PTSD and mental health: Forget the media hype – are we prepared for Army 2020?

Ashley Ryan, a student at City & Islington College, intends to enroll in 2014 for War Studies at King’s College London. Joseph Ryan, PhD, is studying for a PsychD in Psychotherapeutic and Counselling Psychology, specialising in trauma, at the University of Surrey.

On Thursday 3 October 2013, the MoD announced that 5,058 military personnel were diagnosed with mental health conditions over the previous year, representing a rate of 27.1 per 1,000 personnel at strength [1].

Recent media attention focused on an ‘upsurge’ in PTSD cases. The MoD, however, said most of the increase in mental disorders was due to an alteration in reporting methods. Without the change, there would have been only a 3% rise [2]. So, the figures don’t show big increases; rather, they demonstrate for the first time the extent of mental health problems faced by the military.

Since 2007, 22,600 personnel experienced mental health issues during or after deployment to Iraq or Afghanistan [3]. Adjustment disorder was common, accounting for 61% of all neurotic disorders [1]. Other prevalent conditions included depression and alcohol abuse. Increased drinking – a form of self-medication – is a common and traditionally acceptable response to stress among the armed forces.

PTSD remains relatively uncommon, accounting for only 10% of neurotic disorders reported since April 2007 [1]. The impact of the condition, however, sometimes gets lost in the statistics … PTSD is debilitating and, if untreated, worsens progressively, sometimes to the point of suicide. It also has a negative effect on family, friends and colleagues.

Army 2020 plans will increase risk factors associated with PTSD. Since 2001, both regulars and reservists have experienced greater exposure to combat and trauma, due to the scale of operations in Iraq and Afghanistan. Although operations are scaling down, our military presence isn’t due to end anytime soon – and for troops it remains to be seen whether the end of these conflicts will bring a lull in engagements or merely a change of scenery.

The change to lengthier deployments (of 8-9 months) means extended immersion in theatre, compounding the chances of multiple traumatic events occurring. This may partly explain the higher rates of PTSD in the US military, which sees deployments of 12-15 months.

The planned increase in reserve forces (from 15,000 to 30,000) suggests that reservists will be rotated from deployment to civilian life more regularly. Research indicates they have an elevated risk of mental health problems; indeed, the chief executive of Combat Stress stated that rates of PTSD among veterans are 50% higher in reservists.

Reservists may have lower morale and unit cohesion, and greater perception of exposure to trauma. On homecoming, they feel less supported by the military than regulars, experiencing increased marital discord, employment issues and lack of social support. Rapid reintegration into society also causes a sudden loss of the deep bond and camaraderie between members of a unit that they experienced in theatre; whereas for regulars this continues between deployments and, indeed, on their next tour.

The armed forces face severe budget cuts and more than 11,000 personnel have been made redundant since 2011, with further reductions planned. The psychological impact of risking one’s life on operations, combined with disillusionment and loss of morale caused by redundancies, disbandment or merging of regiments, and lack of support from the general public for military action in recent years, has yet to be fully felt.

In summary, the problem isn’t that mental health issues (including PTSD) are common or spiking, because they aren’t – yet. But changes to army structure and deployment length will intensify risk factors as we move towards Army 2020, placing additional pressure on the mental resilience of our men and women in the field. As such, many more personnel are likely to experience PTSD, with even greater numbers suffering common mental health and alcohol problems (which can lead to other social concerns – unemployment, homelessness, imprisonment, etc).

It is time to recognise this and plan accordingly, making provisions for effective mental health treatment for serving personnel (whether regulars or reservists) and veterans alike.

Notes:

[1] Ministry of Defence, ‘UK Armed Forces mental health: Annual Summary & Trends Over Time, 2007/08 – 2012/13’ (3 October 2013). ()

[2] Ministry of Defence, Defence News, Official News Blog of the UK Ministry of Defence, ‘Defence in the Media: 4 October 2013: Mental health support for Service personnel’ (4 October 2013). ()

 

[3] Tom Whitehead, ‘Mental disorders among Afghan veterans rise,’ Telegraph (3 October 2013).

