Search

Background: The link between poor cardiovascular health (CVH), lifestyle and mild cognitive impairment (MCI) has been well established in the general population. However, there is limited research exploring these associations in ageing UK veterans., Aims: This study explored the risk of MCI and its association with nine CVH and lifestyle risk factors (including diabetes, heart disease, high cholesterol, high blood pressure, obesity, stroke, physical inactivity, the frequency of alcohol consumption and smoking) in UK veterans and non-veterans., Methods: This prospective cohort study comprised data from the PROTECT study between 2014 and 2022. Participants comprised of UK military veterans and non-veterans aged ≥50 years at baseline. Veteran status was defined using the Military Service History Questionnaire. CVH and lifestyle risk factors were defined using a combination of self-report measures, medication history or physical measurements. MCI was defined as the presence of subjective and objective cognitive impairment., Results: Based on a sample of 9378 veterans (n = 488) and non-veterans (n = 8890), the findings showed the risk of MCI significantly reduced in veterans with obesity, those who frequently consumed alcohol and were physically inactive compared to non-veterans. The risk of MCI significantly increased in veterans with diabetes (hazards ratio [HR] = 2.22, 95% confidence interval [CI] 1.04-4.75, P ≤ 0.05) or high cholesterol (HR = 3.11, 95% CI 1.64-5.87, P ≤ 0.05) compared to veterans without., Conclusions: This study identified CVH and lifestyle factors of MCI in UK veterans and non-veterans. Further work is needed to understand these associations and the underpinning mechanisms which could determine intervention strategies to reduce the risk of MCI., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society of Occupational Medicine.)

Background: Exposure to potentially morally injurious events is increasingly recognised as a concern across a range of occupational groups, including UK military veterans. Moral injury-related mental health difficulties can be challenging for clinicians to treat and there is currently no validated treatment available for UK veterans. We developed Restore and Rebuild (R&R) as a treatment for UK veterans struggling with moral injury-related mental health difficulties. This trial aims to examine whether it is feasible to conduct a pilot randomised controlled trial (RCT) of R&R treatment compared with a treatment-as-usual (TAU) control group., Methods: We will use a feasibility single-blind, single-site RCT design. The target population will be UK military veterans with moral injury-related mental health difficulties. We will recruit N=46 veteran patients who will be randomly allocated to R&R (n=23) or TAU (n=23). Patients randomised to R&R will receive the 20-session one-to-one treatment, delivered online. Veterans allocated to TAU, as there are currently no manualised treatments for moral injury-related mental health problems available, will receive the one-to-one treatment (online) typically provided to veterans who enter the mental health service for moral injury-related mental health difficulties. We will collect outcome measures of moral injury, post-traumatic stress disorder (PTSD), alcohol misuse, common mental disorders and trauma memory at pretreatment baseline (before randomisation), end of treatment, 12 weeks and 24 weeks post-treatment. The primary outcome will be the proportion of patients who screen positive for PTSD and moral injury-related distress post-treatment., Ethics and Dissemination: This trial will establish whether R&R is feasible, well-tolerated and beneficial treatment for veterans with moral injury-related mental health difficulties. If so, the results of the trial will be widely disseminated and R&R may improve access to effective care for those who struggle following moral injury and reduce the associated negative consequences for veterans, their families and wider society., Trial Registration Number: ISRCTN99573523., Competing Interests: Competing interests: Authors had financial support from a grant from the Forces in Mind Trust for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. DM is a trustee for the funder of this project, the Forces in Mind Trust. DL is a reservist in the UK Armed Forces. This work has been undertaken as part of his civilian employment. For the purposes of open access, the author has applied a Creative Commons Attribution (CC BY) license to any Accepted Author Manuscript version arising from this submission., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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

Moral injury is a relatively new, but increasingly studied, construct in the field of mental health, particularly in relation to current and ex-serving military personnel. Moral injury refers to the enduring psychosocial, spiritual or ethical harms that can result from exposure to high-stakes events that strongly clash with one's moral beliefs. There is a pressing need for further research to advance understanding of the nature of moral injury; its relationship to mental disorders such as posttraumatic stress disorder and depression; triggering events and underpinning mechanisms; and prevalence, prevention and treatment. In the meantime, military leaders have an immediate need for guidance on how moral injury should be addressed and, where possible, prevented. Such guidance should be theoretically sound, evidence-informed and ethically responsible. Further, the implementation of any practice change based on the guidance should contribute to the advancement of science through robust evaluation. This paper draws together current research on moral injury, best-practice approaches in the adjacent field of psychological resilience, and principles of effective implementation and evaluation. This research is combined with the military and veteran mental health expertise of the authors to provide guidance on the design, implementation and evaluation of moral injury interventions in the military. The paper discusses relevant training in military ethical practice, as well as the key roles leaders have in creating cohesive teams and having frank discussions about the moral and ethical challenges that military personnel face., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Traumatic brain injury (TBI) is prevalent in veterans and may occur at any stages of their life (before, during, or after military service). This is of particular concern, as previous evidence in the general population has identified TBI as a strong risk factor for mild cognitive impairment (MCI), a known precursor of dementia. Objectives: This study aimed to investigate whether exposure to at least one TBI across the lifetime was a risk factor for MCI in ageing UK veterans compared to non-veterans. Method: This cross-sectional study comprised of data from PROTECT, a cohort study comprising UK veterans and non-veterans aged ≥ 50 years at baseline. Veteran and TBI status were self-reported using the Military Service History Questionnaire (MSHQ) and the Brain Injury Screening Questionnaire (BISQ), respectively. MCI was the outcome of interest, and was defined as subjective cognitive impairment and objective cognitive impairment. Results: The sample population comprised of veterans ( n  = 701) and non-veterans ( n  = 12,389). TBI was a significant risk factor for MCI in the overall sample (OR = 1.21, 95% CI 1.11-1.31) compared to individuals without TBI. The prevalence of TBI was significantly higher in veterans compared to non-veterans (69.9% vs 59.5%, p  < .001). There was no significant difference in the risk of MCI between veterans with TBI and non-veterans with TBI (OR = 1.19, 95% CI 0.98-1.45). Conclusion: TBI remains an important risk factor for MCI, irrespective of veteran status. The clinical implications indicate the need for early intervention for MCI prevention after TBI.

