face assessment. As the use of triage has not been evaluated within a military occupational mental health service, differences in clinical and occupational outcomes were compared following either standard face-to-face assessment or receipt of TAG-triage interview among members of the UK Armed Forces who were referred for mental health assessment. During a period of service development, 56.6% of patients referred to a military mental health team received TAG-triage assessment (n=419) and 43.5% were assessed as usual (n=323)., Results: There were no significant differences in rank, age, sex and Service background between patients allocated to the two forms of assessment. Patients presenting following acts of deliberate self-harm were as likely to receive TAG-triage as they were to undergo standard assessment, suggesting that clinicians were willing to use TAG-triage for more challenging cases. Patients receiving TAG-triage were as likely to receive further therapy and be allocated a clinical diagnosis as those undergoing standard assessment. Short-term and longer-term occupational outcomes following discharge from care, represented by medical fitness to carry out one's military role, were similar among the TAG-triage and standard assessment groups., Conclusion: TAG-triage appeared to offer a viable alternative to standard face-to-face mental health assessment and could promote more efficient use of clinical time., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: This study aimed to examine currently serving United Kingdom (UK) military Medical and Welfare Officers views on the potential introduction of post-deployment screening for mental ill health., Methods: Semi-structured interviews were conducted with 21 Medical and Welfare Officers. Interview transcripts were analysed using data-driven thematic analysis., Results: Four themes were identified: positive views of screening; reliability of responses; impact on workload; and suggestions for implementation. Interviewees viewed the introduction of screening post-deployment as likely to increase awareness of mental health problems whilst also reporting that service personnel were likely to conceal their true mental health status by providing misleading responses to any screening tool. Concern over reliability of responses may provide one explanation for the reluctance of service personnel to seek help for problems, as they could feel they will not be taken seriously. Welfare Officers felt they would not have the knowledge or experience to respond to help-seeking. Although participants were concerned about potential impact on their personal workload, they indicated a desire to positively engage with the screening programme if research showed it was an effective tool to improve mental health care., Conclusions: Welfare and healthcare providers are well disposed towards a screening programme for mental health but highlight a few concerns in its implementation. In particular Welfare Officers appear to require more training in how to respond to mental ill health. Concerns about available funding and resources to respond to increased workload will need to be addressed should post-deployment screening for mental health be introduced in the UK military.

Approximately 60% of military personnel who experience mental health problems do not seek help, yet many of them could benefit from professional treatment. Across military studies, one of the most frequently reported barriers to help-seeking for mental health problems is concerns about stigma. It is, however, less clear how stigma influences mental health service utilization. This review will synthesize existing research on stigma, focusing on those in the military with mental health problems. We conducted a systematic review and meta-analysis of studies between 2001 and 2014 to examine the prevalence of stigma for seeking help for a mental health problem and its association with help-seeking intentions/mental health service utilization. Twenty papers met the search criteria. Weighted prevalence estimates for the 2 most endorsed stigma concerns were 44.2% (95% confidence interval: 37.1, 51.4) for "My unit leadership might treat me differently" and 42.9% (95% confidence interval: 36.8, 49.0) for "I would be seen as weak." Nine studies found no association between anticipated stigma and help-seeking intentions/mental health service use and 4 studies found a positive association. One study found a negative association between self-stigma and intentions to seek help. Counterintuitively, those that endorsed high anticipated stigma still utilized mental health services or were interested in seeking help. We propose that these findings may be related to intention-behavior gaps or methodological issues in the measurement of stigma. Positive associations may be influenced by modified labeling theory. Additionally, other factors such as self-stigma and negative attitudes toward mental health care may be worth further attention in future investigation., (© The Author 2015. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Recent epidemiological evidence suggests that military personnel commonly remain psychologically resilient in the face of adversity they face on deployment. However, the processes that promote resilience have not been well assessed within the UK military. For many years, the UK Armed Forces have operated a policy of rest and recuperation (R&R), which refers to the brief period during which troops return home when on an operational tour of duty. While R&R is thought to play an import ant role in promoting recovery and well-being, there is as yet no empirical evidence to support its effectiveness., Aims: To explore whether R&R promotes well-being and recovery from the strains of deployment in military personnel., Methods: Participants completed self-report measures of mental health and exposure to potentially traumatic events (PTEs), as well as an R&R Recovery Questionnaire (R&RRQ)., Results: Statistical analysis indicated that the R&RRQ was a reliable measure within the sample of 97 subjects. Participants who reported recovery following R&R reported fewer symptoms of mental health difficulties. However, increased deployment exposure to PTEs was associated with feeling less recovered at the end of R&R., Conclusions: These preliminary data suggest that R&R can be useful for troops if they can use the time to recover. This study's results are relevant to policymakers and leaders in the military and other groups placed in challenging environments but more work is needed to understand how R&R works and to maximize its capacity to promote well-being among military personnel., (© Crown copyright 2014.)

