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Aims: Police employees may experience high levels of stress due to the challenging nature of their work which can then lead to sickness absence. To date, there has been limited research on sickness absence in the police. This exploratory analysis investigated sickness absence in UK police employees., Methods: Secondary data analyses were conducted using data from the Airwave Health Monitoring Study (2006-2015). Past year sickness absence was self-reported and categorised as none, low (1-5 days), moderate (6-19 days) and long-term sickness absence (LTSA, 20 or more days). Descriptive statistics and multinomial logistic regressions were used to examine sickness absence and exploratory associations with sociodemographic factors, occupational stressors, health risk behaviours, and mental health outcomes, controlling for rank, gender and age., Results: From a sample of 40,343 police staff and police officers, forty-six per cent had no sickness absence within the previous year, 33% had a low amount, 13% a moderate amount and 8% were on LTSA. The groups that were more likely to take sick leave were women, non-uniformed police staff, divorced or separated, smokers and those with three or more general practitioner consultations in the past year, poorer mental health, low job satisfaction and high job strain., Conclusions: The study highlights the groups of police employees who may be more likely to take sick leave and is unique in its use of a large cohort of police employees. The findings emphasise the importance of considering possible modifiable factors that may contribute to sickness absence in UK police forces.

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.

Staff in the National Health Service (NHS) are under considerable strain, exacerbated by the COVID-19 pandemic; whilst NHS Trusts provide a variety of health and wellbeing support services, there has been little research investigating staff perceptions of these services. We interviewed 48 healthcare workers from 18 NHS Trusts in England about their experiences of workplace health and wellbeing support during the pandemic. Reflexive thematic analysis identified that perceived stigma around help-seeking, and staffing shortages due to wider socio-political contexts such as austerity, were barriers to using support services. Visible, caring leadership at all levels (CEO to line managers), peer support, easily accessible services, and clear communication about support offers were enablers. Our evidence suggests Trusts should have active strategies to improve help-seeking, such as manager training and peer support facilitated by building in time for this during working hours, but this will require long-term strategic planning to address workforce shortages.

Background: As of March 2020, the UK public were instructed to work from home where possible and as a result, nearly half of those in employment did so during the following month. Pre-pandemic, around 5% of workers chose to work from home; it was often seen as advantageous, for example due to eliminating commuting time and increasing flexibility. However, homeworking also had negative connotations, for example, blurred boundaries between work and home life due to a sense of constant connectivity to the workplace. Understanding the psychological impact of working from home in an enforced and prolonged manner due to the COVID-19 pandemic is important. Therefore, this review sought to establish the relationship between working from home, mental health, and productivity., Methods: In January 2022, literature searches were conducted across four electronic databases: Medline, Embase, PsycInfo and Web of Science. In February 2022 grey literature searches were conducted using Google Advanced Search, NHS Evidence; Gov.uk Publications and the British Library directory of online doctoral theses. Published and unpublished literature which collected data after March 2020, included participants who experienced working from home for at least some of their working hours, and detailed the association in terms of mental health or productivity were included., Results: In total 6,906 citations were screened and 25 papers from electronic databases were included. Grey literature searching resulted in two additional papers. Therefore, 27 studies were included in this review. Findings suggest the association between homeworking and both, mental health and productivity varies considerably, suggesting a complex relationship, with many factors (e.g., demographics, occupation) having an influence on the relationship., Conclusion: We found that there was no clear consensus as to the association between working from home and mental health or productivity. However, there are indications that those who start homeworking for the first time during a pandemic are at risk of poor productivity, as are those who experience poor mental health. Suggestions for future research are suggested., (© 2023. Crown.)