 

 

 

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10 thoughts on “PTSD and mental health: Forget the media hype – are we prepared for Army 2020?

  1. Cincinnatus jr. says:

    Good piece and a cautionary tale so to speak. We in the US have had a rocky road in terms of developing the right systemic and programmatic response to the PTSD problem. A s you point out is more severe (at least for now) than in the UK in terms of severity of the condition on the sufferer and the responses of government and the private sector (mainly service-related charities such as the DAV-Disabled American Veterans and the Wounded Warrior Project)).

    This response has gone hot and cold over the years since 2001 and mainly (and sadly) is usually stimulated toward improvement when there is a notorious suicide or spate of them. See e.g., http://www.ajc.com/news/news/lawmakers-call-for-va-hospital-changes-following-f/nXnrw/ that involves the large regional Veterans Administration hospital in the city nearest to me.

    Currently from my own personal experience the VA has made great strides in identification and treatment of PTSD, which like alcohol is an incurable disease. The current regimen involves a combination of a psychiatrist for overall supervision of the patient care and to prescribe meds (as an MD he or she is the only health profession who can do so), a clinical psychologist for frequent (often weekly) one-on-one therapy (usually Cognitive Behavioral Therapy) and participation of one or more PTSD groups where various aspects of the disease and dealing with it in ones’ daily life are the focus. In my case, it is a “Coping Skills” group comprised of veterans from Vietnam and the “War on Terror” ( I use the term generically not legally) where real life experiences (good and bad) are discussed freely and through group interaction skills to cope with them are “brainstormed.”

  2. Ashley Ryan says:

    Thanks for your response, Cincinnatus jr.

    Agreed, it’s a challenging condition that needs a comprehensive treatment system. A lot’s been done in the 30-odd years since the condition was first recognised, but we have a long way to go before we can say we’ve got a rock-solid system for handling it.

    PTSD is the same condition the world over – we have seen PTSD-related suicides just the same as in the US – and that’s an absolute tragedy wherever it occurs. The VA hospital story you shared is absolutely disgusting (I want to say it shocks me, but it doesn’t). The UK too sees a spate of media attention after a story breaks, and then the status quo returns.

    The point is we need to develop and implement a consistent, empirically proven, effective programme of treatment for everyone. That’s whether they are regulars or reservists, serving personnel or veterans. And (likely off the back of ‘lessons learned’ from that), we need to roll out a system for others in society affected by PTSD … that could be blue-light services or civilians … they are often forgotten in the media buzz around military PTSD, but can experience the condition equally severely.

    The established position is that PTSD is incurable, and many experts would support that view. My take is that we can’t regard our current understanding as set in stone. We have to keep pushing the boundaries, just as for curing any major (physical) disease – we need more research and understanding. I believe ultimately we will reach a stage where PTSD is treatable and curable.

    I am aware of organisations here in the UK that are doing incredible work and getting empirically proven results (one in particular that I know of has a 78% success rate for treating PTSD).

    We need to explore their work along with some of the cutting-edge investigation being done to understand PTSD’s effect on the mind (such as the brain scans being done to investigate the relationship between the amygdala and PTSD, and so on). I would also suggest that phenomena such as Post Traumatic Growth (PTG) should be increasingly recognised and built into the design of treatment programmes.

    This is the subject of a forthcoming article, so I shan’t bang on about it too much for the moment. If you want to discuss further, or get an update when the next piece comes out, follow me at @AshRyan555 on Twitter.

    All the best, and thanks again for your comment.

    Ash

  3. Condor says:

    Good article. A suggestion I have made time and time again is that the services who will be providing treatment for mental health issues such as PTSD should be striving to “fill their ranks” with counselors who have firsthand experience/knowledge on these issues. Case in point, I am a US veteran with 2 operational deployments to Iraq. Post-service, I feel the VA is making great strides in dealing with these issues. With that being said, I know personally many veterans who have turned away from the services offered because they feel disconnected with the counselors that they have experienced. This isn’t to say that many of these counselors aren’t good people or not good at their job, it’s just they can’t always relate to the person they are trying to help. What I feel would be even be better would be to have a system in place where individuals coming out of service could be targeted for their experiences and sent through the appropriate schooling to become counselors and would thus have personal experiences in the field they will be working. As an example, most US veterans qualify for different programs such as the GI Bill. Why not use this program and other programs like vocational rehab for targeting individuals with conditions that could be indispensable as a counselor with “real life experiences”. Fortunately, the VA has recently put forth such a program where they are hiring service connected vets who have “recovered” from a mental health issue and are working towards the professional licensure in that field.

