veterans mental health linked

Writer: Arslaan Ohri
Email: Arslaanwilsonohri@outlook.com
An Inquiry into the mental health issues of the UK Veteran population
1. Issue: To provide an overview of veterans mental health
2. Background:
There is currently a lot of writing on the subject. This paper aims to simplify
the issues. The paper aims covers three main areas.
A) How we define a veteran
B) What the main veterans mental health issues are
C) Operations of charities and services in this space
3. What is a veteran
4. Different countries have different definitions of the word ‘veteran’. The way we define
the word veteran can influence benefits and support systems that UK ex-Service
personnel receive. Public opinion does not reflect the official definitions of what
‘veteran’ means. The official UK government definition for a veteran seems to be the
most inclusive of any countries definition. The government definition of veteran is as
follows: anyone who has performed any military service for at least one day and has
received one day’s pay. This can be at odds with the public perception of what a veteran
is. A 2002 survey found that from 2000 respondents 57% from the UK general public
found the most agreeable term for veterans were ex-service people from either World
War as compared to 37 % who felt the term encompassed all ex-service members.1
5. Some studies of veterans found that it is the case the way in which ex-service personnel
view themselves misrepresents even the existence of their own service.2 In a report
written to understand the term ‘veteran’ among UK ex-service personnel a study sample
of 4,722 regular and reserve personnel who deployed on TELIC 1 (January 18, 2003 to
April 28, 2003) and 5,550 regular and reserve personnel who were not deployed on
TELIC 1 Completed a questionnaire between June 2004 and march 2006. The response
rate for the Phase 1 study was 58.7 %. Respondents were asked the question: ‘would
you describe yourself as a veteran?’ 99% of those asked answered, of which 52%
answered yes. From the study, several factors were associated with self-identification as
1
“Inserted Questions.” This survey was carried out prior to most of the recent military activities in Iraq and
Afghanistan, so public attitudes may have changed.
2
B. C. Frueh, J. D. Elhai, A. L. Grubaugh, J. Monnier, T. B. Kashdan, J. A. Sauvageot, et al.
‘‘Documented Combat Exposure of US Veterans Seeking Treatment for Combat-related
Post-traumatic Stress Disorder,’’ The British Journal of Psychiatry 186, 6 (2005): 467-
72; M. Baggaley, ‘‘‘Military Munchausen’s’: Assessment of Factitious Claims of Military
Service in Psychiatric Patients,’’ Psychiatric Bulletin 22, 3 (1998): 153-54

a veteran. Being male, less educated, serving as a full time regular, and serving for
longer all contributed to identifying as a veteran.3
6. This study aims to make clear that the public perception of what a veteran is and the
official definition are at odds. It stands to reason that all of those included in the study
were veterans, but only 52 % identified as such. Reservists were less likely to identify as
veterans whilst those with a lower educational background were more likely to identify
as veterans. Some 57% of the UK general Public identify veterans as those who served in
one of the World Wars from this perspective none of the respondents would be
considered veterans. It is also the case that this paper only deals with the perceptions of
veterans themselves and is only relevant to more modern veterans. Furthermore, the
sample is of those primarily from a population at risk of poor mental health and
therefore reduces the representativeness of the ex-military population. It is apparent
that we must then treat this paper with caution. However, it does highlight a truth,
which is the official government endorsed definition of ‘Veteran’ is contentious and is at
odds with the perception of the general public, and in many ways with veterans
themselves.
7. Furthermore, it is also important to recognise that veteran’s mental health is at odds
with the public perception. Lord Ashcroft’s review into veteran’s mental health
demonstrated that the public perception seems to be that the majority of veterans have
mental health problems. Whereas, the truth is that only a minority have mental health
issues. In fact, the percentage of PTSD is almost the same as the wider society.
8. ESL’s Early Service Leavers:
It is also important for us to recognise the makeup of those who leave the armed forces.
Here is a breakdown of the outflows (Figure 1.1)
3
Howard Burdett, Charlotte Woodhead, Amy C. Iversen, Simon Wessely, Christopher Danderker, and Nicola T.
Fear. (2012). Are You a Veteran? Understanding of the term 'veteran' among UK Ex-Service Personnel a
research note. 0 (1-9), 5.