Objective: The current study examined links between adverse mental health, job strain, and likelihood and frequency of primary care consultations among police employees., Methods: We conducted secondary data analysis on the Airwave Health Monitoring Study data ( n = 33,730). Measures included self-report data on mental health, job strain, job support, and primary care consultations in the past 12 months. Data were analyzed using a zero-inflated Poisson regression framework., Results: Findings showed that overall, help seeking was low based on mental health status and job strain. Adverse mental health was associated with more primary care consultations. Police employees with high, active, or passive job strain reported more primary care consultation compared with police employees with low strain., Conclusions: Findings suggest that more work to reduce stigma of taking the initial step of help seeking would be beneficial., Competing Interests: Conflict of Interest: N.T.F. reports grants from the UK MoD and Office for Veterans' Affairs (Cabinet Office), is a trustee (unpaid) of Help for Heroes, is a member of the Emergency Responders Senior Leaders Board, the Gallipoli Medical Research Foundation, and is an independent advisor to the Independent Group Advising NHS Digital on the Release of patient Data (IGARD). N.G. runs a psychological health consultancy that provides training and support to some UK police forces. S.W. is Dean IOPPN KCL, a NED on the local mental health trust, SLAM, on the ESRC Council, the JAC, and others. None are relevant to this article. S.A.M.S. is supported by the National Institute for Health and Care Research (NIHR) Maudsley Biomedical Research Centre at South London, Maudsley NHS Foundation Trust, and the NIHR Advanced Fellowship (NIHR300592). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Occupational and Environmental Medicine.)

Background: Diplomatic personnel frequently relocate as part of their roles, requiring them to adapt to various cultural and political conditions; many are also at risk of experiencing trauma from being deployed to high-threat postings. With diplomatic personnel having to balance the usual pressures of their work with the uncertainties of COVID-19 in recent years, it is particularly important now to understand how to protect their mental health., Aims: To synthesize existing literature on the well-being of diplomatic personnel to improve understanding of how to protect their mental health., Methods: A scoping review was carried out to explore what is already known about the well-being of staff working in diplomatic roles. Four databases were searched and reference lists, as well as one key journal, were hand-searched., Results: Fifteen relevant publications were included. There was little consensus as to how the psychological well-being of diplomatic personnel compares to other populations or which factors predict well-being. Diplomats' psychological responses to traumatic experiences appeared similar to those of other trauma-exposed occupational groups., Conclusions: Further research is needed to better understand the well-being of diplomatic personnel, particularly those not deployed to high-threat posts., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society of Occupational Medicine.)

Background: Climate change can negatively affect mental health, and poor mental health can negatively affect work. However, less is known about the relationship between mental health and workplace behaviours within the climate change context., Aims: To explore existing literature relating to climate-induced mental ill-health as a potential predictor of workplace behaviours., Methods: Scoping review, searching five databases for relevant literature using two separate search strategies., Results: Only five studies with any relevant data were found. Results could not be easily synthesized because each of the five considered different work-related outcomes. However, the available data suggest that the psychological impact of extreme events could lead to increased job tension, higher turnover intentions and workplace hostility. Stress about extreme weather could also impede the ability to make essential work-related decisions and, for those who work in the environmental sector, concerns about climate could lead to overcommitment to work. There was some evidence that social support might lessen the effects of climate-induced stress on work outcomes., Conclusions: Very little literature considers the impacts of climate change on employees' mental health and associated workplace function. The available evidence suggests there are potential negative impacts which may be mitigated by social support. It is important for future research to explore ways of supporting staff and fostering resilience., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society of Occupational Medicine.)

Background: Moral injury can significantly negatively impact mental health, but currently no validated treatment for moral injury-related mental health difficulties exists in a UK context. This study aimed to examine whether the Restore and Rebuild (R&R) treatment was feasible to deliver, acceptable and well tolerated by UK military veterans with moral injury related mental health difficulties., Method: The R&R treatment was delivered to 20 patients who reported distress related to exposure to a morally injurious event(s) during military service. R&R is a 20-session psychotherapy with key themes of processing the event, self compassion, connecting with others and core values. Treatment was delivered online, weekly, one-to-one by a single therapist. Qualitative interviews with patients and the therapist who delivered R&R were conducted to explore acceptability and analysed using thematic analysis., Results: Following treatment, patients experienced a significant reduction in symptoms of post-traumatic stress disorder, depression, alcohol misuse and moral injury related distress. R&R was found to be well tolerated by patients and improved their perceived wellbeing., Conclusions: These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment.

