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BackgroundPosttraumatic stress disorder (PTSD) is highly prevalent within prison settings, yet is often unidentified and undertreated. Complex PTSD (CPTSD) has been recently formally recognised in the International Classification of Diseases 11th revision (ICD-11) diagnostic framework but has never been explored in prison settings. We aimed to establish the prevalence of ICD-11 PTSD and CPTSD in a UK prison sample using a validated instrument (the International Trauma Questionnaire). We also explored the associations of these two diagnoses with their traumatic antecedents and psychiatric comorbidities.MethodRandomly selected male, sentenced prisoners in a large medium-security prison in south London (N = 221) took part in a clinical interview which assessed PTSD, CPTSD, trauma histories, and comorbid disorders. Multinomial logistic regression was performed to examine differences between those with PTSD or CPTSD, and those without symptoms.ResultsA total of 7.7% (95% CI 4.5–12) of the male sentenced prisoners met diagnostic criteria for ICD-11 PTSD and 16.7% (95% CI 12.1–22.3) for CPTSD. A diagnosis of PTSD was associated with more recent traumatic exposure, comorbid generalised anxiety disorder, alcohol dependence, and Cluster B personality disorder. A diagnosis of CPTSD was associated with complex trauma exposure antecedents (developmental, interpersonal, repeated, or multiple forms), and comorbid with anxiety, depression, substance misuse, psychosis, and ADHD.ConclusionsThis study confirms that CPTSD is a very common and comorbid condition in male prisoners. There is an urgent need to develop trauma-informed care in prisons.

BackgroundFor 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.MethodsVeteran 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).ResultsWe 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.ConclusionWhilst 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.

Domestic violence and abuse (DVA) is a global public health problem, accounting for up to 7% of the overall burden of disease among women, mostly due to its impact on mental ill health. It includes partner violence and violence perpetrated by other family members on adults, and may involve mutual violence or can involve coercive and controlling behaviours. Women are at greatest risk of serious physical and sexual assaults, including being victims of domestic homicide. There is growing evidence that men and women with mental disorders, particularly severe disorders, are at increased risk of being both victims and perpetrators of DVA. Despite barriers to disclosure, psychiatric services are well placed to identify and reduce the risk of future DVA and treat the mental health consequences.

Purpose There is growing awareness of the problem of intimate partner violence (IPV) among military populations. IPV victimisation has been shown to be associated with mental disorder. A better understanding of the link between IPV and mental disorder is needed to inform service development to meet the needs of military families. We aimed to systematically review the literature on the association between IPV victimisation and mental health disorders among military personnel. Methods Searches of four electronic databases (Embase, Medline, PsycINFO, and Web of Science) were supplemented by reference list screening. Heterogeneity among studies precluded a meta-analysis. Results Thirteen studies were included. There was stronger evidence for an association between IPV and depression/alcohol problems than between IPV and PTSD. An association between IPV and mental health problems was more frequently found among veterans compared to active duty personnel. However, the link between IPV and alcohol misuse was more consistently found among active duty samples. Finally, among active duty personnel psychological IPV was more consistently associated with depression/alcohol problems than physical/sexual IPV. The review highlighted the lack of research on male IPV victimisation in the military. Conclusions There is evidence that the burden of mental health need may be significant among military personnel who are victims of IPV. The influence of attitudes towards gender in the military on research in this area is discussed. Further research is needed to inform development of services and policy to reduce IPV victimisation and the mental health consequences among military personnel. Electronic supplementary material The online version of this article (doi:10.1007/s00127-017-1423-8) contains supplementary material, which is available to authorized users.

BackgroundA proportion of ex-military personnel who develop mental health and social problems end up in the Criminal Justice System. A government review called for better understanding of pathways to offending among ex-military personnel to improve services and reduce reoffending. We utilised data linkage with criminal records to examine the patterns of offending among military personnel after they leave service and the associated risk (including mental health and alcohol problems) and socio-economic protective factors.MethodQuestionnaire data from a cohort study of 13 856 randomly selected UK military personnel were linked with national criminal records to examine changes in the rates of offending after leaving service.ResultsAll types of offending increased after leaving service, with violent offending being the most prevalent. Offending was predicted by mental health and alcohol problems: probable PTSD, symptoms of common mental disorder and aggressive behaviour (verbal, property and threatened or actual physical aggression). Reduced risk of offending was associated with post-service socio-economic factors: absence of debt, stable housing and relationship satisfaction. These factors were associated with a reduced risk of offending in the presence of mental health risk factors.ConclusionsEx-military personnel are more likely to commit violent offences after leaving service than other offence-types. Mental health and alcohol problems are associated with increased risk of post-service offending, and socio-economic stability is associated with reduced risk of offending among military veterans with these problems. Efforts to reduce post-service offending should encompass management of socio-economic risk factors as well as mental health.