Deployed combat personnel are at increased risk of post-traumatic stress disorder (PTSD). People with PTSD often judge ambiguous information as negative or threatening (interpretation bias). However, this may be adaptive during deployment. The current study aimed to investigate the extent to which interpretation bias in combat personnel is associated with PTSD symptoms, rather than with appropriate situational awareness. Combat veterans with and without PTSD and civilians without PTSD generated explanations for ambiguous situations and judged the likelihood of various possible explanations. They also made judgements about future consequences of worst-case scenarios, and their coping ability. Veterans with PTSD generated more negative explanations for ambiguous situations, judged negative interpretations as more likely and felt less able to cope with the worst-case scenario than veteran and civilian controls. Veterans with versus without PTSD judged worst-case scenarios to have more severe and insurmountable consequences, although they did not differ significantly from civilians. Veteran versus civilian controls rated their coping ability as higher; this was the only difference between control groups. In summary, group differences in interpretation bias were associated with PTSD symptoms rather than combat role. Veterans without PTSD may be particularly resilient when coping with everyday adversity., (© 2023 The Authors. International Journal of Psychology published by John Wiley & Sons Ltd on behalf of International Union of Psychological Science.)

Introduction: Evidence is growing regarding the impact of potentially morally injurious events (PMIEs) on mental health; yet how moral injury may affect an individual's occupational and familial functioning remains poorly understood., Method: Thirty male veterans who reported exposure to either traumatic or morally injurious events and 15 clinicians were recruited for semi-structured qualitative interviews., Results: While many veterans experienced psychological distress postevent, those who experienced PMIEs especially reported social withdrawal and engagement in aggressive, risk-taking behaviours. This was highly distressing for family members and created a tense, volatile home and workplace environment that was difficult for others to navigate. Following PMIEs, employment could be used as a cognitive avoidance strategy or as a means to atone for transgressive acts. In cases of moral injury, clinicians considered that targeted support for spouses and accessible guidance to help children to better understand how their military parent may be feeling would be beneficial., Conclusions: This study provides some of the first evidence of the pervasive negative impact of PMIEs on veterans' familial and occupational functioning. These findings highlight the need to comprehensively screen for the impact of moral injury on daily functioning in future studies that goes beyond just an assessment of psychological symptoms., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Experiencing potentially morally injurious events (PMIEs) has been found to be significantly associated with poor mental health outcomes in military personnel/veterans. Currently, no manualised treatment for moral injury-related mental health difficulties for UK veterans exists. This article describes the design, methods and expected data collection of the Restore & Rebuild (R&R) protocol, which aims to develop procedures to treat moral injury related mental ill health informed by a codesign approach. Methods: The study consists of three main stages. First, a systematic review will be conducted to understand the best treatments for the symptoms central to moral injury-related mental ill health (stage 1). Then the R&R manual will be co-designed with the support of UK veteran participants with lived experience of PMIEs as well as key stakeholders who have experience of supporting moral injury affected individuals (stage 2). The final stage of this study is to conduct a pilot study to explore the feasibility and acceptability of the R&R manual (stage 3). Results: Qualitative data will be analysed using thematic analysis. Conclusions: This study was approved by the King's College London's Research Ethics Committee (HR-20/21-20850). The findings will be disseminated in several ways, including publication in academic journals, a free training event and presentation at conferences. By providing information on veteran, stakeholder and clinician experiences, we anticipate that the findings will not only inform the development of an acceptable evidence-based approach for treating moral injury-related mental health problems, but they may also help to inform broader approaches to providing care to trauma exposed military veterans., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Veterinary professionals (VPs) are often exposed to distressing and ethically challenging events in their line of work, yet little is known about whether they may experience moral injury and the impact potentially morally injurious events (PMIEs) may have on their wellbeing. This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of U.K. VPs., Method: Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an anonymous online questionnaire to 90 U.K. VPs between December 2020 and May 2021., Results: Exposure to PMIEs was reported by almost all VPs (89.0%), with acts of omission most frequently reported. Experiences of PMIEs were significantly associated with symptoms of PTSD ( p  < 0.01) and experiencing a betrayal event was significantly associated with PTSD symptoms (p<0.05). However, there was no significant association found between PMIE exposure and alcohol misuse or CMD ( p  > 0.05)., Conclusions: This study provides some of the first evidence that experiences of moral injury are significantly associated with adverse mental health outcomes in U.K. VPs. Future work is needed to design effective pathways for prevention and intervention for VPs exposed to highly challenging events., Highlights: U.K. veterinary professionals were found to experience moral injury.Experiences of moral injury were significantly associated with symptoms of PTSD., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Research has shown that of the myriad services available to veterans in the UK, very few have been independently evaluated. This report presents the results of a randomized controlled trial assessing the impact of Time Line Therapy™ delivered by the Warrior Programme (a third-sector organization)., Aims: This study was aimed to determine if the intervention is effective in reducing emotional and functional difficulties in ex-service personnel., Methods: A mixed-design analysis of variance model was used to investigate whether the Warrior Programme had a statistically significant impact on self-reported scores. The intervention and control group provided data on measures prior to and immediately after the intervention, and at 3-month follow-up., Results: Those in the intervention group (n = 23) reported statistically significant improvements in self-reported scores immediately following intervention: the Clinical Outcomes in Routine Evaluation (CORE) scores (CORE global distress mean difference [MD] = 45.0, 95% confidence interval [CI] 31-60) (CORE subjective well-being MD = 5.9, 95% CI 3.5-8.3) (CORE functioning MD = 16.7, 95% CI 11.4-21.9) (CORE problems/symptoms MD = 19.4, 95% CI 13.1-25.7), general self-efficacy (MD = -9.8, 95% CI -13.6 to -6.8), anxiety (MD = 8.6, 95% CI 5.2-12.1), depression (MD = 10, 95% CI 6.6-13.5), post-traumatic stress disorder (MD = 26.3, 95% CI 17-25) and functional impairment (MD = 11.1, 95% CI 5.3-16.8) over time, compared to the control group (n = 29). However, score improvement was not sustained over time or statistically significant at follow-up., Conclusions: The Warrior Programme was effective in reducing emotional and functional difficulties in ex-service personnel immediately after the intervention, but the effect was not sustained at 3-month follow-up., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