    • Joseph Ryan says:

      Hi Condor, many thanks for your interesting comment!

      The point you make is sound, although it is not always possible to match counsellors and clients in this way. Quite simply, supply often does not keep up with demand!

      Clients, if they have the choice, may employ various schemas when considering which therapist to see, such as the counsellor’s sex, age and education (Karlsson, 2005). They could specify the gender of the therapist but, for example, if there are insufficient male counsellors available, long waiting times are the result. Similarly, it is known that ethnic matching between therapist and client is important, as ethnic differences can undermine the process and outcome of therapy. As such, more ethnic minority trainees need to be encouraged to enter the field of therapy (Farsimadan, Khan, & Draghi-Lorenz, 2011).

      It would, however, be great to encourage combat veterans to become therapists. In the UK, I know that this has happened in the charity Talking2Minds, which has achieved good outcomes when treating PTSD and trauma. Indeed, they make clear that the majority of their practitioners ‘have been there themselves’ (http://www.talking2minds.co.uk/tm/how-we-can-help/).

      My daughter, Ash, and I plan to write a further article on PTSD later this year and I would hope to include something about counsellor-client matching. If you want to get an update when this is (hopefully!) published, follow her @AshRyan555 on Twitter, or else you can e-mail me any questions at joseph_ryan@btinternet.com.

      References

      Farsimadan, F., Khan, A., & Draghi-Lorenz, R. (2011). On ethnic matching: A review of the research and considerations for practice, training and policy. In C. Lago (Ed.), The handbook of transcultural counselling and psychotherapy (pp. 65–80). Maidenhead: Open University Press.

      Karlsson, R. (2005). Ethnic matching between therapist and patient in psychotherapy: An overview of findings, together with methodological and conceptual issues. Cultural Diversity and Ethnic Minority Psychology, 11 (2), 113–129. doi:10.1037/1099-9809.11.2.113

  4. Condor says:

    Mr. Ryan,
    Thanks for taking the time to respond to my comment. I would like to add a little clarification on my original post that I did not articulate well the first time. You are correct that it would be impossible to “fill the ranks” of the counseling professions with people who had all the possible experiences any patient “waking in off the street” may have. What I was implying was that since we are talking about a “targeted group” (veterans) with the same basic experiences (combat,PTSD) that it makes sense to try and kill the proverbial “two birds with one stone” by a) encouraging these combat veterans as they leave the services to seek higher education in the much needed field of mental health counseling and b) that the institution that will provide said counseling to the veteran will have on staff other veterans who have “been there done that”. I personally feel that we would see marked improvements with said approach and at a minimum I think the return rate for counseling would go up amongst the veteran population. I can’t speak to what system the UK has in place in regards to medical services for veterans so I can only go off what I know and have experience with here in the US (sorry for my Yank ignorance).

    • Joseph Ryan says:

      Hi Condor, I instinctively agree with you that matching veterans suffering from combat-related PTSD (CR-PTSD) with therapists who have had similar experiences would result in therapeutic improvements. Psychological interventions, however, require an evidence-based approach to demonstrate their efficacy. I am currently studying CR-PTSD and will bear in mind the idea of client-therapist matching as I conduct a review of the literature.

      I know that some veterans who receive treatment for CR-PTSD later become mentors for those about to have therapy. Although this may be useful, the Chairman of the charity Invisible Injuries (http://www.ii-uk.org) said recently that meeting a veteran who has undergone a similar experience is not a requirement for change to occur (Stott, 2013). Similarly, a civilian can be trusted and accepted by veterans if that therapist displays various relevant personal and professional characteristics (Jones, 2013).

      Thanks again for your comments!

      References

      Jones, M. W. (2013, October). Solider, veteran, survivor. Therapy Today, 24(8), 18–20.

