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Abstract
Background Little is known about the mental and physical health differences of treatment-seeking military veterans across the different nations that make up the UK. The aim of this research was to explore potential health differences in order to support better service planning.
Methods A random cross-sectional sample of treatment-seeking veterans residing in England, Scotland, Wales and Northern Ireland was identified from a national mental health charity. 403 veterans completed a questionnaire highlighting their demographics, mental health and physical health difficulties. The data were analysed using a multinomial logistic regression with England as the baseline comparison.
Results Help-seeking veterans residing in Northern Ireland tended to be older, have experienced less childhood adversity, joined the military after the age of 18 and took longer to seek help. Additionally, veterans from Northern Ireland had higher levels of obesity, sensory, mobility and systemic problems and a greater number of physical health conditions. Scottish and Welsh veterans had a higher risk of smoking and alcohol misuse. No differences were found in mental health presentations.
Conclusion The findings from this paper suggest that a greater focus needs to be placed on treating physical problems in Northern Irish veterans. Alcohol misuse should be addressed in more detail in treatment programmes, particularly in Scotland and Wales. As few differences were found in the mental health presentations, this suggests that standardised services are adequate.
- mental
- physical
- health
- veterans
- military
- risk
- nations
- UK
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Key messages
There are no differences in post-traumatic stress disorder, common mental health difficulties and anger in help-seeking UK veterans.
Help-seeking veterans from Northern Ireland had higher levels of obesity, sensory, mobility and systemic problems and a greater number of physical health conditions.
Scottish and Welsh veterans seeking help from Combat Stress had a higher risk of smoking and alcohol misuse.
A greater focus needs to be placed on treating physical problems in Northern Irish veterans.
Alcohol misuse should be addressed in more detail in treatment programmes, particularly in Scotland and Wales.
As few differences were found in the mental health presentations, this suggests that standardised services are adequate.
Introduction
Military veterans have been acknowledged as a high-risk group for developing health problems.1 Evidence has found a higher prevalence of both physical and mental health difficulties in veteran compared with civilian populations. Military veterans appear to be twice as likely to suffer from common mental health problems such as depression and anxiety.1 Veterans are 14% more likely to abuse alcohol2 3 and 7% more likely to have physical mobility impairments.1 Despite these increased risks, many veterans go undiagnosed and untreated due to the stigma surrounding mental health and perceived practical barriers to accessing services.4 Consequently, those who do seek help often wait a considerable length of time to do so, potentially exacerbating their difficulties and leading to poorer treatment outcomes.5 6 A study of veterans in the UK reported that while there have been reductions in the time taken for veterans to seek help in recent years, on average individuals wait approximately 11 years from leaving the military before contacting services.5 7 Further, it seems that when veterans do engage in treatment, they report more modest gains than members of the general public.8 Gaining a better understanding of the mental health needs of veteran populations may help to increase the effectiveness of target interventions.
Previous studies have indicated that regional variations such as socioeconomic status, urbanisation and deprivation have an impact on physical and mental health functioning. For example, there appear to be differences in common mental health disorders in the general public across different European countries and between rural and urban areas in the UK.9 10 In veteran populations, a recent UK study illustrated regional variations in levels of deprivation, with Scottish veterans at the highest risk and Northern Irish veterans at the lowest risk.11 In addition, deprivation was shown to vary between neighbourhoods in England.12 As deprivation has been shown to adversely affect both physical and mental health outcomes,13 this suggests that health differences may exist between the four nations. However, to our knowledge, no existing study explores the differences in health problems in veterans solely based on nation of residence. As such, these findings imply the value of exploring regional health variations and demographic factors further.
The aim of the current study was to investigate the health differences in a group of treatment-seeking veterans from England, Scotland, Wales and Northern Ireland. The study looked into whether the nation the veteran resided in affected their levels of mental and physical health difficulties. Implications for these findings could help to inform resource allocation within Combat Stress (CS) services to those most in need and tailor it to the difficulties faced by veteran treatment centres in different national regions.