Background: Whilst the wellbeing of law enforcement personnel has been widely researched, border security personnel as a discrete group appear to be far less discussed, despite their roles frequently exposing them to potentially traumatic and challenging events such as contact with criminals or witnessing personal tragedies due to trafficking or smuggling., Aims: This scoping review aimed to explore existing literature to better understand the mental health of border security personnel and the factors affecting their wellbeing., Methods: Four electronic databases and grey literature were systematically searched for studies relevant to the review's aims. Following the extraction of relevant data from each study, thematic analysis was used to synthesize findings., Results: Thirteen studies included relevant data and were included in the review, identifying stressors including poor management; fatigue; negative public attitudes; inadequate staffing levels, resources, and training; poor opportunities for promotion; low pay; work overload; dangerous working environments; and work-related moral dilemmas., Conclusions: The review found that there has been little academic attention paid to border security personnel as a specific branch of law enforcement. Many of the stressors identified in this review are those also reported by law enforcement generally, although negative attitudes from the public and exposure to moral dilemmas appear to be more relevant for border security staff. Directly addressing work-related stress (e.g. by fostering a supportive organizational culture, addressing mental health stigma, and encouraging help-seeking) may be useful in enhancing the resilience of border security personnel., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society of Occupational Medicine.)

Background: Mental disorders and alcohol misuse are often comorbid, and this comorbidity is more common in those who develop mental disorders following exposure to traumatic events., Aims: To investigate the relationship between combat exposure and operational role (support versus combat) with mental disorders and associated comorbidity in a UK military cohort., Methods: 4896 participants from a UK military cohort reported their operational role and frequency of exposure to combat events during deployment. Outcome measures included self-reported post-traumatic stress disorder, common mental disorder and alcohol misuse., Results: Personnel reporting higher levels of combat exposure were more likely to meet criteria for two or more co-occurring mental disorders (odds ratio [OR] 3.90, 95% confidence interval [CI] 2.73-5.58). While having a combat role increased the risk of developing co-occurring disorders compared to having a support role (OR 1.67, 95% CI 1.26-2.23), this effect diminished following adjustment for variables including combat exposure (OR 0.89, 95% CI 0.62-1.27)., Conclusions: Combat exposure may play a greater role in the development of comorbid mental disorders than operational role, i.e. job title. Clinicians treating military personnel should be alert to the increased risk of comorbid mental disorders and alcohol misuse among those with a history of combat exposure.

Background: Seafaring has frequently been reported to be a 'risky occupation' in terms of both physical and mental health. Individuals working in seafaring professions are exposed to various stressors in the workplace, including social isolation, exposure to poor physical conditions and long work hours. This systematic review aimed to update previous reviews by collating recent literature (published between 2012 and 2021) on the factors associated with mental health and wellbeing in seafaring personnel., Methods: Four electronic databases were searched in April 2021 for primary peer-reviewed studies on factors associated with the mental health and psychological wellbeing of seafarers or interventions to improve the wellbeing of seafarers, published in English in or after the year 2012. Thematic analysis was used to synthesise the data and standardised measures of quality appraisal were used to assess risk of bias., Results: Sixty-three studies were reviewed. Risk factors for poor mental health among seafarers appear to be younger age; being single; poor physical health; exposure to noise/vibration; feeling unsafe; high job demands; long working hours; night/irregular shifts; poor sleep; poor team cohesion; poor perception of management; poor social support; lack of autonomy; scheduling uncertainties; long duration at sea; and over-commitment., Conclusions: There are numerous steps that maritime managers could take to improve the wellbeing of their personnel, including increased monitoring of the potential for poor mental health in their staff, increasing crew numbers and provision of education and support., (© 2022. The Author(s).)