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

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.

Purpose: Emerging evidence suggests that ICD-11 CPTSD is a more common condition than PTSD in treatment seeking samples although no study has explored risk factors and comorbidities of PTSD and CPTSD in veteran populations. In this study, risk factors and comorbidity between veterans meeting criteria for PTSD or CPTSD using the ICD-11 International Trauma Questionnaire (ITQ) were explored., Methods: A sample of help-seeking veterans who had been diagnosed with a mental health difficulty (n = 177) was recruited. Participants completed a range of mental health and functioning measures. Multinomial logistic regression analysis was conducted to explore differences in the above factors between participants meeting case criteria for PTSD, CPTSD or another mental health disorder., Results: Those with CPTSD appeared to have taken longer to seek help, reported higher rates of childhood adversity and more experiences of emotional or physical bullying during their military careers. Further, participants with CPTSD reported a greater burden of comorbid mental health difficulties including high levels of dissociation, anger, difficulties related to moral injury and common mental health difficulties and greater degree of impairment including social isolation, sleep difficulties and impaired functioning., Conclusions: Considering that CPTSD is a more debilitating condition than PTSD, there is now an urgent need to test the effectiveness of new and existing interventions in veterans with CPTSD.

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: Experiences of potentially morally injurious events (PMIEs) have been found to negatively impact the mental health of US personnel/veterans, yet little is known about the effect of PMIEs on the mental health of the UK Armed Forces (AF). This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of UK AF veterans., Method: Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an online questionnaire to 204 UK veterans. Subjects were classified as having experienced a morally injurious event (n = 66), a non-morally injurious traumatic event (n = 57), a 'mixed' event (n = 31), or no event (n = 50)., Results: Potentially morally injurious experiences were associated with adverse mental health outcomes, including likely anxiety disorders and suicidal ideation, compared to those who reported no event exposure. The likelihood of meeting criteria for probable PTSD was greatest in those who had experienced a non-morally injurious trauma. No statistically significant association between alcohol misuse and experiencing a PMIE or traumatic event was observed., Conclusions: The results provide preliminary evidence that potentially morally injurious experiences are associated with adverse mental health outcomes in UK AF veterans. Further work is needed to better understand the interplay between morally injurious events and threat-based trauma in order to design effective pathways for prevention and intervention for people exposed to highly challenging events.