Methods
Setting
The current study was conducted at Combat Stress; the largest national charity providing psychological treatments for UK Armed Forces veterans. Combat Stress is commissioned by the NHS to provide specialist treatment for veterans with post-traumatic stress disorder (PTSD).
Participants
In total, 3335 veterans contacted Combat Stress between January 2015 and February 2016. Of these, 20% was randomly selected as the sample for this study, giving a sample size of 667. In total, 146 individuals did not respond, 51 opted out, 63 were removed due to invalid contact information and 4 were removed due to deaths. Taking into account participants who were removed, this left an effective sample size of 600, of which we had a response rate of 67.2% (403/600). We have previously presented data showing there were no differences between responders and non-responders in this sample.14
Measures
Data for this study were collected using a questionnaire with information on demographics, physical and mental health. Questionnaires were sent via the mail to participants three times. Following this, three attempts were made to contact non-responders via telephone to give individuals the opportunity to participate.
Demographics
Sociodemographic information included preservice factors; age participants joined the military and childhood adversity. Childhood adversity was gathered through a 16-item measure examining both positive and negative experiences from childhood. This measure has previously been used in an epidemiological study of the UK Armed Forces at King’s College London.15 The number of negative experiences was summed and participants in the top tertile were classified as the high-risk group (mean=9.8), those in the bottom two tertiles were known as the low-risk group. Questions related to service factors included whether individuals were early service leavers or not (completed <4 years’ service). Finally, postservice factors included current relationship status, employment status, financial issues, age and time taken to seek help.
Physical health measures
Participants were asked their height and weight in order to calculate their body mass index (BMI) score and also if they smoked. The Brain Injury Screening Index (BISI) was used to assess the presence of traumatic brain injuries (TBI).16 The BISI asked individuals if they had ever had a serious blow to the head. If participants answered yes, they were then asked three questions. The first question was if the event left them dazed, the second if it left them with a gap in their memory of over an hour and the third if they were left unconscious. A positive answer to any of the three questions for the purpose of this study indicated they had experienced a brain injury. Next, a closed-answer question asked participants to tick which, if any, of the 13 health problems they had and specify any others not included. These categories were grouped into three themes of mobility (amputation, chronic pain, poor mobility), sensory (hearing impairment, sight impairment, communication problems) and systemic problems (diabetes, BP, heart, respiratory, liver or kidney, neurological, digestive problems). Participants who had at least one condition fitting into this category were classed as having a problem. Additionally, the total number of physical conditions was added up and results divided into binary categorisations of ‘high group’ (top tertile; mean=5.2) and ‘low group’ (bottom two tertiles).
Mental health measures
PTSD was assessed using the Post-traumatic stress disorder Checklist for DSM-5 (PCL-5).17 The PCL-5 comprised 20 questions using a five-point Likert scale. Participants rated how much they had been bothered by each symptom in the past month from 0 ‘not at all’ to 4 ‘extremely’. The cut-off for a PTSD diagnosis was a score >38.17 The General Health Questionnaire (GHQ-12) was used to assess for common mental health problems (such as symptoms of anxiety and depression).18 The GHQ-12 comprised 12 questions rated on a four-point Likert scale. The four response categories range from 3 ‘better than usual’ to 0 ‘much less than usual’. The cut-off for the GHQ-12 was a score >4.19 The five-item Dimension of Anger Reactions DAR-5 scale assessed anger.20 The DAR-5 is a Likert scale ranging from 0 ‘not at all’ to 4 ‘very much’. The cut-off for having an anger problem was a score >12.20 Finally, the severity of alcohol problems was assessed using the Alcohol Use Disorders Identification Test (AUDIT).21 The scale ranged from 0 ‘never’ to 4 ‘daily or almost daily’. A score of ≥16 was classed as a high level of alcohol problems,21 equating to a need for community-based case management and assisted withdrawal at Combat Stress.