Competing Interests: We declare no competing interests. The opinions and assertions expressed in this Comment are those of the authors and do not reflect the official policy or position of the authors' governments or institutions.

Background: Reservists often have different experiences to regular military personnel which may impact their mental health., Aims: To investigate the incidence of mental health problems in both active and veteran reservists and determine how this compares to regular service personnel and ex-regular veterans., Method: Five studies which included reservist and/or veteran participants, a validated assessment of mental health problems, and provided primary data were included in the synthesis. Common mental health disorders, post-traumatic stress disorder and alcohol use disorder were examined., Results: Nondeployed mobilized reservists were significantly less likely to report common mental health disorders than nondeployed regulars. There were no other significant differences between groups. Regardless deployed reservists reported more mental health problems than nondeployed reservists. Similarly, ex-regular deployed veterans were more likely to experience mental health difficulties than nondeployed ex-regular veterans. Notably, a large proportion of non-deployed reservists reported probable alcohol use disorders, indicating that problematic alcohol consumption may not be due to deployment in this group., Conclusion: These results highlight the need for ongoing support for military regular, ex-regular and reservist personnel. Additional research is needed to examine potential risk and protective factors for mental health problems in both deployed and nondeployed reservists.Key pointsOverall, mobilized deployed reservists were more likely to experience mental health problems than non-deployed reservists. Nondeployed regulars reported significantly more common mental health problems than nondeployed mobilized reservists.Reservists and (ex-)regulars reported similar rates of PTSD. This suggests reservists are vulnerable to developing PTSD following non-combat related trauma that may not lead to PTSD in regulars and this warrants future research.Reservists were less likely to report problematic alcohol consumption compared to regular personnel and ex-regular veterans. The greatest amount of reservist problematic drinking was reported in non-deployed veteran reservists. This indicates problematic alcohol consumption is not deployment related in this group and highlights the need for ongoing formal support for alcohol use disorders in the UK Armed Forces.

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.)

Competing Interests: VW, DM, and NG had financial support from a Forces in Mind Trust grant (FiMT17/0920E) for the submitted work. NG was funded by the National Institute for Health Research Health Protection Research Unit in Emergency Preparedness and Response, a partnership between Public Health England, King's College London, and the University of East Anglia. The views expressed are those of the authors and not necessarily those of the NIHR, Public Health England, or the Department of Health and Social Care. The funders did not have a role in the drafting of the manuscript or the decision to submit for publication. The other authors declare no competing interests.

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.)

The COVID-19 pandemic has extracted an enormous physical health toll on many millions worldwide, and the wider societal impact from economic turmoil, unemployment, social isolation and so forth continue to be measured. A less explored aspect has been the psychological impact on treating healthcare staff, with emerging evidence of 'moral injury' and mental illness for some. This review explores the evidence base for implementing a tiered model of care to minimise this and foster 'post-traumatic growth', and describes the authors' implementation of this in the London Nightingale hospital, with lessons for the armed forces., Competing Interests: Competing interests: NG runs a psychological health consultancy that provides resilience training for a wide range of organisations, including a few NHS teams. The work was supported by the National Institute for Health Research (NIHR) Health Protection Research Unit in Emergency Preparedness and Response at King’s College London, in partnership with Public Health England and in collaboration with the University of East Anglia and Newcastle University., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

There is an urgent need to provide evidence-based well-being and mental health support for front-line clinical staff managing the COVID-19 pandemic who are at risk of moral injury and mental illness. We describe the evidence base for a tiered model of care, and practical steps on its implementation.

