Putting military mental health on the front line

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It is well-recognised that serving in the military can bring with it potentially devastating mental as well as physical health consequences. But, as Ashleigh Webber heard at the Health and Wellbeing at Work conference, the Ministry of Defence is working hard to ensure service personnel are well-supported both during and after their service.

Serving in the military can have devastating and lasting effects on a person’s mental health, both during and after service. Not only might military personnel witness traumatic events or feel cut-off from their families and home life if posted abroad, they might also have trouble re-adjusting to civilian life.

But as Dr Jeya Balakrishna, a consultant psychiatrist for the Departments of Community Mental Health (DCMH) at the Ministry of Defence (MoD), said at the Health and Wellbeing at Work conference earlier this year, service personnel are well supported during and after service – and mental health “issues” might not be as widespread as initially thought.

Dr Balakrishna was keen to move the conversation away from the idea that military veterans or reserves are “damaged” or “vulnerable”, and wanted employers to see that their service has given them valuable, transferrable skills that will enable them to thrive in the workplace.

“The longer you serve in the Army, the Navy or the Air Force, the more you’re going to learn about adaptability and resilience. So, not surprisingly, the early service leavers – those that leave two or three years into service – tend to be at greater risk of mental health problems,” he stated.

Outdated perceptions

He said that the public perception of military service being linked with conditions like post-traumatic stress disorder (PTSD) and violent or detached behaviour was outdated and needed to be challenged. In 2016/17, 3.2% of British forces personnel reported having a mental health condition, compared with roughly 17% of adults in England. Adjustment disorders (32%) and mood disorders such as anxiety or depression (33%) were the most common conditions.

“We read in the papers that military service is the cause of a whole range of mental health problems, but the reality is they are more resilient than the general population,” Dr Balakrishna said. “[The military] is a selective population – they’ve gone through screening, certainly physically.

“These problems are not unique to the military – they’re common in all of us regardless of where we’re employed, whether its stress at work, problems with colleagues or you might have stress at home.”

However, issues with adjusting to changes – perhaps after leaving the military or learning to live with a physical disability following an injury, were more frequently felt. “Uniquely for the military, because the nature of the job requires postings and relocating, the transition issues that arise can be quite significant, let alone the transition from the military into civilian life,” he said.

Contrary to the commonly-held presumption that military personnel are susceptible to post-traumatic stress disorder (PTSD), only 6% experienced the condition. Likewise, only 4% reported alcoholism, challenging another outdated stereotype.

“It’s not very common that we deal with people who have PTSD. We do diagnose it, and it will happen, especially in personnel who have been deployed and some of their experiences have been traumatic. But of course it doesn’t mean that they’re all going to suffer post-traumatic stress disorder. It really depends on how the individual responds to circumstances,” he said.

PTSD as ‘a badge of honour’

However, Dr Balakrishna warned that that some servicemen or women viewed PTSD as “a badge of honour” because they believed “it’s a more acceptable and palatable diagnosis to have than something like depression, which more often than not is harder to treat than PTSD”.

According to a King’s College London study, 86.5% of male military veterans who were referred to the Combat Stress military veterans mental health charity had symptoms of “probable” PTSD.

Dr Balakrishna said the DCMH has a lower threshold of what it considers a mental health issue compared with the NHS and secondary mental health services. He said this allowed the service to “capture problems when they’re brewing” and make adjustments to help avoid any long-term problems from developing.

He described healthcare in the military as a “collaboration between primary care, occupational health and mental health clinicians”. Each base in the UK will have access to the DCMH; a medical centre – which he said was “essentially like a GP surgery”; and an occupational health team with a consultant OH clinician and a team of OH advisers.

“The medical centres work very closely with military units,” Dr Balakrishna explained. “They will sit on military health committees and help make the right decisions on occupational fitness.”

The teams are responsible for helping “anything between 10,000 and 20,000 serving personnel” and if specialist input is required, personnel will be referred to the NHS.