Analysis
Univariate multinomial logistic regression models were used to explore the differences in study variables between the four UK nations. England, as the largest nation, was used as the baseline comparison. The first stage of the analysis was to explore whether differences were present in sociodemographic characteristics of participants residing in different nations. Variables included age, experiences of childhood adversity, age when joined the military, current relationship status, current employment status, financial issues, being an early service leaver and the number of years it took participants to seek help after leaving the military. Following this, models were fitted to explore the differences in physical health presentations between nations. BMI, smoking status, self-reported brain injury and physical health problems were examined. The final stage of analysis assessed for differences across a range of mental health presentations (PTSD, common mental health difficulties, anger problems and alcohol misuse). All analyses were conducted using STATA V.13.0.
Results
A comparative analysis of the participant demographics is included in Table 1. The sample comprised of 403 UK treatment-seeking veterans with 60.3% of the sample from England, 22.1% from Northern Ireland, 10.4% from Scotland and 7.2% from Wales. The data showed participants from Northern Ireland were more likely to be older than other nations, with 24.6% within the 45–54 age group and 54.5% in the 55+ category. A greater number of Northern Irish participants appeared to have joined the Armed Forces after the age of 18 compared with England, where more participants had joined before 18. Individuals from Northern Ireland experienced fewer incidences of childhood adversity, with only 11.8% in the high group, compared with 25.5% in England, 29.2% in Scotland and 32.6% in Wales. Differences in relationship status appeared to only be statistically significant for Wales with a higher proportion of single participants (53.9%). Analysis revealed that individuals from Northern Ireland and Wales waited significantly longer to contact Combat Stress with 70.5% from Northern Ireland and 68.3% from Wales waiting >5 years compared with 36.1% in England and 37.5% in Scotland.
Table comparing the demographics of veterans across different UK nations to England as a baseline
Table 2 explores the physical health differences between participants from each UK nation. Data showed that Northern Irish participants were significantly more likely to be overweight. Specifically, 83.9% of Northern Irish participants had a BMI range classified as overweight or obese. Scottish (56.5%) and Welsh (59.3%) participants were more likely to smoke than English (36.5%) and Northern Irish residents (27.5%). In terms of physical health, analyses showed a significantly higher rate of sensory problems (62.1%), mobility problems (60.9%), systemic problems (68.7%) and total number of health conditions (43.8% in the high group) in Northern Ireland. Further, Welsh participants appeared to be more likely to experience mobility problems (68.1%) than those from England (44.0%) and Scotland (49.3%).
Table comparing the physical health of veterans across different UK nations to England as a baseline
Table 3 examines the relationship between the UK nations and different mental health outcomes. No significant differences were found in symptoms of PTSD (PCL-5), common mental health problems (GHQ-12) and anger difficulties (DAR-5). However, data showed that participants residing in Scotland (33.3%) and Wales (37.9%) were significantly more likely to report alcohol problems than those from England (18.5%) or Northern Ireland (15.7%).
Table comparing the mental health of veterans across different UK nations to England as a baseline
Discussion
Summary of results
Several overall patterns emerged from the data, demonstrating a higher risk of health difficulties in help-seeking veterans compared with the general UK veteran population. Compared with a study on veterans by the Royal British Legion (RBL),1 help-seekers across all nations appeared almost twice as likely to have physical problems of sensory (40% vs 19%), systemic (57% vs 15%) and mobility difficulties (56% vs 28%). There also appeared to be higher rates of mental health problems in the help-seekers from this study, including depression and anxiety (75% vs 4%), PTSD (83% vs 2%) and alcohol misuse (26% vs 1%).