Purpose: Beliefs about other people's potential views or reactions may be powerful determinants of mental health help-seeking behaviours. United Kingdom Armed Forces (UK AF) have made considerable efforts to promote appropriate help seeking though it is often suggested that military personnel remain reluctant to seek help. This study evaluated a novel stigma-reduction method, stand-up comedy, in service personnel., Method: Personnel viewed a regular comedy show or a show containing mental health information. Pre, immediately post-show and 3 months later, military stigmatisation, potential discrimination, mental health knowledge, help-seeking and coping behaviour, talking about mental health, current mental health and alcohol use were measured., Results: Response rates were 81.3 % pre-show, 67.6 % post-show and 18.9 % at follow-up. Inclusion of mental health material did not appear to detract from show satisfaction. Post-show, intervention group (IG) participants reported significantly less stigmatisation and accurately answered mental health-related questions; in the small numbers followed up, neither difference was maintained, however, IG personnel were statistically significantly more likely to discuss mental health and to advise others about mental health; adjusted analyses suggested that this was related to factors other than the show., Conclusion: In UK AF personnel, embedding mental health awareness within a comedy show format had a short-term positive effect upon military stigmatisation regarding mental health. The low rate of follow-up limited our ability to assess whether this effect was durable. If the longevity of change can be adequately assessed and demonstrated in further research, comedy could potentially form a component of a comprehensive stigma-reduction strategy.

Objectives: A pilot study to assess the practicality of introducing an enhanced mental health assessment (EMHA) into all routine and discharge medicals of the UK Armed Forces in order to facilitate treatment prior to and on return to civilian life., Methods: A pilot study was conducted using an EMHA questionnaire with questions about depression, anxiety, post-traumatic stress disorder, alcohol use, sleep and anger/irritability. At pilot sites, the EMHA was completed during all routine and discharge medicals between May 2011 and July 2011. At the end of the study period, qualitative data were collected from participating medical officers and practice managers regarding their opinions about the pilot study., Results: The quantitative data revealed an average pick-up rate for mental health (MH) problems. Out of the four military medical centres who participated and the 325 questionnaires collected, one referral to a Department of Community Mental Health was made. 26 (8%) patients were categorised as 'some concern and patient offered advice and/or reassurance'. The vast majority of patients were found to have no evidence of MH problems. However, using a validated alcohol screening tool, 64% of service personnel were found to have a score indicating 'higher risk drinking'. Analysis of the qualitative data suggests that the EMHA is an easy tool to implement with minimal additional time and resources needed. The interviewees pointed out a number of limitations and suggestions for possible further studies., Conclusions: The pilot study successfully demonstrated that the EMHA questionnaire is easy to administer, does not take up a large amount of additional resources or manpower and provides a useful check of MH status. The study picked up an average number of MH cases and the questions on alcohol consumption highlighted that military personnel may be at a 'higher risk of drinking'.