The DCMH has a multidisciplinary team which Dr Balakrishna said is not unlike what which would be seen in the NHS, including psychologists, psychiatrists, nurses, social workers, therapists. It no longer has an inpatient department – this service is contracted to NHS trusts.

Short referral times

Routine referrals for suspected mental ill health must be seen within 15 days, but he claimed the majority of patients are usually seen after nine or 10 days. Urgent referrals are dealt with either on the same day or the next working day.

Support is not just available to UK-based personnel – those posted to major bases in countries including Germany and Cyprus also have access to the DCMH and associated medical services. Treatment is also available for the families of posted servicemen and women, if they have relocated with them.

Rehabilitation is not unlike what would be seen in other occupations. Dr Balakrishna said the aim would always be to prepare servicemen or women to return to “work”, perhaps in limited duties or through a graduated return scheme.

There is also a unit dedicated to supporting the mental health of the wounded. Rehabilitation in this regard might consist of classroom and group-based learning or outdoor activities.

As mental health is such a complex area, especially in often challenging working and living conditions, Dr Balakrishna said the DCMH does not seek to “label” a person’s mental health concern too quickly. Instead, clinicians look to understand the difficulties service personnel are having and what might be done to help, rather than automatically medicating.

He gave the example of an RAF reserve who came to the DCMH after experiencing low mood, angry outbursts and problems in his home life. “When this came through to us we were talking about degrees of unhappiness and how [he] was being affected. There was a sense of ‘Is this anxiety? Is this depression?’ and the GP was keen to prescribe anti-anxiety drugs.

“I was less keen because we don’t always have to medicate these things. We don’t know where anger comes from as it can manifest in so many ways. Someone who’s angry might not simply be angry – there might be a number of issues,” he explained.

Support is also offered to military reserves – whom some organisations might employ. Dr Balakrishna spoke of a reserve combat medical technician – who usually worked as a paramedic in the north of England – who came to the DCMH after experiencing low mood and sleep problems.

She was unable to make firm decisions in home life, job and personal relationships and felt she did not have a sense of purpose. She felt she had been affected by the loss of a close reservist friend and having dealt with casualties. Dr Balakrishna said she benefited from psychological therapy – rather than the anti-depressants her GP had recommended.

There is a strong sense of community in military settings, with many seeing their colleagues as family. This teamwork ethic can be hugely beneficial to service personnel’s mental wellbeing and can help them overcome adversity.

Research from the Institute of Employment Studies (IES) has discovered that while mindfulness techniques like meditation are less appealing in the military due to their “self-help” connotations, approaching it as a team activity helped service personnel “respond unitedly” to stressful situations by learning to be “mindful as a team”. On the other hand, prolonged period of quiet, individual contemplation was found to unearth trauma.

Those who took part in team mindfulness programmes for IES’s study remained calm and focused in stressful situations and worked more effectively in challenging environments.

Dr Balakrishna said simply listening to service personnel’s stories and understanding what has affected them can go a long way towards their recovery, especially as they adapt to a civilian working environment.

He said: “It’s good to talk – mental health conversations aren’t just about the story, they’re about the story teller. Most people who have left the military have a story to tell and our job, as clinicians, is to listen.”

McManus S, Bebbington P, Jenkins R, Brugha T (2016). Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Available online at: https://files.digital.nhs.uk/pdf/q/3/mental_health_and_wellbeing_in_england_full_report.pdf
Murphy D, Ross J, Busuttila W, Greenberg N and Armour, C (2019). A latent profile analysis of PTSD symptoms among UK treatment seeking veterans. Available online at: https://www.kcl.ac.uk/kcmhr/publications/assetfiles/2019/murphy2019.pdf
Serving personnel: mental health services. Available online at: https://www.nhs.uk/using-the-nhs/military-healthcare/in-service-mental-health-contacts/
Carter A, Tobias Mortlock, J (2019). Mindfulness in the military: improving mental fitness in the UK Armed Forces using next generation team mindfulness training. Available online at: https://www.employment-studies.co.uk/resource/mindfulness-military

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