Background: Moral injury is known to be associated with mental health difficulties in US military populations, however its impact on wellbeing in a UK Armed Forces (AF) context is less well understood. Additionally, it is not clear whether other factors known to affect service personnel's mental health, such as adverse childhood experiences (ACEs) or military trauma, may influence whether personnel experience moral injury., Aim: To examine the relationship between moral injury and ACEs, adverse military events as well as the impact of moral injury on the mental health of UK AF veterans., Method: A nationally representative sample of UK AF veterans seeking psychological treatment (n = 177) were recruited. Participants completed self-report psychometric measures and expressions of moral injury, ACEs and traumatic in-service events., Results: Analyses yielded a significant association between ACEs and veteran expressions of moral injury (p < .001). A significant although weak relationship was found between veteran expressions of moral injury and experiencing adverse events during military service, including physical abuse (AOR 1.04; 95 % CI 1.02-1.06) and emotional abuse (AOR 1.03; 1.01-1.05). Those meeting criteria for mental health disorders, including probable posttraumatic stress disorder (AOR 1.09; 95 % CI 1.05-1.12), were significantly more likely to report expressions of moral injury., Conclusions: These results illustrate the relationship between traumatic life events, including childhood adversity, and experiencing moral injury in UK AF veterans. The findings underscore the need for a validated measurement tool appropriate for the UK AF to better understand the impact of moral injury on wellbeing and to ensure that appropriate treatment can be given to those identified as suffering post-trauma., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Research suggests that moral injury (MI) in US veterans is associated with poor psychological outcomes and disruption in functioning. However, little is known about how MI may impact UK Armed Forces (AF) veterans. This study aimed to explore the impact of MI on veteran psychological well-being and functioning., Methods: Six veterans identified as having had exposure to MI and four clinicians who treated veterans with MI were recruited from a UK charitable organisation which provides psychological care for veterans. Data were analysed using thematic analysis., Results: MI was perceived to cause substantial psychological distress in this sample. Our data suggest that some veterans held extremely negative self-appraisals which appeared to contribute towards and maintain their distress. Issues relating to spirituality following MI were thought to be infrequent; however, a loss of faith was perceived by clinicians to be more common in morally injured veterans than heightened spiritual/religious views. Several difficulties relating to employment were described, including increased trouble coping with occupational stress and authority figures. Interpersonal difficulties were frequently reported, with withdrawal from others often leading to relationship breakdown with spouses and children., Conclusion: This study provides some of the first evidence of the impact of MI on UK AF veterans' psychological, spiritual, social and day-to-day functioning all of which would pose challenges to clinicians aiming to manage such difficulties. These findings highlight several gaps in existing care provision for morally injured veterans, including addressing issues related to spirituality, employment and family functioning, which could ultimately improve veteran well-being., Competing Interests: Competing interests: NG is the Royal College of Psychiatrists Lead for Military and Veterans’ Health but was free to provide his independent views on this research., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Veterans with post-traumatic stress disorder (PTSD) typically report a poorer treatment response than those who have not served in the Armed Forces. A possible explanation is that veterans often present with complex symptoms of PTSD. ICD-11 PTSD and complex PTSD (CPTSD) have not previously been explored in a military sample., Aims: This study aimed to validate the only measure of ICD-11 PTSD and CPTSD, the International Trauma Questionnaire, and assess the rates of the disorder in a sample of treatment-seeking UK veterans., Method: A sample of help-seeking veterans (N = 177) was recruited from a national charity in the UK that provides clinical services to veterans. Participants completed measures of ICD-11 PTSD and CPTSD as well as childhood and adult traumatic life events. Confirmatory factor analysis was used to assess the latent structure of PTSD and CPTSD symptoms, and rates of the disorders were estimated., Results: The majority of the participants (70.7%) reported symptoms consistent with a diagnosis of either PTSD or CPTSD. Results indicated the presence of two separate disorders, with CPTSD being more frequently endorsed (56.7%) than PTSD (14.0%). CPTSD was more strongly associated with childhood trauma than PTSD., Conclusions: The International Trauma Questionnaire can adequately distinguish between PTSD and CPTSD within clinical samples of veterans. There is a need to explore the effectiveness of existing and new treatments for CPTSD in military personnel.

Background: PTSD Resolution is a charitable provider of mental health support and treatment via Human Givens Therapy to members of the Armed Forces Community. This study utilized data from their client database to evaluate outcomes of their services., Aims: To determine whether treatment by the service resulted in improvements in mental health; to the extent possible, compare these outcomes with those of NHS IAPT (National Health Service - Improving Access to Psychological Therapies) services; and to evaluate how other factors, notable reported stress levels and prior treatment, impacted outcomes., Methods: Administratively collected data from the service provider collected between 2014 and 2016 were utilized. Clients still undergoing services were excluded. The CORE-10 (10-item Clinical Outcomes in Routine Evaluation) measure was used as the outcome measure. Demographic factors examined included age, sex, employment, accommodation, relationship status, distress at the time of presentation and prior treatment history. The effect of the factors was analysed using χ2 test as well as linear regression and Poisson regression analyses according to the nature of the variable., Results: PTSD Resolution clients appeared to show a similar degree of improvement as IAPT patients. Job-seekers and those who are living alone benefited less from the treatment. Despite high levels of distress and prior treatment among this client group, these factors did not seem to affect treatment outcomes., Conclusions: The services of this provider appear to be an acceptable alternative for IAPT treatment, to the degree such a comparison can be made given differences in measures and client groups., (© 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: Previous studies have found that perceptions of mental health related stigma can negatively impact help-seeking, particularly in military samples. Moreover, perceptions of stigma and barriers to care can vary between individuals with different psychiatric disorders. The aim of this study was to examine whether perceptions of stigma and barriers to care differed in a UK military sample between those with and without a current likely mental health diagnosis., Method: Structured telephone interviews were carried out with 1432 service personnel and veterans who reported recent subjective mental ill health in the last 3 years. Participants completed self-reported measures relating to perceived stigma, barriers to care and psychological wellbeing., Results: Those meeting criteria for probable common mental disorders (CMD) and PTSD were significantly more likely to report concerns relating to perceived and internalised stigma and barriers to care compared to participants without a likely mental disorder. Compared to individuals with likely CMD and alcohol misuse, those with probable PTSD reported higher levels of stigma-related concerns and barriers to care - although this difference was not significantly different., Conclusions: These results indicate that perceptions of stigma continue to exist in UK serving personnel and military veterans with current probable mental disorders. Efforts to address particular concerns (e.g. being seen as weak; difficulty accessing appointments) may be worthwhile and, ultimately, lead to improvements in military personnel and veteran wellbeing.