Background: Concerns are being raised about the impact of inadequate safety equipment on the mental health of healthcare workers during the COVID-19 medical response., Aims: To assess the impact of inadequate safety equipment on the mental health of service personnel deployed on operations in order to better understand the impact on those working under the similarly demanding conditions of the COVID-19 medical response., Methods: Self-report surveys were conducted in four operational environments with 3435 personnel providing data. Surveys recorded data on socio-demographic, military and operational characteristics, mental health measures and specific occupational stressors. Analysis through logistic regression explored the association between inadequate equipment and all other factors., Results: A total of 3401 personnel provided data on their perceptions of the adequacy of their equipment, of which 532 (15%) stated that they had a lot of concerns that they did not have the right equipment in working order. Analysis found significantly greater odds of reporting symptoms of common mental health disorders (CMD), 2.49 (2.03-3.06), post-traumatic stress disorder (PTSD), 2.99 (2.11-4.24), poorer global health 2.09 (1.62-2.70) and emotional problems 1.69 (1.38-2.06) when individuals reported working with inadequate equipment. Analyses remained significant when adjusted for confounding factors such as rank, sex and operational environment., Conclusions: An individual's perception of having inadequate equipment is significantly associated with symptoms of CMD, probable PTSD, poorer global health and increased reporting of emotional problems. This in turn may impact on their ability to safely carry out their duties and may have longer-term mental health consequences., (© 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.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have the following interests to declare: NG runs a psychological health consultancy that provides resilience training for a wide range of organisations, including a few NHS teams. The work was supported by the National Institute for Health Research (NIHR) Health Protection Research Unit in Emergency Preparedness and Response at King’s College London, in partnership with Public Health England and in collaboration with the University of East Anglia and Newcastle University. The views expressed are those of the authors and not necessarily those of the NHS, NIHR, Department of Health and Social Care, or Public Health England.

Background: Internationally, women are about to undertake combat duties alongside their male colleagues. The psychological effect of this policy change is largely unknown., Aims: To explore the mental health impact of combat exposure among military women., Methods: Self-report, between-subjects survey data were collected in Iraq and Afghanistan on four occasions between 2009 and 2014 (n = 4139). Differences in mental health, stigmatization, deployment experiences, intimate relationship impact, perception of family support levels, unit cohesion, leadership and help-seeking were compared between deployed men and women. Comparisons were repeated with the study sample stratified by level of combat exposure. Outcomes were examined using logistic regression adjusted for socio-demographic, mental health and military factors., Results: Overall, 4.1% of women and 4.3% of men reported post-traumatic stress disorder (PTSD) (odds ratio (OR) 1.31, 95% confidence interval (95% CI) 0.70-2.46); 22% of women and 16% of men reported symptoms of common mental disorder (CMD) (OR 1.52, 95% CI 1.11-2.08). Women were less likely to report mental health-related stigmatization (OR 0.68, 95% CI 0.53-0.87), negative relationship impact from deployment (OR 0.69, 95% CI 0.49-0.98) and subjective unit cohesion (OR 0.69, 95% CI 0.53-0.90). Help-seeking for emotional problems was similar by gender (OR 1.22, 95% CI 0.84-1.77). Overall, outcomes were minimally impacted by level of combat exposure., Conclusions: Although women experienced more CMD symptoms, PTSD symptoms were similar by gender. Subject to confirmation of the study findings, women may not require enhanced mental healthcare during deployment for exposure-based conditions such as PTSD when undertaking the ground close combat role., (© The Author(s) 2019. 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: Disasters are becoming more prevalent across the world and people are frequently exposed to them as part of their occupational groups. It is important for organisations to understand how best to support employees who have experienced a trauma such as a disaster. The purpose of this study was to explore employees' perceptions of workplace support and help-seeking in the context of a disaster., Methods: Forty employees in England took part in semi-structured interviews. Thematic analysis was used to extract recurring themes from the data., Results: Participants reported both positive and negative psychological outcomes of experiencing a disaster or emergency at work. Most had little training in how to prepare for, and cope with, the psychological impact. They perceived stigma around mental health and treatment for psychological issues which often made them reluctant to seek help. Many reported that the psychological support available in the workplace was insufficient and tended to be reactive rather than proactive. Interpersonal relationships at work were viewed as being important sources of support, particularly support from managers. Participants suggested that psychosocial training in the workplace could be beneficial in providing education about mental health, encouraging supportive workplace relationships, and developing listening skills and empathy., Conclusions: Organisations can take steps to reduce the psychological impact of disasters on employees. This could be done through provision of training workshops incorporating mental health education to reduce stigma, and team-building exercises to encourage supportive workplace relationships.

