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looked upon as a form of disgrace to the soldier’ to discourage Servicemen from seeking a psychological discharge. A commander of medical services in Tunisia ordered two newly arrived psychiatrists not to disclose their specialist training, while his counterpart on Malta, refused to allow a psychiatrist to land on the island. Thus, during both World Wars, it was believed that by their mere presence, military psychiatrists could undermine the fighting spirit. Indeed, many soldiers were reluctant to report their illnesses for fear of ridicule or shame; stigma was such that in the post-1945 period admissions registers and case notes were systematically destroyed to protect their identity.
The creation of the new category of PTSD by the American Psychiatric Association in 1980 signaled a sea change in the acceptance of psychological injury by the Armed Forces and society in general. During the Vietnam conflict, psychiatric casualties were actually surprisingly few, apparently at lower levels than in WW2 or Korea, causing some to say that the problem of psychiatric battle casualties had been resolved. But then came the new diagnosis of PTSD. Using new concepts, a key study conducted fifteen years after the end of the war found that 15% of male veterans then suffered from PTSD and about one third would suffer from PTSD during their lifetime.
Evidence from operations in Iraq Although the UK Armed Forces had been engaged in numerous conflicts since the end of the Second World War, it was not until after the 1991 Gulf War that a robust approach to studying the health of the UK Armed Forces began. Even then, the results of the numerous studies into the saga that became Gulf War Syndrome were conducted as a reaction to the substantial numbers of media fuelled stories. Despite this, no single biomedical cause has been confirmed to explain why a proportion of coalition troops that suffered, and indeed continue to suffer from multiple physical symptoms which they attribute to service in the 1991 Gulf War. The UK studies found that about 1 in 5 of UK Service personnel who took part in the 1991 Gulf War reported, and in 2001 continued to report, more symptoms of poor physical health than those who had not; the nature of this ill health remains obscure.
The Gulf War Syndrome issue, with its negative impact on individual health and institutional reputations, was an important driver for MoD deciding to formally fund a wide ranging, proactive, cohort study into the health of UK Service personnel who were to deploy to Iraq in 2003. Another important driver
18 Autumn 2010
was the PTSD class action brought by ex Service personnel against the MoD in 2001. Although the case was successfully defended, at a considerable cost (~£20M), it again highlighted the need to base policy upon research rather than speculation.
The first UK focused study into the effects of OP TELIC found that overall service in Iraq had not led to an increase in mental health problems, compared to a comparable sample of the UK Armed Forces who had not at that time served on OP TELIC. Despite the fears that history might repeat itself there was no evidence of an ‘Iraq War Syndrome’ a finding of interest when one recalls that some of the possible culprits identified as contributing to GWS, such as anthrax vaccination, NAPS tables and the use of depleted uranium munitions, were also used in 2003. The initial OP TELIC studies were, therefore, somewhat reassuring.
Since completion of research, operations in Iraq intensified and there was an expansion of the UK military presence in Afghanistan. The numbers of physical casualties also increased. Since the link between psychological and physical injury is well established, there was every reason to envisage that the health of the UK Armed Forces may have changed, most probably for the worse.
The US experience
Another driver for conducting further research was the psychological health of the US military that had been in Iraq and Afghanistan alongside UK forces. There had been numerous studies of US troops which have identified them as suffering substantially higher rates of psychological ill health, especially PTSD. More perplexingly, US PTSD rates have been observed to increase with time since return from deployment, the opposite to what might be expected from other studies of the natural history of traumatic distress. Therefore, there has been speculation that the UK would be faced with a ‘tidal wave’ of mental disorders in years to come. Furthermore, US data have found an association between multiple deployments and increased frequency of mental disorders.
The result was that the King’s College London research team were asked to extend the original study to examine three main areas of interest: a) what was the legacy of deployment to Iraq and Afghanistan from 2003 to the beginning of 2009; b) what was the impact of multiple deployments and c) had there been a similar increase in mental disorders over time since deployment as observed in the US.
Given the high operational tempo that UK forces had been operating under, the results of the survey were again both surprising but in part reassuring. The overall mental health of the UK Armed Forces remained good and did not significantly differ from the results of the earlier study.
These results should not, however, be viewed as suggesting that there has been no impact of deployment as the results clearly speak otherwise.
However, it is of interest that the UK rates, in respect of PTSD in particular, are different to rates found in US troops since both nations operate in similarly intense environments.
The finding that combat troops reported higher rates of psychological ill health is not surprising given the nature of The operational duties that combat troops carry out. The finding that reserve forces appeared to be more at risk if they deploy is worthy of some consideration. The increased reporting of probable PTSD among reservists did not appear to be a result of experiencing more trauma during deployment but is instead most probably a product of the context in which deployment takes place – in particular reservists’ lower perception of support whilst on deployment, and their domestic and employment circumstances when they return.
Impact on Reserves
It is also notable that studies found that reserve personnel reported higher levels of combat exposures than regular troops. This
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