Objectives: In the first study of its kind in the UK, we linked pensions data on benefit claims with data from the King's Military Cohort to assess uptake of unemployment and disability benefits in military veterans of the UK Armed Forces., Methods: Benefits data were matched with data on the mental health, demographics and military-related variables for 7942 veterans who had previously served as regulars and transitioned to civilian life between 2003 and 2016. Associations between demographic and service-related factors and benefit claims were assessed using Cox regression to take into account period at risk., Results: Around 20% of veterans claim unemployment benefits (UB) shortly after leaving, but this proportion drops rapidly to around 2% in the first 2 years post service. Receipt of disability benefits (DB) is less common (1.5%), but longer-term. The most consistent predictors of postservice benefit usage were: low rank (a proxy for socio-economic status while in service) (HR 1.42 (95% CI 1.23 to 1.65) for UB and 1.59 (95% CI 1.11 to 2.27) for DB); leaving service (HR 1.29 (95% CI 1.07 to 1.56) between unplanned leaving and UB, and 7.51 (95% CI 5.31 to 10.6) between medical discharge and DB), and having a history of claiming benefits before joining the Services (HR 1.62 (95% CI 1.34 to 1.95) between preservice and postservice UB, and 2.86 (95% CI 1.09 to 7.47) between preservice and postservice DB)., Conclusions: Benefit claims by veterans are largely driven by socioeconomic, rather than military, factors. Additional employment-focused support to Service leavers may be particularly useful to lower-ranked personnel and those leaving in an unplanned way. Continuity of care and medical oversight is a key concern for those with medical discharges., Competing Interests: Competing interests: Dr RJR and Dr HB report grants from Ministry of Defence (MOD), grants from Forces in Mind Trust (FiMT), during the conduct of the study. Dr NG reports personal fees from King’s College London, during the conduct of the study, and is the Royal College of Psychiatrists Lead for Military and Veterans Health and also a trustee for two military charities. He was not required to act in any particular way by these organisations in relation to the paper. Professor NF and Professor SW have nothing to disclose., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

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: The principles of the Armed Forces Covenant state that Armed Forces Veterans should be at no disadvantage resulting from their service compared with a general adult population. However, despite being at increased risk of experiencing common mental health difficulties, evidence indicates that 82% of Armed Forces Veterans receive no treatment, compared with 63% of the general adult population., Aim: To gain a better appreciation of factors that inform the type of adaptations to cognitive behavioural therapy (CBT) interventions for depression and mainstream service promotion materials to enhance acceptability for Armed Forces Veterans., Method: This is a qualitative study employing a focus group of 12 participants to examine the main impacts of depression on Armed Forces Veterans alongside attitudes towards terminology and visual imagery. Thematic analysis was used to identify themes and sub-themes with rigour established through two researchers independently developing thematic maps to inform a final agreed thematic map., Results: A behavioural activation intervention supporting re-engagement with activities to overcome depression had good levels of acceptability when adapted to reflect an Armed Forces culture. Preferences regarding terminology commonly used within CBT adapted for Armed Forces Veterans were identified. Concerns were expressed with respect to using imagery that emphasized physical rather than mental health difficulties., Conclusions: There is the need to consider the Armed Forces community as a specific institutional culture when developing CBT approaches with potential to enhance engagement, completion and recovery rates. Results have potential to inform the practice of CBT with Armed Forces Veterans and future research.

Objectives: Military veterans often experience physical health problems in later life; however, it remains unclear whether these problems are due to military service or are a feature of the ageing process. This study aimed to explore veteran and non-veteran perceptions of the impact of their occupation on their physical well-being later in life., Design: Semi-structured qualitative interviews analysed using thematic analysis., Setting: Interviews were conducted face-to-face in participants' homes or via telephone., Participants: 35 veterans (≥65 years), 25 non-veterans (≥65 years) were recruited, as well as a close companion of all participants for triangulation (n=60)., Results: Most veterans reported good physical health later in life which they attributed to the fitness they developed during military service. However, several veterans described challenges in maintaining their desired level of physically activity due to new commitments and limited sports facilities when they left service. Fewer non-veterans had experienced work-related fitness activities or exercise in their civilian jobs. Ongoing physical health difficulties, such as deafness, were perceived to be due to exposure to workplace hazards and appeared more common in veterans compared with non-veterans. Veterans also described greater reluctance than non-veterans to seek medical treatment for physical health difficulties, which could be challenging for close companions who had to provide informal care., Conclusions: Military service was largely perceived to be beneficial for physical well-being; although when occupation-related physical health problems were experienced, many veterans were unwilling to seek treatment. These findings may inform clinicians of the needs of older veterans and highlight potential barriers to care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