Background: Most accounts of deployment mental health in UK armed forces personnel rely on retrospective assessments., Aims: We present data relating to the burden of mental ill health and the effect of support measures including operational, family, welfare and medical support obtained on two occasions some 18 months apart., Method: A total of 2794 personnel completed a survey while deployed to Afghanistan; 1363 in 2011 and 1431 in 2010. Their responses were compared and contrasted., Results: The prevalence of self-report mental health disorder was low and not significantly different between the surveys; the rates of probable post-traumatic stress disorder (PTSD) were 2.8% in 2010 and 1.8% in 2011; for common mental health disorders the rates were 17.0% and 16.0% respectively. Remembering receiving predeployment psychoeducation, perceptions of good leadership and good family support were all significantly associated with better mental health. Seeking support from non-medical sources and reporting sick for medical reasons were both significantly associated with poorer mental health., Conclusions: Over a period of 18 months, deployment mental health symptoms in UK armed forces personnel were fewer than those obtained from a military population sample despite continuing deployment in a high-threat context and were associated with perceptions of support.

Objective: Rest and Recuperation (R&R) is a period of home leave taken during an operational deployment; we sought to examine the relationship between taking R&R and mental health., Design: A survey-based post-intervention evaluation., Setting: UK PARTICIPANTS: 232 members of the UK Armed Forces; 42 of which completed pre and post R&R surveys., Main Outcome Measures: Alcohol use, Post Traumatic Stress Disorder, Common Mental Disorder Symptoms and R&R experiences., Results: 12.1% of respondents (n=27) reported symptoms of common mental disorder and 3.7% (n=8) reported probable PTSD. 50.0% (n=110) reported hazardous use of alcohol during R&R. In the pre- and post-assessed sample, mental health status and alcohol use levels were similar at both survey points. Using principal component analysis, five components of R&R were identified; mentally switching off from deployment, travel experience, physical recovery, relaxation, rest and social support. R&R was extremely popular and although it did not improve mental health overall, the ability to engage with or derive satisfaction from aspects of the five components was significantly associated with better mental health and less alcohol use at the end of R&R., Conclusion: Operational commanders should advise personnel about the best way to actively engage with R&R before they leave theatre and be aware of the significant detrimental impact of disrupted travel arrangements upon the ability to benefit from R&R.

Objectives: To compare attitudes to mental illness in the U.K. military and in the general population in England., Methods: Using data from a cross-sectional survey of 821 U.K. military personnel and a separate cross-sectional survey of 1,729 members of the general population in England, levels of agreement with five statements about mental illness were compared in the military and the general population., Results: The majority of respondents from both populations showed positive attitudes toward mental illness. The general population showed slightly more positive attitudes toward integrating people with mental illness into the community (68.0% [65.7%-70.1%] agreed that "People with mental illness have the same rights to a job as everyone else," vs. 56.7% [51.5%-61.7%] of the military). However, the general population showed more negative attitudes about the causes of mental illness (62.4% [60.1%-64.6%] disagreed that "One of the main causes of mental illness is a lack of self-discipline and willpower," vs. 81.3% [77.0%-84.9%] of the military)., Conclusions: Overall, attitudes toward mental illness are comparable in the general population in England and the U.K. military. Differences included the military holding more positive attitudes about the causes of mental illness, but more negatives attitudes about job rights of those with mental illness. Strategies aiming to improve attitudes toward mental illness could focus particularly on personnel's concerns around mental illness impacting on their career., (Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.)

Stigmatizing beliefs about seeking help for mental health conditions and perceived barriers to care (BTC) may influence the decision to seek support and treatment in U.K. military personnel. Many coalition partners, including the U.K. Armed Forces (UKAF), have made considerable efforts to reduce stigma/BTC although the impact of these efforts over time has not been assessed. We surveyed a total of 23,101 UKAF personnel who deployed to Afghanistan and Iraq between 2008 and 2011 and examined whether stigma/BTC levels changed during this time. The results suggested that stigma, including the fear of being treated differently by commanders and loss of trust among peers, was greater than perceived BTC. The likelihood of reporting stigma/BTC, although significantly greater during deployment than postdeployment, reduced significantly over the survey period. A similar reduction was less apparent during postdeployment phase. These findings support the notion that UKAF's anti-stigma campaigns may have had some positive effects, particularly among deployed personnel. However, we suggest that stigma still plays a part in inhibiting help-seeking, particularly during deployment when stigma rates are higher, and that a careful balance must be struck between encouraging help-seeking and maintaining the operational effectiveness of deployed personnel., (Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.)