Our results revealed differences in demographic and physical health presentations across different UK nations. Veterans from Northern Ireland tended to be older, more overweight and had a greater number of physical health problems, including sensory, mobility and systemic problems. Veterans who resided in Scotland were significantly more likely to smoke and veterans from Wales were more likely to be single, smoke and have physical health problems affecting their mobility. On the whole, no significant differences were found in mental health problems across the nations, with the exception of higher rates of alcohol misuse in veterans residing in Scotland and Wales.
Interpretation
Significant demographic variations were found between veterans of the UK nations. In terms of population size, our findings evidenced a different pattern of characteristics in help-seeking veterans compared with the general UK veteran population as explored in the RBL study. The RBL study showed that the majority of veterans lived in England (80%), followed by Scotland (9%), Wales (7%) and then Northern Ireland (2%).1 Whereas our findings found that 60.3% of our sample were from England, followed by Northern Ireland (22.1%), Scotland (10.4%) and Wales (7.2%). The contrast between the distributions of veterans could indicate that help-seekers are over-represented in Scotland, Wales and Northern Ireland, suggesting there is a higher number of help-seekers in these countries. Help-seekers in Northern Ireland may be over-represented due to the nature of serving and living in the same area, exacerbating mental health difficulties. This is further emphasised by the fact that the main help-seeking population of CS is veterans who have served in Northern Ireland.5 On the other hand, an alternative interpretation could be that significantly more barriers exist in England, preventing veterans from seeking help.
The current study highlighted that treatment-seeking veterans reported high rates of childhood adversity and experiences varied between nations. Veterans residing in Northern Ireland appeared to report fewer childhood adversities than other nations. Moreover, the time taken to seek help was significantly longer for Northern Irish and Welsh veterans. This delay could be attributed to the older age of veterans residing in these areas as previous research has demonstrated a link between older age and less willingness to seek support from mental health services.22 Indeed, evidence suggests that veterans from more recent conflicts, such as Iraq and Afghanistan, seek help more quickly than their peers from previous conflicts.5 Collectively, these findings illustrate the need to support Northern Irish and Welsh veterans to seek help sooner.
The higher rates of physical conditions found in Northern Irish veterans may be related to the older age of the population, with a significant number of veterans >45. Additionally, the greater number of health problems, along with more mobility and systemic problems, could be linked to the higher risk of being overweight. Veterans from Scotland and Wales were found to consume more alcohol and cigarettes than other nations. These findings parallel the higher rates of alcohol-related mortalities and consumption in Scotland compared with any other UK nation.23 It is difficult to determine why this is the case; however, there may be a link to population age. For instance, it was found that younger veterans drink more.24 Therefore, as Northern Ireland had an older population, this would explain why they were found to drink less. However, this fails to account for why England, with a younger population, did not have a significant risk of substance misuse. Interestingly, no significant differences were found between the number of veterans meeting case criteria for PTSD, common mental health problems and anger between nations. This may be due to the psychological conditions in veterans being linked to the nature of military service and experiencing trauma as opposed to their current residential area. Moreover, as CS primarily treats PTSD (as opposed to the other comorbid mental health problems), these findings suggest that veterans contacting CS are doing so appropriately across all regions.
Implications
The literature currently demonstrates a lack of research into the differences in veterans’ health profiles across UK nations. This current study aimed to address the gap by determining if treatment-seeking veterans residing in different nations have different health needs. The findings from this study could aid resource allocation and implement changes to current veteran treatment programmes. For example, this study highlights the need for a greater emphasis on substance misuse, including cessation support and management in Scotland and Wales. Furthermore, treatment programmes in Northern Ireland may benefit from addressing weight-related issues, including healthy diet tips and exercise programmes. Although the increased levels of physical conditions in Northern Ireland would need to be accommodated for, encouraging weight loss could help reduce these difficulties and improve mental health.25While Northern Irish veterans were most at risk of higher BMI scores, the observed distribution of BMI scores across the whole of the UK indicate that support around weight loss and comorbid health problems would be prudent. Due to the high numbers of sensory, mobility and systemic problems in veterans residing in Northern Ireland, support around the relationship between physical health and mental health as well as coping strategies could be advantageous. The lack of differences found between mental health presentations suggests that standardised treatments across the nations should be adequate.