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: Despite developments in mental health services for armed forces veterans and family members, barriers to access associated with poor levels of acceptability regarding service provision remain. Adapting a Step 2 mental health service based on low-intensity cognitive behavioural therapy (CBT) interventions to represent a familiar context and meet the needs of the armed forces veteran community may serve to enhance acceptability and reduce help-seeking barriers., Aims: To examine acceptability of a Step 2 low-intensity CBT mental health service adapted for armed forces veterans and family members provided by a UK Armed Forces charity., Methods: Qualitative study using individual semi-structured interviews with armed forces veterans and family members of those injured or becoming unwell while serving in the British Armed Forces. Data analysis was undertaken using thematic alongside disconfirming case analysis., Results: Adapting a Step 2 mental health service for armed forces veterans and family members enhanced acceptability and promoted help-seeking. Wider delivery characteristics associated with Step 2 mental health services within the Improving Access to Psychological Therapies (IAPT) programme also contributed to service acceptability. However, limitations of Step 2 mental health service provision were also identified., Conclusion: A Step 2 mental health service adapted for armed forces veterans and family members enhances acceptability and may potentially overcome help-seeking barriers. However, concerns remain regarding ways to accommodate the treatment of post-traumatic stress disorder and provide support for family members.

Background: Dementia is currently incurable, irreversible and a major cause of disability for the world's older population. The association between mental health difficulties, such as post-traumatic stress disorder (PTSD) and major depressive disorder (MDD), and dementia has a long history within the civilian population. Despite the increased importance of this link within the military veteran population, who suffer a greater propensity of mental health difficulties and consist largely of over 65s, attention is only recently being paid to the salience of such an association for this group. This paper aims to explore the relationship between PTSD and MDD with dementia within the military veteran population., Method: A systematic review was conducted on articles from 1990 to July 2016 on MEDLINE, EMBASE, EBSCO and Web of Science electronic databases with an update conducted in February 2017., Results: Six empirical studies were identified from the review, the majority of which originated from the USA. Five of the studies asserted that veterans with a diagnosis of either PTSD or MDD are at a significantly greater risk of developing dementia than 'healthy' controls. The final study, conducted in Australia, found only a small, but non-significant, correlation between earlier MDD and future dementia, but no concurrent correlation., Conclusions: While causality cannot be determined, it is likely that PTSD and depressive disorders are related to an increased risk of dementia in military veterans. Potential pathological explanations and risk factors are reviewed and the clinical and neuroscience implications of these findings are explored.

Objective: Older veterans may be vulnerable to mental health problems. Meta-analytic and systematic review methods sought to determine the prevalence rate of mental health disorders in older military veterans (≥65 years)., Methods: Eleven studies were eligible, and meta-analyses of veteran depression, substance abuse, post-traumatic stress disorder (PTSD), anxiety, dementia, bipolar disorder, and schizophrenia were conducted., Results: Although conducted exclusively with U.S. veterans, high prevalence rates of substance (5.7%) and alcohol use disorders (5.4%) in older veterans were found. However, the prevalence of other mental health disorders, including PTSD and depression, in older veterans was not markedly high., Conclusion: The rates of disorder prevalence observed indicates a need for continued awareness of mental health difficulties, particularly substance and alcohol use disorders, in older veterans. In the future studies with non-U.S. military samples using a longitudinal design are required to further understand the prevalence of mental health disorders in geriatric veterans., (Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Purpose: Previous research has mainly focused on veterans' mental health problems, especially on posttraumatic stress disorder (PTSD). Less is known about the impact that the veteran's experienced potentially traumatic events (PTEs) might have on their significant others. Therefore, we reviewed the scientific literature to find out what is known about the prevalence of secondary traumatic stress (STS) in significant others of veterans., Methods: We systematically searched Pubmed, PsycINFO, Embase, Cochrane Library and PILOTS for relevant articles. This search resulted in 3100 records from which we included 48 articles., Results: Two studies that reported on parental PTSD did not find evidence that parents were affected by their offspring's experience. Nine studies that reported on PTSD in mainly adult children of veterans found only scant evidence that children were affected by their parent's experienced PTE. Twenty-seven studies investigated PTSD symptoms in partners of veterans. Here results varied largely between studies with PTSD rates between 0 and 51 %., Conclusions: Overall, we found the strongest evidence of STS in partners of help-seeking veterans with PTSD. The lack of clarity provided by the currently available evidence suggests a pressing need for further work to examine this subject in more detail., Competing Interests: On behalf of all authors, the corresponding author states that there is no conflict of interest. Ethical standards The manuscript does not contain clinical studies or patient data.

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.)