Objective: Third Location Decompression (TLD) is an activity undertaken by UK Armed Forces (UK AF) personnel at the end of an operational deployment which aims to smooth the transition between operations and returning home. We assessed whether TLD impacted upon both mental health and postdeployment readjustment., Method: Data collected during a large cohort study was examined to identify personnel who either engaged in TLD or returned home directly following deployment. Propensity scores were generated and used to calculate inverse probability of treatment weights in adjusted regression analyses to compare mental health outcomes and postdeployment readjustment problems., Results: TLD had a positive impact upon mental health outcomes (post-traumatic stress disorder (PTSD) and multiple physical symptoms) and levels of harmful alcohol use. However, when the samples were stratified by combat exposure, although postdeployment readjustment was similar for all exposure levels, personnel experiencing low and moderate levels of combat exposure experienced the greatest positive mental health effects., Conclusions: We found no evidence to suggest that TLD promotes better postdeployment readjustment; however, we found a positive impact upon alcohol use and mental health with an interaction with degree of combat exposure. This study suggests that TLD is a useful postdeployment transitional activity that may help to improve PTSD symptoms and alcohol use in UK AF personnel.

Background: Approximately 18,000 personnel leave the UK Armed Forces annually. Those leaving before completing the minimum term of their contracts are called early Service leavers (ESLs). This study aims to identify characteristics associated with being an ESL, and compare the post-discharge mental health of ESLs and other Service leavers (non-ESLs)., Method: A cross-sectional study used data on ex-Serving UK Armed Forces personnel. ESLs were personnel leaving before completing their 3-4.5 years minimum Service contracts and were compared with non-ESLs. Multivariable logistic regression was used to estimate odds ratios and 95% confidence intervals for the associations between Service leaving status with socio-demographics, military characteristics and mental health outcomes., Results: Of 845 Service leavers, 80 (9.5%) were ESLs. Being an ESL was associated with younger age, female sex, not being in a relationship, lower rank, serving in the Army and with a trend of reporting higher levels of childhood adversity, but not with deployment to Iraq. ESLs were at an increased risk of probable post-traumatic stress disorder (PTSD), common mental disorders, fatigue and multiple physical symptoms, but not alcohol misuse., Conclusions: The study suggests that operational Service is not a factor causing personnel to become an ESL. Current mental health problems were more commonly reported among ESLs than other Service leavers. There may be a need to target interventions to ESLs on leaving Service to smooth their transition to civilian life and prevent the negative mental health outcomes experienced by ESLs further down the line.

Deployments increase risk for adjustment problems in service members. To mitigate this increased risk, mental health training programs have been developed and implemented in several nations. As part of a coordinated effort, three nations adapted a U.S. mental health training program that had been validated by a series of group randomized trials demonstrating improvement in postdeployment adjustment. Implementation of evidence-based programs in a new context is challenging: How much of the original program needs to remain intact in order to retain its utility? User satisfaction rates can provide essential data to assess how well a program is accepted. This article summarizes service member ratings of postdeployment mental health training and compares ratings from service members across four nations. The participating nations (Canada, New Zealand, United Kingdom, and the United States) administered mental health training to active duty military personnel in their respective nations. Following the training, military personnel completed an evaluation of the training. Overall, across the four nations, more than 70% of military personnel agreed or strongly agreed that they were satisfied with the mental health training. Although some differences in evaluations were observed across nations, components of training that were most important to overall satisfaction with the training were strikingly similar across nations. Fundamentally, it appears feasible that despite cultural and organizational differences, a mental health training program developed in one nation can be successfully adapted for use in other nations., (PsycINFO Database Record (c) 2013 APA, all rights reserved.)