Aims: To review both mental and physical health consequences of bullying for healthcare employees., Design: Systematic literature review., Data Sources: EMBASE, MEDLINE, PsycINFO, PUBMED and Web of Science Core Collection were searched for articles published between 2005 - January 2017., Review Methods: This review was conducted using the framework described by Khan and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two independent reviewers performed systematic data extraction and appraised the methodological quality of included articles. A pooled mean prevalence of bullying was estimated., Results: Forty-five papers met inclusion criteria. Bullying prevalence ranged from 3.9% to 86.5%, with a pooled mean estimate of 26.3%. Perceived bullying was associated with mental health problems including psychological distress, depression and burnout, and physical health problems including insomnia and headache. Bullied staff took more sick leave., Conclusion: Bullying occurs frequently amongst healthcare staff and is deleterious to health and occupational functionality., (© 2019 John Wiley & Sons Ltd.)

Background: There may be ongoing psychological problems associated with military service later in life; yet as the elderly in the general population also suffer from mental health problems, whether such issues can be attributed to military service or are a feature of ageing remains unclear. This study aimed to explore veteran and nonveteran perceptions of the impact of their occupation on their psychological well-being later in life., Methods: Twenty-five veterans (≥65 y); 25 nonveterans (≥65 y); 10 veterans with diagnoses of mental health issues (≥65 y); and a close companion of all participants (≥18 y, spouse, child, and close friend) were recruited. Using a qualitative approach, participants completed semistructured qualitative interviews with measures of psychological adjustment used to describe the sample., Results: Veterans were found to experience higher levels of workplace stress and trauma exposure compared with nonveterans. When such challenges were positively appraised, veterans described increased confidence and resilience. Social support in response to occupational stress was central to veteran and nonveteran well-being, especially for those with mental health problems. Nonetheless, providing support was challenging for close companions, with many feeling overwhelmed and requiring additional guidance from the veteran's clinical care team., Conclusions: The findings delineate the impact of occupation on the well-being of older veterans and nonveterans. The results illustrated the psychological support needs and formal guidance desired by veterans, nonveterans, and their families, which could ultimately improve coping of both the individual and family., (© 2019 John Wiley & Sons, Ltd.)

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: 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., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: DM is Lead Consultant Psychiatrist for the London and South East NHS Veteran Mental Health Service, and NG carries out expert witness work related to veterans mental health. RS and HD declare no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

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.

Background: In the UK, little is known about the perceived effects of deployment, on military families, from military personnel in theatre., Aims: To investigate military personnel's perceptions of the impact of deployment on intimate relationships and children., Methods: Deployed service personnel who were in a relationship, and who had children, completed a survey while deployed on combat operations. Data were taken from four mental health surveys carried out in Iraq in 2009 and Afghanistan in 2010, 2011 and 2014., Results: Among 4265 participants, after adjusting for military and social-demographic covariates, perceiving that deployment had a negative impact on intimate relationships and children was associated with psychological distress, and traumatic stress symptoms. Military personnel who reported being in danger of being injured or killed during deployment, were more likely to report a perceived negative effect of deployment on their intimate relationships. Reservists were less likely to report a perceived negative impact of deployment on their children compared with regulars. Military personnel who themselves planned to separate from their partner were more likely to report psychological distress, and stressors at home. Perceived insufficient support from the Ministry of Defence was associated with poor mental health, and holding a junior rank., Conclusions: Deployed UK military personnel with symptoms of psychological distress, who experienced stressors at home, were especially likely to perceive that their family were inadequately supported by the military. Those planning to separate from their partner were at increased risk of suffering with mental health problems while deployed., (© The Author 2017. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Objective: Fear et al identified a small but significant increase in probable post-traumatic stress disorder (PTSD) in UK military personnel from around 3% in first year post deployment to around 6% by year 5. As yet it is not clear what factors are linked to the increase in probable PTSD, and therefore, serial measurement of poor mental health would be helpful., Method: Rates of mental ill health among UK service personnel were compared upon deployment completion and at follow-up and identified factors associated with maladjustment., Results: Poor mental health symptomatology increased from baseline to follow-up, PTSD symptoms and related functional impairment increased significantly. Poor baseline mental health was predictive of transition and family relationship difficulties., Conclusions: The results are discussed in relation to encouraging recognition and reporting of symptoms among personnel and their social networks., (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/)