BackgroundThere is growing risk from terrorism following radicalisation of young men. It is unclear whether psychopathology is associated.AimsTo investigate the population distribution of extremist views among UK men.MethodCross-sectional study of 3679 men, 18–34 years, in Great Britain. Multivariate analyses of attitudes, psychiatric morbidity, ethnicity and religion.ResultsPro-British men were more likely to be White, UK born, not religious; anti-British were Muslim, religious, of Pakistani origin, from deprived areas. Pro- and anti-British views were linearly associated with violence (adjusted odds ratio (OR) = 1.51, 95% CI 1.38–1.64,PPPP= 0.003, respectively).ConclusionsMen at risk of depression may experience protection from strong cultural or religious identity. Antisocial behaviour increases with extremism. Religion is protective but may determine targets of violence following radicalisation.

Large numbers of British and American Reservists have been deployed to operations in Iraq and Afghanistan. Little is known about the impact of deployment and combat exposure on violent behavior in Reservists. The purpose of this study was to determine the prevalence of self-reported violent behavior among a representative sample of United Kingdom Reservists, the risk factors associated with violence and the impact of deployment and combat exposure on violence. This study used data from a large cohort study of randomly selected UK military personnel and included Reservists who were in service at the time of sampling (n = 1710). Data were collected by questionnaires that asked about socio-demographic and military characteristics, pre-enlistment antisocial behavior, deployment experiences, post-deployment mental health, and self-reported interpersonal violent behavior. The prevalence of violence among Reservists was 3.5%. Deployment was found to be a risk factor for violent behavior even after adjustment for confounders. The association with violence was similar for those deployed in either a combat role or non-combat role. Violence was also strongly associated with mental health risk factors (PTSD, common mental disorders, and alcohol misuse). This study demonstrated higher levels of self-reported post-deployment violence in UK Reservists who had served in either Iraq or Afghanistan. Deployment, irrespective of the role was associated with higher levels of violent behavior among Reservists. The results also emphasize the risk of violent behavior associated with post-deployment mental health problems. Aggr. Behav. 9999:1–8, 2016. © 2016 Wiley Periodicals, Inc.

Background: UK armed forces personnel are at risk of occupational psychological injury; they are often reluctant to seek help for such problems. Objective: We aimed to examine and describe sources of support, prevalence and associates of help-seeking among UK serving and ex-serving personnel. Method: A total of 1450 participants who self-reported a stress, emotional or mental health problem in the past 3 years were sampled from a health and wellbeing study and subsequently completed a telephone interview comprising measures of mental disorder symptoms, alcohol misuse and help-seeking behaviour. Results: Seven per cent of participants had not sought any help, 55% had accessed medical sources of support (general practitioner or mental health specialist), 46% had received formal non-medical (welfare) support and 86% had used informal support. Gender, age, perceived health, functional impairment, social support, deployment, alcohol and comorbidity impacted upon the choice of help source. Conclusions: This study found that the majority of those with perceived mental health problems sought some form of help, with over half using formal medical sources of support. • In contrast to previous studies of help-seeking in serving and ex-serving personnel, and the public perception, this study found that the majority of those with perceived mental health problems sought some form of help.• Over half used formal medical sources of support.• Younger males who reported lower levels of social support were less likely to seek support.

BackgroundResearch into violence among military personnel has not differentiated between stranger- and family-directed violence. While military factors (combat exposure and post-deployment mental health problems) are risk factors for general violence, there has been limited research on their impact on violence within the family environment. This study aims to compare the prevalence of family-directed and stranger-directed violence among a deployed sample of UK military personnel and to explore risk factors associated with both family- and stranger-directed violence.MethodThis study utilised data from a large cohort study which collected information by questionnaire from a representative sample of randomly selected deployed UK military personnel (n = 6711).ResultsThe prevalence of family violence immediately following return from deployment was 3.6% and 7.8% for stranger violence. Family violence was significantly associated with having left service, while stranger violence was associated with younger age, male gender, being single, having a history of antisocial behaviour as well as having left service. Deployment in a combat role was significantly associated with both family and stranger violence after adjustment for confounders [adjusted odds ratio (aOR) = 1.92 (1.25–2.94), p = 0.003 and aOR = 1.77 (1.31–2.40), p < 0.001, respectively], as was the presence of symptoms of post-traumatic stress disorder, common mental disorders and aggression.ConclusionsExposure to combat and post-deployment mental health problems are risk factors for violence both inside and outside the family environment and should be considered in violence reduction programmes for military personnel. Further research using a validated measurement tool for family violence would improve comparability with other research.