Background: Recently, proposals have been made to improve mental health care for U.K. military veterans. Combat stress (CS), a veteran's charity, has provided mental health services for veterans since 1919. Since 2003, service users have included veterans from the Iraq and Afghanistan conflicts; however, their pattern of help-seeking has not been evaluated., Aims: To describe the characteristics of the veteran population of the recent Iraq or Afghanistan conflicts who sought help from CS between 2003 and May 2011., Methods: CS Iraq and Afghanistan veteran clinical and welfare records were evaluated., Results: Nine hundred and eighty-eight records were evaluated. The median time for veterans of recent conflicts to seek help from CS since discharge from military service was ~2 years, considerably shorter than the mean time of 14 years previously estimated by CS. Approximately, three-quarters of the veterans receiving a full clinical assessment (n = 114), received a diagnosis of post traumatic stress disorder (PTSD) (n = 87). Approximately half of the clinically assessed veterans self-referred to CS (51%); their most frequent diagnosis was PTSD., Conclusions: Veterans who have served in Iraq and Afghanistan are presenting to Combat stress sooner, and at a younger age, than veterans of previous conflicts and operations.

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

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.

Background: As with the general population, a proportion of military personnel with mental health problems do not seek help. As the military is a profession at high risk of occupational psychiatric injury, understanding barriers to help-seeking is a priority., Method: Participants were drawn from a large UK military health study. Participants undertook a telephone interview including the Patient Health Questionnaire (PHQ); a short measure of PTSD (Primary Care PTSD, PC-PTSD); a series of questions about service utilisation; and barriers to care. The response rate was 76% (821 participants)., Results: The most common barriers to care reported are those relating to the anticipated public stigma associated with consulting for a mental health problem. In addition, participants reported barriers in the practicalities of consulting such as scheduling an appointment and having time off for treatment. Barriers to care did not appear to be diminished after people leave the Armed Forces. Veterans report additional barriers to care of not knowing where to find help and a concern that their employer would blame them for their problems. Those with mental health problems, such as PTSD, report significantly more barriers to care than those who do not have a diagnosis of a mental disorder., Conclusions: Despite recent efforts to de-stigmatise mental disorders in the military, anticipated stigma and practical barriers to consulting stand in the way of access to care for some Service personnel. Further interventions to reduce stigma and ensuring that Service personnel have access to high quality confidential assessment and treatment remain priorities for the UK Armed Forces.

Background: The health and well-being of military veterans has recently generated much media and political interest. Estimating the current and future size of the veteran population is important to the planning and allocation of veteran support services., Methods: Data from a 2007 nationally representative residential survey of England (the Adult Psychiatric Morbidity Survey) were extrapolated to the whole population to estimate the number of veterans currently residing in private households in England. This population was projected forward in two ten-year blocks up to 2027 using a current life table., Results: It was estimated that in 2007, 3,771,534 (95% CI: 2,986,315-4,910,205) veterans were living in residential households in England. By 2027, this figure was predicted to decline by 50.4 per cent, mainly due to large reductions in the number of veterans in the older age groups (65-74 and 75+ years)., Conclusion: Approximately three to five million veterans are currently estimated to be living in the community in England. As the proportion of National Service veterans reduces with time, the veteran population is expected to halve over the next 20 years.

For the majority service in the Armed Forces is beneficial and, in the main, military veterans have successful lives. However, a minority have a bleaker outlook as a result of on-going ill health and social exclusion. Whilst the media focuses on Post Traumatic Stress Disorder, in reality the most frequent mental health problems for veterans are alcohol problems, depression and anxiety disorders. These difficulties are difficult to manage as veterans, particularly those who are unwell, demonstrate a reticence to seek help for mental health problems. Another issue is that many veterans are now reserve personnel who have been found to be at greater risk of developing mental health problems than their regular counterparts. Steps to improve the knowledge and expertise of primary care services about veteran's mental health issues and increasing the availability of treatment options are important and are underway.

Background: Little is known about the patterns of alcohol use in the U.K. Armed Forces or the factors associated with heavy drinking., Methods: Analysis of existing data from the King's Military Cohort was conducted of a large, randomly selected cohort of service personnel. The original sample consisted of 8,195 service personnel who served in the U.K. Armed Forces in 1991: a third deployed to the Gulf (1990-1991), a third deployed to Bosnia (1992-1997), and the final third, an "Era" comparison group, in the Armed Forces in 1991 but not deployed. For the purposes of this study, female serving personnel were excluded. The study used a "case-control" study design nested within the above cohort; "heavy drinkers" (those who drank >30 units/week) were compared with "light drinkers" (those who drank <21 units a week)., Results: Heavy drinking was associated with current military service and being unmarried or separated/divorced. Heavy drinking was more common in younger personnel who had deployed to Bosnia. Those who drank heavily were also more likely to smoke; heavy drinking was associated with poorer subjective physical and mental health., Conclusions: Certain subgroups of the Armed Forces appear to be more at risk and it may be possible to target resources to such individuals to improve detection and allow prompt treatment.

Background: Little is known about the psychological health or treatment experiences of those who have left the British armed forces., Aims: To describe the frequency and associations of common mental disorders and help-seeking behaviours in a representative sample of UK veterans at high risk of mental health problems., Method: A cross-sectional telephone survey of 496 'vulnerable' ex-service personnel selected from an existing epidemiological military cohort., Results: The response rate was 64%; 44% of these had a psychiatric diagnosis, most commonly depression. Those with a diagnosis were more likely to be of lower rank and divorced or separated. Just over half of those with self-reported mental health problems were currently seeking help, most from their general practitioners. Most help-seekers received treatment, usually medication; 28% were in touch with a service charity and 4% were receiving cognitive-behavioural therapy., Conclusions: Depression is more common than post-traumatic stress disorder in UK ex-service personnel. Only about half of those who have a diagnosis are seeking help currently, and few see specialists.