4
9. Each year around 18,000 service personnel leave the UK armed forces5. Those who leave
before completing the minimum term of their contract are known as Early Service
Leaders (ESLs).
10. ‘Early Service leavers: a study of the factors associated with premature separation from
the UK Armed Forces and the mental health of those that leave early’ was a report
designed through the use of self-report questionnaires completed between June 2004
and March 2006. As well as visits to military bases across the UK and Germany and
traced personnel through both military systems. From a sample of 10,272 a response
rate of 61 % (adjusted for those who had never received the questionnaire booklet).
There are various factors associated with being an ESL. ESL’s were more likely to be
younger, female, not in a relationship, to have been in the Army and to have held a
lower rank than non- ESLs, and there was a statistically significant trend for reporting
higher levels of childhood adversity in the fully adjusted model. ESL’s were less likely to
have children or higher educational attainments in some analyses.6
11. The key findings of this report demonstrate that ESLs were more likely to self-report
signs common mental disorders, PTSD and physical symptoms compared with non-ESLs.
ESLs are less likely to be in a relationship. Moreover, Being single is associated with a
greater likelihood of being unemployed in comparison to married people.7 Men are less
4
(2013). The Transition Mapping Study. Understanding the transition process for Service personnel returning
to civilian life. 1 (1), 6.
5
Defence Analytical Services and Advice. UK Defence Statistics 2010. 2010. Available at:
http://www.dasa.mod.uk/modintranet/UKDS/UKDS2010/pdf/UKDS2010.pdf. (13/September/2016 ), date last
accessed).
6
Joshua E. J. Buckman1 , Harriet J. Forbes1 , Tim Clayton2 , Margaret Jones1 , Norman Jones3 , Neil
Greenberg3 , Josefin Sundin1 , Lisa Hull1 , Simon Wessely1 , Nicola T. Fear1. (2012). Early Service leavers: a
study of the factors associated with premature separation from the UK Armed Forces and the mental health of
those that leave early. The European Journal of Public Health Advance Access . 1 (1), 3
7
United States Department of Labor, Bureau of Labor Statistics, USA. Available at: http://
www.bls.gov/opub/ee/empearn200801.pdf (13 September 2016, date last accessed).

likely to leave early this may be accounted for by the number of women who leave due
to pregnancy or family related matters.
12. There is a greater discussion to be had on the subject of ESLs. The question should be
raised: is it the case that service life afflicts strains which are too much to bear on ESL’s
or is it the case that ESL’s come from more vulnerable sections of society as the evidence
demonstrates. If we accept that Early ESLs come into the services more vulnerable than
is it the role of the MOD to help better transition them into civilian life? The Ministry of
Defence must then ask itself where the responsibility lies.
13. What are the mental health issues
14. One of the main issues is stigma. There exists a perception that stigma is attached to
asking for help. For some military personnel, there is still the social pressure of
maintaining a ‘stiff upper lip’. Arguably where a culture of stoicism and silence are
valued there can be a reluctance to seek help.
15. In short, the picture of mental health of veterans does not differ greatly from that of the
general public, in fact it mirrors it. However, male respondents reported more violent
tendencies and female veterans reported more suicidal thoughts. Moreover, no
evidence suggested that veteran’s differed from non-veterans in terms of social support
experiences of homelessness or money problems, but male veterans did endorse more
childhood adversity factors than male non-veterans.
16. There are an estimated 5 million veterans in the UK, and a further 18,000 personnel
leave the forces each year. When staff leave the Armed Forces healthcare provisions
transfers from the military to the NHS. Only around 0.1% of regular service personnel
are discharged annually for mental health reasons. However some veterans develop
mental health problems after leaving service, with a minority experiencing PTSD. Until
recently, little was known about these veterans. What is known is that only half of those
experiencing mental health problems sought help from the NHS, and those that did
were rarely referred to specialist mental health services. Veterans’ mental health
problems may be made worse or caused by post-service factors, such as the difficulty in
making the transition to civilian life, marital problems, and loss of family and social
support networks. Younger veterans are at high risk of suicide in the first two years after
leaving service. Ex-service personnel are also vulnerable to social exclusion and
homelessness, both of which are risk factors for mental ill health. Alcohol misuse is also
high.8
17. For the majority, service in the Armed Forces is beneficial and military veterans go on to
lead 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
8
Iverson et al., 2009; Murphy., 2008). A.C. Fear, N.T Simonoff, E., Hull, L., Hall (2009). The prevalence of
common mental disorders and PTSD in the UK militry: Using Data from a clinical interview based study.