A systematic review and meta-analyses were conducted on studies of the prevalence of aggressive and violent behavior, as well as of violent offenses and convictions, among military personnel following deployment to Iraq and/or Afghanistan; the relationship with deployment and combat exposure; and the role that mental health problems, such as post-traumatic stress disorder (PTSD), have on the pathway between deployment and combat to violence. Seventeen studies published between January 1, 2001, and February 12, 2014, in the United States and the United Kingdom met the inclusion criteria. Despite methodological differences across studies, aggressive behavior was found to be prevalent among serving and formerly serving personnel, with pooled estimates of 10% (95% confidence interval (CI): 1, 20) for physical assault and 29% (95% CI: 25, 36) for all types of physical aggression in the last month, and worthy of further exploration. In both countries, rates were increased among combat-exposed, formerly serving personnel. The majority of studies suggested a small-to-moderate association between combat exposure and postdeployment physical aggression and violence, with a pooled estimate of the weighted odds ratio = 3.24 (95% CI: 2.75, 3.82), with several studies finding that violence increased with intensity and frequency of exposure to combat traumas. The review's findings support the mediating role of PTSD between combat and postdeployment violence and the importance of alcohol, especially if comorbid with PTSD.

We assessed the strength of the association of several mental health problems, childhood difficulties, and combat role with anger, as well as the contribution of these factors to explain anger assessed by population attributable fraction (PAF). A total of 9885 UK service personnel, some of them deployed to Iraq and Afghanistan, participated in the study. There was a strong or intermediate association between cases and subthreshold cases of symptoms of posttraumatic stress disorder, psychological distress, multiple physical symptoms and alcohol misuse, having a combat role, childhood adversity, and childhood antisocial behavior with anger. The PAF for any mental health problem and combat role and childhood difficulties was 0.64 (95% confidence interval [CI], 0.56-0.70) and increased to 0.77 (95% CI, 0.69-0.83) if subthreshold cases were included. Anger is a frequent component of mental disorders; health care professionals need to be aware of the interference of anger in the management of mental illness and that anger infrequently presents as an isolated phenomenon.

The longer term mental health outcomes of UK serving and ex-serving personnel have been the subject of much speculation. The latest research findings from the third phase of a longitudinal study will be presented, which is the only military cohort study of its kind in the UK. Data was collected among 8093 personnel between 2014 and 2016. The study examined the prevalence of mental disorders and alcohol misuse, whether rates differed between serving and ex-serving regular personnel and the impact of various deployment exposures. The prevalence of probable posttraumatic stress disorder was 6.2% (95% confidence interval (CI) 5.5–6.9), 21.9% (95% CI 20.8–23.0) for common mental disorders and 10.0% (95% CI 9.2–10.9) for alcohol misuse. Deployment to Iraq or Afghanistan and self-reported 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. There was no association with number of deployments for any outcome. The findings highlight the importance of the continued monitoring of following personnel throughout their military career and beyond. The implications of the study outcomes will be discussed in the light of the mental health provision for serving and ex-serving personnel.

The aetiology of offending among military personnel, in particular violent offending, is a topic of increased political interest in the aftermath of the Iraq/Afghanistan conflicts. This paper will present findings from research which linked data from a representative sample of UK military personnel with official criminal justice records to explore how early life factors, military-experiences, mental health and post-service factors impact on offending behaviour in this population. In particular the impact of combat exposure and the mediating role of PTSD and alcohol misuse will be described, as well as the protective role of socioeconomic stability after the leaving service.

Concern has been raised over alleged increases in antisocial behaviour by military personnel returning from the deployment in Iraq and Afghanistan. U.S.-based research has shown that post-deployment violence is related not only to combat experience, but also to pre-enlistment antisocial behaviour (ASB). This study aimed to examine the association between pre-enlistment ASB and later behavioural outcomes, including aggression, in a large randomly selected U.K. military cohort.Baseline data from a cohort study of 10,272 U.K. military personnel in service at the time of the Iraq war in 2003 were analysed. The associations between pre-enlistment ASB and a range of socio-demographic and military variables were examined as potential confounders. Logistic regression analyses were performed to examine the relationship between pre-enlistment ASB and military behavioural outcomes such as severe alcohol use, violence/aggression and risk-taking behaviour, controlling for confounders.18.1% were defined as having displayed pre-enlistment ASB. Pre-enlistment ASB was significantly associated with factors such as younger age, low educational achievement, male gender, non-officer rank, Army personnel, being a regular, increasing time spent on the deployment and having a combat role. Pre-enlistment ASB was associated with increased risk of negative behavioural outcomes (severe alcohol misuse, outbursts of anger or irritability, fighting or assaultative behaviour and risk-taking behaviour), after controlling for confounders, suggesting that such background information may identify individuals who are more vulnerable to subsequent behavioural disturbance.The results of this study suggest that those already demonstrating ASB prior to joining the military are more likely to continue on this trajectory, thus emphasising the importance of considering pre-enlistment behaviour when exploring the aetiology of aggression in military personnel.