Background: Violent offending by veterans of the Iraq and Afghanistan conflicts is a cause for concern and there is much public debate about the proportion of ex-military personnel in the criminal justice system for violent offences. Although the psychological effects of conflict are well documented, the potential legacy of violent offending has yet to be ascertained. We describe our use of criminal records to investigate the effect of deployment, combat, and post-deployment mental health problems on violent offending among military personnel relative to pre-existing risk factors., Methods: In this cohort study, we linked data from 13,856 randomly selected, serving and ex-serving UK military personnel with national criminal records stored on the Ministry of Justice Police National Computer database. We describe offending during the lifetime of the participants and assess the risk factors for violent offending., Findings: 2,139 (weighted 17.0%) of 12,359 male UK military personnel had a criminal record for any offence during their lifetime. Violent offenders (1,369 [11.0%]) were the most prevalent offender types; prevalence was highest in men aged 30 years or younger (521 [20.6%] of 2,728) and fell with age (164 [4.7%] of 3027 at age >45 years). Deployment was not independently associated with increased risk of violent offending, but serving in a combat role conferred an additional risk, even after adjustment for confounders (violent offending in 137 [6.3%] of 2178 men deployed in a combat role vs 140 (2.4%) of 5,797 deployed in a non-combat role; adjusted hazard ratio 1.53, 95% CI 1.15-2.03; p=0.003). Increased exposure to traumatic events during deployment also increased risk of violent offending (violent offending in 104 [4.1%] of 2753 men with exposure to two to four traumatic events vs 56 [1.6%] of 2944 with zero to one traumatic event, 1.77, 1.21-2.58, p=0.003; and violent offending in 122 [5.1%] of 2582 men with exposure to five to 16 traumatic events, 1.65, 1.12-2.40, p=0.01; test for trend, p=0.032). Violent offending was strongly associated with post-deployment alcohol misuse (violent offending in 120 [9.0%] of 1363 men with alcohol misuse vs 155 [2.3%] of 6768 with no alcohol misuse; 2.16, 1.62-2.90; p<0.0001), post-traumatic stress disorder (violent offending in 25 [8.6%] of 344 men with post-traumatic stress disorder vs 221 [3.0%] of 7256 with no symptoms of post-traumatic stress disorder; 2.20, 1.36-3.55; p=0.001), and high levels of self-reported aggressive behaviour (violent offending in 56 [6.7%] of 856 men with an aggression score of six to 16 vs 22 [1.2%] of 1685 with an aggression score of zero; 2.47, 1.37-4.46; p=0.003). Of the post-traumatic stress disorder symptoms, the hyperarousal cluster was most strongly associated with violent offending (2.01, 1.50-2.70; p<0.0001)., Interpretation: Alcohol misuse and aggressive behaviour might be appropriate targets for interventions, but any action must be evidence based. Post-traumatic stress disorder, though less prevalent, is also a risk factor for violence, especially hyperarousal symptoms, so if diagnosed it should be appropriately treated and associated risk monitored., Funding: Medical Research Council and the UK Ministry of Defence., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objectives: British forces have a comprehensive system for managing acute psychological distress in a combat zone. This includes peer support via Trauma Risk Management (TRiM), access to deployed medical personnel, and a Field Mental Health Team (FMHT). TRiM and medical personnel need to be aware of the FMHT's presence in the combat zone and capability to provide specialist mental health care., Methods: TRiM and medical personnel completed a survey based on 6 audit standards. Differences between TRiM and medical personnel and the effects of rank, role, and location in theater were assessed using the Pearson χ(2) statistical test. Statistical significance was defined as p ≤ 0.05., Results: Most TRiM and medical personnel knew that an FMHT was embedded within the deployed force. Significantly less TRiM than medical personnel knew that the FMHT would carry out clinical assessments at forward locations. There was a high degree of satisfaction with the service provided by the FMHT., Conclusion: Corporate knowledge of the FMHT by both Medical and TRiM personnel was generally good. TRiM training should increase its emphasis on the FMHT's ability to undertake assessments at forward locations. Efforts by the FMHT to ensure corporate knowledge among TRiM personnel should focus on more forward locations., (Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.)