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. Contrary to media speculation the rates of PTSD have been
found to be relatively low. The reason for this could be the USA’s focus on PTSD
following the Vietnam War. The rates of PTSD following the Iraq war were as low as 4%
versus 17-19 % for their American equivalents.9
18. It is also the case that those who served in the Army, who were single and from the
lower ranks were at increased risk of suffering from mental health problems. It is also
apparent, that veterans with pre-enlistment or childhood adversity are more likely to
report mental health problems following deployment.10
19. Furthermore, given that during conflicts Permanent Joint Head Quarters plan for
casualties with the intention of providing the right support, could it not be the case that
we do the same for mental health. In the current political climate, mental health issues
carry a particular salience. It can be argued that if we mitigate for mental health issues
then we can create a self-fulfilling prophecy. In that, where there exists an official
method by which one can claim against mental health issues there almost becomes an
incentive to ask for help. In other words, where no such service existed there was no
need to search for it. However, I believe it is a recognisable truth that conflicts can have
mental strains, and this simple truth should be enough for us to consider mitigating
mental health cases from conflicts or military experiences.
20. Symptoms of anxiety and depression appear to be twice as frequent in the UK military as
in the general working population, according to research carried out at the King’s Centre
for Military Health Research (KCMHR), King’s College London and published in
Psychological Medicine.
21. The study compared data from over 7,000 personnel serving in the UK Armed Forces
with 7,000 people from the general population identified as being in employment from
the Health Survey for England. Both surveys used the General Health Questionnaire
(GHQ) and it was found that symptoms of common mental disorders (CMD) (i.e. anxiety
and depression), appeared to be twice as frequent in the military as in the general
working population. In fact, 18% of men and 25% of women serving in the Armed Forces
reported symptoms of CMD compared to 8% of men and 12% of women in the general
working population. This difference was apparent at both time points of the study, 2003
and 2008.
22. Lead author, Dr Laura Goodwin from KCMHR said ‘This is the first formal comparison of
common mental disorders between the serving military and the general working
population. Whilst symptoms of common mental disorders appear to be twice as
9
D Murphy1 , A Iversen1 , N Greenberg. (2008). THE MENTAL HEALTH OF VETERANS. King’s Centre for Military
Health Research, King’s College London., 2 Academic Centre for Defence Mental Health, King’s College
London.. 1 (-), 136.
10
Cabrera, O. A., Hoge, C. W., Bliese, P., Castro, C. A. and Messer, S. C.
(2007) Childhood Adversity and Combat: Effects on Depression and Post
Traumatic Stress. (submitted