Background A small but significant proportion of military veterans become involved in the criminal justice system (CJS) after leaving service. Liaison and Diversion (L&D) services aim to identify vulnerable offenders in order to provide them with the health/welfare support they need, and (where possible) divert them away from custody. An administrative database of L&D service-users was utilised to compare the needs of veterans with those of non-veteran L&D service-users.Method National data collected from 29 L&D services in 2015–2016 was utilised. Of the 62,397 cases, 1,067 (2%) reported previous service in the Armed Forces, and 48,578 had no previous service history. The associations between veteran status and socio-demographic characteristics, offending behaviour, health- and mental health-problems were explored. The associations between specific types of offending and mental health problems within the veterans in the sample were also investigated.Results Veterans tended to be older, and less likely to be unemployed than non-veterans, but just as likely to have unstable living arrangements (including homelessness). Veteran status was associated with increased levels of interpersonal violence, motoring offences, anxiety disorders and hazardous drinking patterns. Veteran status was associated with decreased levels of acquisitive offending, schizophrenia, ADHD, and substance misuse. Among veterans, the presence of an anxiety disorder (umbrella term which included GAD, Phobias, PTSD etc.) was associated with increased interpersonal violence, alcohol misuse was associated with increased motoring offences, and substance use was associated with increased acquisitive offending.Conclusions Our study indicates that among offenders in the CJS who have been identified as needing health or welfare support, veterans differ from non-veterans in terms of their health and welfare needs and offending behaviour. These differences may be influenced by the impact of military service and the transition into civilian life. Our findings support the identification of military personnel within the CJS to provide appropriate interventions and support to improve outcomes and reduce offending.

BackgroundThere is concern surrounding the psychological health and uptake of treatment services among veterans of the UK Armed Forces.MethodData from a cross-sectional, nationally representative sample were used to compare health outcomes and treatment seeking among 257 post-national service veterans aged 16–64 years and 504 age and sex frequency-matched non-veterans living in the community in England. Early leavers (ResultsMale veterans reported more childhood adversity and were more likely to have experienced a major trauma in adulthood than non-veterans. There was no association between any measure of mental health and veteran status in males, except reporting more violent behaviours [adjusted odds ratio (aOR) 1.44, 95% confidence interval (CI) 1.01–2.06]. In females, a significant association was found between veteran status and ever having suicidal thoughts (aOR 2.82, 95% CI 1.13–7.03). No differences in treatment-seeking behaviour were identified between veterans and non-veterans with any mental disorder. Early service leavers were more likely to be heavy drinkers (aOR 4.16, 95% CI 1.08–16.00), to have had suicidal thoughts (aOR 2.37, 95% CI 1.21–4.66) and to have self-harmed (aOR 12.36, 95% CI 1.61–94.68) than longer serving veterans.ConclusionsThe findings of this study do not suggest that being a veteran is associated with adversity in terms of mental health, social disadvantage or reluctance to seek treatment compared with the general population. Some evidence implies that early service leavers may experience more mental health problems than longer-serving veterans.

SummaryBackgroundViolent 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.MethodsIn 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.Findings2139 (weighted 17·0%) of 12 359 male UK military personnel had a criminal record for any offence during their lifetime. Violent offenders (1369 [11·0%]) were the most prevalent offender types; prevalence was highest in men aged 30 years or younger (521 [20·6%] of 2728) 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 5797 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