Background: Little is known about the factors associated with leaving the armed forces, or what predicts subsequent employment success for veterans. It is likely that there is a complex interaction of adverse social outcomes and mental health status in this group., Method: Analysis of existing data from the King's Military Cohort, a large, randomly selected, longitudinal cohort of service personnel, many of whom have now left the armed forces. The sample consisted of 8195 service personnel who served in the armed forces in 1991; a third deployed to the Gulf (1990-91), a third deployed to Bosnia (1992-97) and the final third an 'Era' control group in the Armed Forces in 1991 but not deployed., Results: The majority of service leavers do well after leaving and are in full-time employment. Those with poor mental health during service were more likely to leave and had a greater chance of becoming unemployed after leaving. Mental health problems appear to remain static for veterans after leaving. Veterans of the Gulf War enjoyed more favourable employment outcomes, provided that they came home well., Conclusions: Only a minority of veterans fare badly after service, even amongst those with active tours of duty behind them. Veterans with mental health problems during service seem to be at higher risk of social exclusion after leaving and therefore these individuals represent an especially vulnerable group of the veteran population.

Background: Post-traumatic stress disorder (PTSD) occurs more commonly in military veterans than the general population. Whilst current therapies are effective, up to half of veterans commencing treatment do not complete it. Reconsolidation of Traumatic Memories (RTM) protocol is a novel, easy to train, talking therapy with promising findings. We examine the feasibility of undertaking an efficacy trial of RTM in veterans. Methods: A parallel group, single-centre randomised controlled feasibility trial with a post-completion qualitative interview study. Sixty military veterans were randomised 2:1 to RTM (n = 35) or Trauma Focussed Cognitive Behaviour Therapy (CBT) (n = 25). We aimed to determine the rate of recruitment and retention, understand reasons for attrition, determine data quality and size of efficacy signal. We explored veterans' perceptions of experiences of joining the trial, the research procedures and therapy, and design improvements for future veteran studies. Military veterans with a diagnosis of PTSD or complex PTSD, and clinically significant symptoms, were recruited between January 2020 and June 2021. Primary outcome was feasibility using pre-determined progression criteria alongside PTSD symptoms, with depression, recovery, and rehabilitation as secondary outcomes. Data were collected at baseline, 6, 12, and 20 weeks. Interviews (n = 15) were conducted after 20 weeks. Both therapies were delivered by trained charity sector provider therapists. Results: Participants' mean age was 53 years, the mean baseline PTSD symptoms score assessed by the Post-traumatic Stress Checklist (PCL-5) was 57 (range 0–80). Fifty had complex PTSD and 39 had experienced ≥ 4 traumas. Data were analysed at 20 weeks for feasibility outcomes (n = 60) and mental health outcomes (n = 45). Seven of eight progression criteria were met. The RTM group experienced a mean 18-point reduction on the PCL-5. TFCBT group participants experienced a mean reduction of eight points. Forty-eight percent of the RTM group no longer met diagnostic criteria for PTSD compared to 16% in the TFCBT group. All veterans reported largely positive experiences of the therapy and research procedures and ways to improve them. Conclusion: RTM therapy remains a promising psychological intervention for the treatment of PTSD, including complex PTSD, in military veterans. With specific strengthening, the research protocol is fit for purpose in delivering an efficacy trial. Trial registration: ISRCTN registration no 10314773 on 01.10.2019. Full trial protocol: available on request or downloadable at ISRCTN reg. no. 10314773. [ABSTRACT FROM AUTHOR]

Copyright of European Journal of Psychotraumatology is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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

Background: Rates of hazardous and harm-related drinking are higher in the military and veteran populations compared to the general population. Brief alcohol interventions (BAIs) targeting alcohol use appear to reduce harmful drinking in the general population. However, less is known about the efficacy of BAIs targeting alcohol in military and veteran populations.Methods: A systematic review and meta-analysis was conducted to assess the type and efficacy of BAIs used to reduce alcohol use in military and veteran populations conducted from 2000 onwards. The meta-analysis was conducted using a standardised outcome measure of change in average weekly drinks (AWDs) from baseline to follow-up.Results: The search revealed 10 papers that met the search criteria, and that reported data on 11 interventions included in the systematic review. 8 papers (reporting on 9 different interventions) were included in the meta-analysis after 2 papers were excluded for which the relevant outcome data were not available. There was no overall effect of BAIs; a non-significant weekly drink reduction of 0.95 drinks was found (95% CI, -0.17 to 2.07). This lack of efficacy persisted regardless of military group (conscripts, serving or veterans) and method of delivery (i.e., face-to-face, web-based or written information). Furthermore, sensitivity analyses revealed this small drink reduction was driven mainly by a single study.Conclusions: Based on these findings, existing BAIs do not seem to be efficacious in reducing alcohol use in military populations, despite some encouraging results from one electronic intervention which was of extensive duration. [ABSTRACT FROM AUTHOR]