In 2008, Joseph Stiglitz, the Nobel laureate and famous economist, first assessed the economic and human cost of the Iraq War. In his book ‘The Three Trillion Dollar War’, he quoted the American military psychiatrist, Jonathan Shay, who wrote that ‘the mental health toll of the Iraq War is more comparable to Vietnam’.1 Stiglitz and Bilmes estimated the overall medical cost for treating American veterans returning from the Iraq War at US$717 billion, with a significant proportion being needed for the treatment of mental health problems.1 They estimate that the cost of the medical treatment of British veterans returning from Iraq or Afghanistan to be in the region of £20 billion.1

The end of the Iraq War and the rise of public concern regarding the mental health of returning veterans have coincided with the deepest economic crisis in living memory, while the NHS is required to find £20 billion of efficiencies from already stretched budgets. More and more veterans are being referred to the NHS after their discharge from the Armed Forces, where many of them have had exposure to severe psychological trauma, while NHS psychological trauma services are under-resourced, patchy or non-existent.

The original costs continue to be challenged as a significant undervaluation of the overall expense of the conflict, with Linda Bilmes2 recently arguing that the costs are more likely to be between US$4 and US$6 trillion.

It is also likely that the true cost of mental health treatment is underestimated as figures do not include the impact of secondary or vicarious trauma on family members, not to mention the emotional impact of caring for seriously physically injured veterans. In the UK, we have little understanding of how military families access mental health services, their needs or the effectiveness of interventions, and consequently the cost.

The Department of Health has suggested that veterans with common mental health problems should be treated by the Improving Access to Psychological Therapies (IAPT) programme.3 There is a concern that the IAPT programme—with its current structure, skill base and resources—is not able to meet the potential needs of the current veterans’ population. We have argued for military families to have access to appropriate services,4 but again are concerned that the potential needs of this population are not fully understood, and may not be appropriately catered for. Data are being collected for both veterans and military families accessing IAPT services, but to date, this has not been made available, and no formal evaluation has been published.

A recent study showed that while post-traumatic stress disorder (PTSD) and common mental health disorders are not significantly higher in British veterans serving in Iraq and Afghanistan compared with the general population, alcohol misuse is significantly higher, at a rate of 16%–20%, in these veterans.5 There is also evidence that suggests an increased rate of mental health problems, including PTSD, in reservists following deployment to the Iraq War in 2003.6 ,7

Studies have found that the mental health difficulties that veterans are experiencing might be a consequence of their difficulties in integrating back into the community socially after their return to civilian life following their discharge from the Armed Forces. This, in turn, is due to the fact that they had developed mainly military social and friendship networks while they were in the Armed Forces. This inability to create or maintain social networks after leaving the Armed Forces exposes them to a heightened risk of alcohol misuse, common mental disorders and PTSD as a consequence.8

For those who are severely injured while serving (polytrauma), there is a growing body of, mainly US, research setting out the challenges of recovery and rehabilitation on the mental health of both the individual9 and, in more recent years, their families.10 ,11 There is a concern as to how these findings, especially the importance of family therapy and family-orientated rehabilitation, could be translated into the UK system of care where there are profound delivery and cultural differences. Although the numbers of service personnel affected are relatively small compared with the USA, we have no projections for demand on the NHS, and policy in this area does not pay enough attention to the psychological impacts of injury.12

There is clearly a need for studies to be carried out in order to assess how the mental health problems of veterans affect their families, and one of the primary aims of our Institute is the development of an evidence base in order to understand the impact of military service and the transition of veterans on military families.

The coalition government's response to increased public concern regarding the mental health problems of veterans was published in the Armed Forces Covenant13 and in the report ‘Fighting Fit: A mental health plan for servicemen and veterans’,14 with the emphasis of service provision on the delivery of secondary mental health services for those with the most profound conditions. It is of concern that part of the response to the Murrison report has seen the provision of services and interventions that have little or no evidence as to their efficacy. When public money is being spent in the delivery of these services, there should be openness and clarity about their uptake, effectiveness and impact.

Can services cope? There remains limited research into the mental health of veterans and their families, and there is no clarity about the potential demand for services. In the UK, we also have no national register of veterans or service families. The corollary is that we cannot adequately predict service demand and plan to meet need. Consequently, many veterans and service families are left to cope without access to specialist provision, and, at worse, are offered suboptimal or harmful treatments.