Reserve and National Guard forces have been mobilized to an unprecedented degree in recent overseas conflicts. There is concern that rates of psychological problems may continue to rise for many years after deployment. The authors conducted a cohort study of 552 United Kingdom Reservists who deployed to Iraq in 2003 and 391 nondeployed Reservists. Measures of mental health and social functioning were collected a mean of 16 months and 4.8 years after return from possible deployment. At the first follow-up, deployment was associated with increased common mental disorder, post-traumatic stress disorder (PTSD), and poor general health. By the second follow-up, those who had deployed were no longer at increased risk for common mental disorder or poor general health and had good levels of social functioning. However, those who deployed continued to have over twice the odds of PTSD (odds ratio = 2.42, 95% confidence interval: 1.04, 5.62) and were more likely to report actual or serious consideration of separation from their partner. In conclusion, the authors found that the majority of mental health and social problems following deployment are transient. However, Reservists who deployed in the Iraq War remain at increased risk of PTSD and relationship problems 5 years after their tour of duty.

Objective: The objective of the study was to elicit beliefs and experiences of the value of a screening programme for mental illness among UK military personnel., Method: Three months after returning from Afghanistan 21 army personnel participated in a qualitative study about mental health screening. One-to-one interviews were conducted and recorded. Data-driven thematic analysis was used. Researchers identified master themes represented by extracts of text from the 21 complete transcripts., Results: Participants made positive remarks on the advantages of screening. Noted barriers to seeking help included: unwillingness to receive advice, a wish to deal with any problems themselves and a belief that military personnel should be strong enough to cope with any difficulties. Participants believed that overcoming barriers to participating in screening and seeking help would be best achieved by making screening compulsory., Conclusions: Although respondents were positive about a screening programme for mental illness, the barriers to seeking help for mental illness appear deep rooted and reinforced by the value ascribed to hardiness.

Background: There is no doubt that the perceived stigma of having a mental disorder acts as a barrier to help seeking. It is possible that personnel may be reluctant to admit to symptoms suggestive of poor mental health when such data can be linked to them, even if their personal details are only used to help them access further care. This may be particularly relevant because individuals who have a mental health problem are more likely to experience barriers to care and hold stigmatizing beliefs. If that is the case, then mental health screening programmers may not be effective in detecting those most in need of care. We aimed to compare mental health symptom reporting when using an anonymous versus identifiable questionnaire among UK military personnel on deployment in Iraq., Methods: Survey among UK military personnel using two questionnaires, one was anonymous (n = 315) and one collected contact details (i.e. identifiable, n = 296). Distribution was by alternate allocation. Data were collected in Iraq during January-February 2009., Results: No significant difference in the reporting of symptoms of common mental disorders was found (18.1% of identifiable vs. 22.9% of anonymous participants). UK military personnel were more likely to report sub-threshold and probable PTSD when completing questionnaires anonymously (sub-threshold PTSD: 2.4% of identifiable vs. 5.8% of anonymous participants; probable PTSD: 1.7% of identifiable vs. 4.8% of anonymous participants). Of the 11 barriers to care and perceived social stigma statements considered, those completing the anonymous questionnaire compared to those completing the identifiable questionnaire were more likely to endorse three statements: "leaders discourage the use of mental health services" (9.3% vs. 4.6%), "it would be too embarrassing" (41.6% vs. 32.5%) and "I would be seen as weak" (46.6% vs. 34.2%)., Conclusions: We found a significant effect on the reporting of sub-threshold and probable PTSD and certain stigmatizing beliefs (but not common mental disorders) when using an anonymous compared to identifiable questionnaire, with the anonymous questionnaire resulting in a higher prevalence of PTSD and increased reporting of three stigmatizing beliefs. This has implications for the conduct of mental health screening and research in the US and UK military.