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: 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: Diplomatic organizations routinely send staff to high-threat postings (HTPs) and consequentially have moral and legal obligations to protect their health as far as is reasonably practicable., Aims: To carry out an international survey of diplomatic organizations that send personnel to HTPs to establish how they deal practically with their obligations to protect the mental health of their staff., Methods: An online anonymous survey about their organizations' policies relating to HTPs completed by international diplomatic organizations., Results: Fourteen of 30 organizations approached completed the questionnaire, with a response rate of 47%. Deployment length varied: no minimum (15%), a minimum of 2 years (39%) and a maximum of 2 (31%), 3 (15%) or 4 years (31%); one organization did not state any maximum. HTP and low-threat postings had the same policies in 46% of organizations. Additional care and support (66%), additional preparation (50%), enhanced leave (33%) and additional physical and mental health assessments were informally adopted to address psychosocial risks of deployment to HTPs., Conclusions: There was little consensus on policies and practice for HTP deployment. We suggest that formal, consistently written guidelines, based on available quality evidence, and associated training and quality assurance should be formulated to make international practice more consistent and equitable., (© Crown copyright 2015.)

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.

Background: While there has been considerable research into the psychosocial consequences of tour length for military personnel, this subject has not been studied in other occupational groups who also deploy staff to high-threat areas., Aims: To carry out a comprehensive review of relevant published literature to inform diplomatic organizations that deploy staff in high-threat postings (HTPs)., Methods: We searched appropriate scientific databases for studies relevant to deployment length, mental health and well-being for diplomats. A systematic review related to military personnel was found and used as the foundation for the literature review. Other relevant papers identified by the search have also been included., Results: The majority of identified papers had examined military personnel. Results suggested that longer deployments were associated with poorer mental health including post-traumatic stress disorder, depression and alcohol problems and this was most likely to be a function of increased exposure to potentially traumatic events. Exceeding a threshold of 6-12 months within a 3 year period, for military personnel, appeared to elevate the risk of psychosocial problems. Furthermore, diplomats deploying on their first HTP, and those whose tour length is altered after deployment, could be especially vulnerable., Conclusions: While further research of this topic is required, this review provides an evidence-based insight into the increased risks of developing mental health problems when deployed to HTPs. This information is relevant to generating policies, which may reduce the impacts of adverse psychosocial effects on diplomatic staff and their families., (© 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.