We found that a greater number of help-seeking veterans resided in Northern Ireland, Wales and Scotland compared with general veteran population studies, highlighting the need for greater resources within these nations. Veterans have been shown to take a long time to seek support for mental health difficulties;5 however, this study has illustrated that Northern Irish and Welsh veterans appear to take significantly longer than other nations. As such, epidemiological research to understand the effects of geographic area and service provision is needed along with increased support in these nations to encourage veterans to seek help more quickly.
Limitations
This study benefits from the use of randomisation to select participants from a nationally recognised clinical mental health service to improve the generalisability of the findings to overall treatment-seeking veterans. However, low numbers of veterans from Scotland and Wales were included in this sample, suggesting that there may have been a lack of power to detect differences between the nations. In addition, due to the increased presence of military stigma in Northern Ireland, it is difficult to determine if those seeking help from Combat Stress are representative of overall Northern Irish veterans. It must also be acknowledged that Combat Stress receives referrals from veterans with acute mental health needs and specialises in treating PTSD. Consequently, the current sample may differ from veterans who seek treatment from other services. For example, the majority of veterans seeking treatment from Combat Stress present with PTSD and comorbid difficulties such as common mental health problems and alcohol misuse.14 On the other hand, common mental health difficulties are the most prevalent conditions in veterans in general.1 Hence, there may be selection bias in this sample. While data from one mental health charity will not represent the entirety of the treatment-seeking veteran population, given the relatively large numbers of referrals each year (approximately 2500) and the national reach of Combat Stress, this increases confidence in the validity of this study’s results.
A further limitation is the use of unadjusted beta coefficients and CIs. Therefore, there may be bias in the findings due to the presence of confounders that were not accounted for. This could have affected the relationship between the variables and resulted in significant findings not being shown and vice versa. This decision was made because the aim was to explore the profile of veterans’ health presentations and understand how needs varied by nation. Therefore, adjustment would not have provided an accurate representation of the treatment-seeking veteran population. For example, even though the older age of veterans residing in Northern Ireland may explain their heightened risk of physical health problems, mental health services will still need to take physical health difficulties into account when providing support.
Conclusion
To our knowledge, this is the first paper to explore the differences in health presentations of treatment-seeking veterans between UK nations. No differences in mental health presentations were found, with the exception of high-risk drinking in Wales and Scotland. Conversely, differences were found in demographics and physical health presentations. In Northern Ireland, veterans were more likely to be >45 years of age, have joined the military after 18 years of age, taken >5 years to seek help, have an overweight BMI, have a greater total number of physical health problems, a higher risk of sensory, mobility and systemic problems and were less likely to have experienced high levels of childhood adversity. In Scotland, veterans appeared more likely to smoke and drink. In Wales, veterans were significantly more likely to be single, wait >5 years to seek help, have mobility problems, smoke and have drinking problems. These findings could help to inform resource allocation across health services in the UK. For example, a greater focus on physical health, tailored to an older population in Northern Ireland and substance misuse in Scotland and Wales. As the proportion of veterans meeting case criteria for PTSD, common mental health difficulties and anger were similar across the four nations, this suggests that veterans are seeking help in relation to their difficulties and Combat Stress services do not need to be tailored to meet different regional needs.
References
Footnotes
Contributors RA was the lead author for this study, was involved in the design of the study, developed the analytical strategy for the paper and wrote the manuscript. DM was the principal investigator for this study, was involved in the design of the study, developed the analytical strategy for the paper, conducted the analyses and edited and commented on the manuscript.
Funding This work was supported by the Ministry of Defence Covenant Fund.
Competing interests None declared.
Ethics approval Combat Stress Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.