common in the military after accounting for age, gender and social class, there is more
to be done to understand these differences.’
23. The researchers had previously found that there is a tendency for over reporting of
symptoms of anxiety and depression in occupational studies aimed at specific groups
such as police, teachers and social workers. The Health Survey for England was a
population study in which an individual’s occupation was not the main focus, which is
likely to have had some effect on the results.
24. One way it was a considerable improvement on earlier research was that previous
studies have all been forced to compare different measures of CMD, which is a major
limitation, whereas in this study all participants completed the same questionnaire, the
GHQ. Also, some previous surveys have included individuals who are unemployed and
those with long-term health problems and disabilities and these groups are more likely
to report symptoms of depression and anxiety, so this comparison of military employees
with only those in employment from the general population is a fairer like-for-like
comparison.
25. The survey included questions such as whether the subject felt they were ‘playing a
useful part in things’, and military respondents were almost three times more likely to
disagree with this statement than the general population at both time points. On the
other hand, the smallest difference between the military and general population was
found for the statement ‘felt constantly under strain’.
26. The researchers suggest that differences in the prevalence of symptoms of depression
and anxiety in this extensive study could be explained by the frequency and intensity of
stressful events experienced by military personnel and that military life requires
extended periods spent away from family and friends, for training and exercises as well
as for deployment.
27. Professor Nicola Fear, KCMHR concludes: ‘This highlights that symptoms of depression
and anxiety are common in the Armed Forces, in fact, they are more common than
alcohol misuse or post-traumatic stress disorder (PTSD). The findings draw attention to
the need for Defence Medical Services to continue to focus on identifying and treating
depression and anxiety in addition to PTSD.’11
28. Services / Charities
29. Historically mainstream NHS mental health services have been ill-equipped to identify
and respond to the needs of veteran’s mental health. The problems of ex- serving
personnel may fall through the cracks of existing services, too complex for primary care
but not considered to cross to threshold for community mental health services, which
11
Goodwin, L. ‘Are common mental disorders more prevalent in the UK serving military compared to the
general working population?’ published in Psychological Medicine DOI:
http://dx.doi.org/10.1017/S0033291714002980

are more focused on severe mental illness. Various charities have aimed to fill such gaps,
alongside more established brands such as the Royal British Legion and Combat Stress,
which have endeavoured to fill in the cracks and deliver veteran-specific care and
support to the UK veteran community for many years. This has resulted in a plethora of
different approaches, interventions, philosophies and governance procedure’s. It is also
unclear exactly where the quality control over such charities lie and also where the
boundaries between treatment and support lie. There exists a reluctance to admit to
perceive weakened or being in a position to ask for help. It is also the case, that among
the veteran community there is an unrealistic expectation about waiting times and
service responses and perceptions that civilians can’t or don’t understand military
culture. Furthermore, there is a lack of awareness and understanding about the options
available and which services are provided either in the armed forces charities or
statutory services in the NHS and local authorities. All of which contribute to a common
experience reported by veterans and other stakeholders that veterans with mental
health problems struggle to engage with services and often fall out of the care
pathways.
30. There are no nationally recommended care pathways for veterans with mental and
related health needs. The common assumption amongst commissioners and service
providers has been that veterans do not need a separate care pathway, as their
problems are perceived to be the same as those in the general population with the
exception of combat PTSD. However, evidence from this review suggests that there are
significant barriers for veterans in accessing and benefitting from current services and
that the care pathway for veterans may in fact be more problematic than had been
supposed.12
31. The problem becomes apparent when we consider the types of treatment being offered
by such charities which often implement treatments without supporting
studies/evidence. This becomes ever more problematic when we consider the role of
the government and its limited hand the regulation of charities.
32. Recommendations
 Consider shifting the parameters in which veterans mental health is understood.
When a veteran overcomes physical trauma they are held in high esteem. Veterans
with prosthetic limbs running marathons conjure up images of determination and
courage. Could we not create a similar culture around veteran’s mental health?
Instead of seeing veteran’s mental health as a dark issue, we ought to recognise
veterans for the skills they have. The discipline, time management and leadership
skills are all transferable skills which are deserving of the same admiration.
12
Community Innovations Enterprise on behalf of the Forces In Mind Trust and NHS England. (2015). Call to
Mind: A Framework for Action. Findings from the review of veterans and family member’s mental and related
health need assessments. Executive Summary (1), 8

 Prior to a conflict Permanent Joint Head Quarters plans for casualties and deaths in
an attempt to provide the right support and care when necessary. Consider
implementing policy which would have the same approach to mental health. Create
estimations of returned mental health cases and from gaining an understanding of
the numbers of mental health cases we can then develop tools to mitigate these, in
the same way we do with physical casualties.

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