Objective: To explore the psychological consequences of improvised explosive device (IED) exposure as IEDs have been the greatest threat to UK military personnel in Afghanistan though the mental health consequences of IED exposure are largely unknown., Method: Deployed UK military personnel completed a survey while deployed in Afghanistan. Combat personnel and those dealing specifically with the IED threat were compared with all other deployed personnel; the relationship between IED exposure, general combat experiences, Post Traumatic Stress Disorder (PTSD) Checklist-Civilian Version (PCL-C) and General Health Questionnaire scores were evaluated., Results: The response rate was 98% (n=2794). Half reported IED-related concerns, a third experienced exploding IEDs and a quarter gave medical aid to IED casualties. Combat and counter-IED threat personnel had higher levels of IED exposure than other deployed personnel. 18.8% of personnel who witnessed exploding IEDs scored positive for common mental disorder (General Health Questionnaire-12 scores ≥4) and 7.6% scored positive for probable PTSD symptoms (PTSD Checklist-Civilian Version scores ≥44). After adjusting for general combat exposure and other observed confounders, PTSD symptoms were associated with IED exposure whereas common mental disorder symptoms were not. IED exposure, IED-related concerns and functional impairment accumulated during deployment but functional impairment was related to factors other than IED exposure alone., Conclusions: In Afghanistan, a substantial proportion of personnel were exposed to exploding IEDs however, the majority of exposed personnel were psychologically healthy. Psychological effects were similar for combat personnel and those dealing specifically with the IED threat but both groups were at greater psychological risk than other deployed personnel., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The recent conflicts in Iraq and Afghanistan have attracted considerable political and media interest in the mental health of UK military personnel. As a result of the close operational collaboration between US and UK forces, there have inevitably been many comparisons drawn between the mental health status of the two forces. Considerable research activity suggests that the mental health of UK forces appear to have remained relatively resilient in spite of their considerable exposure to traumatic events; one stark exception to this is the high rates of alcohol misuse which seem to be related to deployment. This paper explores the recently published literature relating to UK military forces and attempts to draw conclusions about the reasons for the apparent resilience shown by the majority of the regular forces., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

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'.

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.

This study focuses on the influence of structural aspects of social integration (social networks and social participation outside work) on mental health (common mental disorders (CMD), that is, depression and anxiety symptoms, post-traumatic stress disorder (PTSD) symptoms and alcohol misuse). This study examines differences in levels of social integration and associations between social integration and mental health among service leavers and personnel still in service. Data were collected from regular serving personnel (n=6,511) and regular service leavers (n=1,753), from a representative cohort study of the Armed Forces in the UK. We found that service leavers reported less social participation outside work and a general disengagement with military social contacts in comparison to serving personnel. Service leavers were more likely to report CMD and PTSD symptoms. The increased risk of CMD but not PTSD symptoms, was partially accounted for by the reduced levels of social integration among the service leavers. Maintaining social networks in which most members are still in the military is associated with alcohol misuse for both groups, but it is related to CMD and PTSD symptoms for service leavers only., (© 2013 The Authors. Sociology of Health & Illness © 2013 Foundation for the Sociology of Health & Illness/JohnWiley & Sons Ltd. Published by John Wiley & Sons Ltd.)

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.)

Background: The negative impact of sustaining an injury on a military deployment on subsequent mental health is well-documented, however, the relationship between having an illness on a military operation and subsequent mental health is unknown., Methods: Population based study, linking routinely collected data of attendances at emergency departments in military hospitals in Iraq and Afghanistan [Operational Emergency Department Attendance Register (OpEDAR)], with data on 3896 UK Army personnel who participated in a military health study between 2007 and 2009 and deployed to Iraq or Afghanistan between 2003 to 2009., Results: In total, 13.8% (531/3896) of participants had an event recorded on OpEDAR during deployment; 2.3% (89/3884) were medically evacuated. As expected, those medically evacuated for an injury were at increased risk of post deployment probable PTSD (odds ratio 4.27, 95% confidence interval 1.80-10.12). Less expected was that being medically evacuated for an illness was also associated with a similarly increased risk of probable PTSD (4.39, 1.60-12.07) and common mental disorders (2.79, 1.41-5.51). There was no association between having an OpEDAR event and alcohol misuse. Having an injury caused by hostile action was associated with increased risk of probable PTSD compared to those with a non-hostile injury (3.88, 1.15 to 13.06)., Conclusions: Personnel sustaining illnesses on deployment are just as, if not more, at risk of having subsequent mental health problems as personnel who have sustained an injury. Monitoring of mental health problems should consider those with illnesses as well as physical injuries.