BackgroundBoth involuntary dyskinetic movements and psychotic-like experiences (PLEs) are reported to be antecedents of schizophrenia that may reflect dysfunctional dopaminergic activity in the striatum. The present study compared dyskinetic movement abnormalities displayed by children with multiple antecedents of schizophrenia (ASz), including speech and/or motor developmental lags or problems, internalising/externalising problems in the clinical range, and PLEs, with those displayed by children with no antecedents (noASz).MethodThe sample included 21 ASz and 31 noASz children, aged 9–12 years old. None had taken psychotropic medication or had relatives with psychosis. The antecedents of schizophrenia were assessed using questionnaires completed by children and caregivers. A trained rater, blind to group status, coded dyskinetic movement abnormalities using a validated tool from videotapes of interviews with the children.ResultsASz children reported, on average, ‘certain experience’ of 2.5 PLEs, while noASz children, by definition, reported none. The ASz children, as compared with noASz children, displayed significantly more dyskinetic movement abnormalities in total, and in the facial and the upper-body regions, after controlling for sex and age. Receiver operator characteristics analyses yielded high area under the curve values for the total score (0.94), facial score (0.91) and upper-body score (0.86), indicating that these scores distinguished between the ASz and noASz children with great accuracy.ConclusionsBrief questionnaires identified children with multiple antecedents of schizophrenia who displayed significantly more involuntary dyskinetic movement abnormalities than children without antecedents. The presence of PLEs and dyskinesias could reflect early disruption of striatal dopamine circuits.

BackgroundThere is growing concern about an alleged rise in violent behaviour amongst military personnel returning from deployment to Iraq and Afghanistan. The aims of this study were to determine the prevalence of violence in a sample of UK military personnel following homecoming from deployment in Iraq and to examine the impact of deployment-related experiences, such as combat trauma, on violence, and the role of sociodemographics and pre-enlistment antisocial behaviour.MethodThis study used baseline data from a cohort study of a large randomly selected sample of UK Armed Forces personnel in service at the time of the Iraq war (2003). Regular personnel (n=4928) who had been deployed to Iraq were included. Data, collected by questionnaire, included information on deployment experiences, sociodemographic and military characteristics, pre-enlistment antisocial behaviour, post-deployment health outcomes and a self-report measure of physical violence in the weeks following return from deployment.ResultsPrevalence of violence was 12.6%. This was strongly associated with pre-enlistment antisocial behaviour [adjusted odds ratio (aOR) 3.6, 95% confidence interval (CI) 2.9–4.4]. After controlling for pre-enlistment antisocial behaviour, sociodemographics and military factors, violence was still strongly associated with holding a combat role (aOR 2.0, 95% CI 1.6–2.5) and having experienced multiple traumatic events on deployment (aOR for four or more traumatic events 3.7, 95% CI 2.5–5.5). Violence on homecoming was also associated with mental health problems such as post-traumatic stress disorder (aOR 4.8, 95% CI 3.2–7.2) and alcohol misuse (aOR 3.1, 95% CI 2.5–3.9).ConclusionsExperiences of combat and trauma during deployment were significantly associated with violent behaviour following homecoming in UK military personnel. Post-deployment mental health problems and alcohol misuse are also associated with increased violence.

Purpose In the context of increasing concerns for the health of UK armed forces veterans, this study aims to compare the prevalence of current mental, physical and behavioural difficulties in conscripted national service veterans with population controls, and to assess the impact of length of service in the military. The compulsory nature of national service sets these veterans apart from younger veterans. Method Data are drawn from a nationally representative community-dwelling sample of England. We compared 484 male national service veterans to 301 male non-veterans aged 65? years. Results There were no differences in mental, behavioural or physical outcomes, except that veterans were less likely to have ‘‘any mental disorder’’ than non-veterans (age adjusted OR = 0.56, 95% CI 0.31, 0.99). Longer serving veterans were older but were not different in terms of mental, behavioural or physical outcomes. Conclusions Community-dwelling national service veterans are at no greater risk of current adverse mental, physical or behavioural health than population controls.

New report emphasises the role of alcohol, social exclusion, and financial problems On 23 June the well respected Howard League for Penal Reform published their report on ex-serving armed forces personnel in prison.1 The league’s remit was to find out why so many of these people become involved in the criminal justice system, to explore the problems facing them on transition back into civilian life, and to look at the reasons underlying their offending behaviour. It is hoped that the report can provide information on how these individuals’ needs can best be met both in prison and in the community. Concerns about how service personnel will reintegrate into society after war are nothing new. After the second world war, returning veterans were often seen less as heroes and more as potential social problems with violence and offending high on the list of concerns.2 Since 2001, more than 160 000 UK regular and reserve forces have been deployed in Iraq, Afghanistan, or both counties. There have been many accounts in the media of the challenges these individuals face in their transition back to civilian life, including problems related to housing, mental health, employment, relationship breakdown, and substance misuse,3 but also aggression, violent offending, and incarceration.4 Research examining the effects of war on psychological functioning has focused mainly on clinical outcomes, such …