Background: Most studies of the mental health of UK armed forces focus on retrospective accounts of deployment and few sample personnel while they are deployed., Aims: This study reports the results of a survey of deployed personnel, examining the perceived impact of events at home and military support for the family on current mental health during the deployment., Method: Surveys were conducted with 2042 British forces personnel serving in Iraq and Afghanistan. Prevalence of common mental disorders was assessed with the 12-item General Health Questionnaire (GHQ-12) and post-traumatic stress disorder (PTSD) was assessed with the PTSD Checklist - Civilian version (PCL-C)., Results: The prevalence of common mental disorders was 17.8% and of probable PTSD was 2.8%. Perceived home difficulties significantly influenced the mental health of deployed personnel; the greater the perception of negative events in the home environment, the greater the reporting of adverse mental health effects. This finding was independent of combat exposure and was only partially mitigated by being well led and reporting subjectively good unit cohesion; however, the effect of the totality of home-front events was not improved by the latter. Poor perceived military support for the family had a detrimental impact on deployment mental health., Conclusions: The armed forces offer many support services to the partners and families of deployed personnel and ensuring that the efforts being made on their behalf are well communicated might improve the mental health of deployed personnel.

UK Armed Forces (AF) personnel deployed to Afghanistan are frequently exposed to intense combat and yet little is known about the short-term mental health consequences of this exposure and the potential mitigating effects of military factors such as cohesion, morale, and leadership. To assess the possible modulating influence of cohesion, morale, and leadership on post-traumatic stress disorder (PTSD) symptoms and common mental disorders resulting from combat exposure among UK AF personnel deployed to Afghanistan, UK AF personnel, during their deployment to Afghanistan in 2010, completed a self-report survey about aspects of their current deployment, including perceived levels of cohesion, morale, leadership, combat exposure, and their mental health status. Outcomes were symptoms of common mental disorder and symptoms of PTSD. Combat exposure was associated with both PTSD symptoms and symptoms of common mental disorder. Of the 1,431 participants, 17.1% reported caseness levels of common mental disorder, and 2.7% were classified as probable PTSD cases. Greater self-reported levels of unit cohesion, morale, and perceived good leadership were all associated with lower levels of common mental disorder and PTSD. Greater levels of unit cohesion, morale, and good leadership may help to modulate the effects of combat exposure and the subsequent development of mental health problems among UK Armed Forces personnel deployed to Afghanistan., (© 2012 Guilford Publications, Inc.)

Background: Employers such as the Armed Forces (AF) and emergency services, who predictably expose their staff to potentially traumatic events (PTEs), often provide psycho-educational briefings in an attempt to mitigate possible adverse psychological sequelae. Within the military, psycho-educational briefings are widely used, particularly following exposure to PTEs on operations. The aim of this review was to evaluate the efficacy of these interventions and make appropriate recommendations., Method: A search of Medline, PsycINFO and EMBASE was conducted, bibliographies of retrieved articles were searched and experts in the field were consulted., Results: Two surveys and seven intervention studies were identified for inclusion in the review. Only three studies were randomized controlled trials (RCTs). Overall, the review found some evidence of benefit of psycho-educational interventions but it was not consistent across studies or outcomes and effects were small. However, there was also little evidence to suggest that they caused harm. There was some evidence that the beneficial effects may be greater for those who have been exposed to a higher number of PTEs., Conclusions: Given the high operational tempo currently faced by coalition forces personnel, there remains a pressing need to identify the most effective way of minimizing the impact of exposure to potentially traumatic deployment incidents. To date, few psycho-educational interventions designed to prevent deployment-related psychological ill-health have been evaluated systematically in methodologically robust studies. The review recommends that future interventions are theoretically based and evaluated in cluster RCTs that examine both process and outcome variables.