      Stott, M. (2013, October). From soldier to civilian. Therapy Today, 24(8), 14–17.

  5. Patrick says:

    Interesting article and summary of where the UK is now. From my own anecdotal experience though, the real PTSD sufferers are the ones who return from tour, get the hell out of the army and then develop sometimes severe symptoms over time. Who collects the data on these? I’m not sure…but know General Dannatt has said the HO/TO procedures between mil medical records and the NHS needs to be vastly improved…

  6. http://www.kcl.ac.uk/kcmhr/publications/15YearReportfinal.pdf
    You might look at the research of KCMHR – a research centre based on IoP and War Studies at King’s. The research we have done is summarised in the link above.
    The website has a searchable digest of papers – many of which are free downloads. If the first author does do a PhD in War studies it might be worthwhile contacting the Centre. We would be happy to discuss your work and ideas
    CD

  7. I am the Royal College of Psychiatrists Lead for Military and Veteran’s Health. Whilst this is article is well written as far as it goes it completely fails to acknowledge the very considerable differences between rates of mental disorder in people who present for help and the rates of mental disorder in the forces as a whole. Various studies have shown tha the vast majority of people (be they military, Veterans or civilians who have never served in the Armed Forces) do not seek help for mental disorder. Estimates from the Adult Psychiatric Morbidity Study suggest that about 70% of individuals with PTSD do not seek any professional help for mental disorders.

    It is not especially helpful to confused rates of disorder in help seekers with the rates that may exist in the whole force or indeed in the Veteran community. The Royal College of Psychiatrists is committed to improving the mental health of serving personnel and ex-Service members. It may well be that larger numbers of people presenting for care could reflect an increase in help-seeking which I am sure the authors would agree would be a cause for celebration. Whilst a minority of Service personnel develop mental health disorders, including but not limited to PTSD, it is important not to overstate the scale of the problem and to promote, wherever possible, those who need it to seek professional help so they can recover their health and continue to lead a fulfilling life either in Service or as a Veteran.

    • Ashley Ryan says:

      Hi Neil,

      Thanks very much for your feedback. You’re absolutely right, there’s a fine line to be drawn between recognising the (likely significant) number of unreported cases, without overstating or dramatising the scale of the problem. I have close friends in the veteran community, some of whom have experience with PTSD, so I am deeply conscious of the issue. I am particularly aware of those who do not report issues whilst in the military, and/or go on to develop mental health conditions as veterans. As you say, it is of course important to obtain appropriate treatment at the earliest possible stage, so that people can continue to live fulfilling lives.

      Discovering the true rate of prevalence in the veteran community would benefit from the development of improved reporting systems between the NHS and MoD. This might be one way we could improve provision and support for our armed forces and veterans, and through achieving a greater understanding, improve the robustness of our mental health system in preparation for any potential issues posed by Army 2020 plans (such as greater use of reservists, a group known to be at increased risk for certain mental health issues).

      As to the unreported prevalence of mental health conditions; there are, of course, inherent challenges in producing reliable figures. If you will pardon the tired analogy, the proportions (of reported vs. unreported issues) might be described as an ‘iceberg’ – only a tiny part is visible, with the bulk of the issue remaining unseen … yet expressing this rather amorphous concept, or general impression of the situation, in any remotely empirical fashion represents a layer of complexity that is challenging to capture fully in such a brief format as a blog post. Yet this is an issue we were, and are, cognizant of, and one that merits full attention. And not just in attempting to quantify the matter – the most important aspect must be in identifying, and rectifying where possible, the reasons behind people’s reluctance to seek help. You are right to point out that this latest increase might indicate a greater willingness to seek help, which would indeed be excellent news … yet my overall feeling on this – as your figure of about 70% would suggest – is that, despite the good progress made to date, there is still much to be done in increasing help-seeking, whether in the military, blue-light or civilian arenas. Thank you for drawing our attention to the Adult Psychiatric Morbidity Study, which appears both useful and informative.

      Thanks once again for taking the time to respond, Neil. We will keep your comments in mind for any future articles. Best regards, Ash.

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