13 e-Letters

  • Screening for Mental Health Contributing to Lower Suicide Rates in the Armed Forces

    Whilst it was interesting to have confirmed that suicide rates in the military are lower than that of the general population, I feel that a major contributor to this was not addressed. As well the strategies in place in the UK Armed Forces to support the Mental Health of personnel and to prevent suicides, a significant number of candidates are screened out on application due to a history of mental health issues. This includes previous episodes of self-harm and overt suicide attempts as well as other significant histories of mental illness. The exclusion of this population inevitably will reduce the risk of suicide in service personnel.

  • Palliative Care and Expectant Casualties

    Regarding deployed palliative care, Kayleigh McMillan has brought up a very important topic that needs more discussion from Western military medical leaders. In U.S. Department of Defense doctrine, the “expectant” casualty triage designation is reserved for “casualties who are so critically injured that only complicated and prolonged treatment can improve life expectancy. This category is to be used only if resources are limited”(1). It also says this designation “includes patients where wounds are so extreme that even if they were the only patient and had all medical resources available, their survival would be unlikely… About 20 percent of casualties will be in this category.” (2) The U.S. is similarly ill-positioned to provide appropriate palliative care to these expectant casualties and needs to undergo a similar transformation in light of the possibility of future peer-to-peer conflict. Our two main concerns in the deployed palliative care discussion are: 1) determining what resources expectant casualties will receive, and 2) integration between medical and other care providers, such as chaplaincy personnel. We have given our general thoughts on these concerns in a response to a paper by Riley on a NATO Article 5 collective defense operation (3).

    In this response, we would like to offer some potential actions to address our concerns that could be added to McMillan’s table 1. Concerning what resources expectant casualties should receive, McMillan has laid out an...

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  • NATO Collective Defense and Expectant Casualties

    During a recent NATO conference in Helsinki, to which one of us (TLR) was invited, the topic of how best to continue providing care to expectant casualties in an austere environment was discussed among participants, though no definitive conclusion was reached. This aligns with Mark Robert Riley’s recent perspective on the preparedness of the Defence Medical Services for a potential Article 5 NATO collective defense operation, especially concerning the possibility of encountering a high influx of combat-related casualties (1).

    In US Department of Defense doctrine, “expectant” is reserved for “casualties who are so critically injured that only complicated and prolonged treatment can improve life expectancy. This category is to be used only if resources are limited” (2). As Riley states, if the Russo-Ukrainian war is a model, NATO would experience 45,000 casualties in the first six months. The number of expectant casualties would likely increase because of a larger denominator, lethality of weapons used, and the number of wounded straining medical resources, requiring medical professionals to make triage decisions, oftentime in the field at point of injury. NATO forces currently lack substantial doctrine regarding the management of expectant casualties, primarily due to the exceptional performance of medical evacuation systems in swiftly transporting individuals from the point of injury to definitive care over the past two decades. As Riley mentioned, that will not be...

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  • Enlistment of under-18s: Abiding concerns

    Dear Editor

    Dr. Bergman and colleagues’ retrospective cohort study of armed forces veterans in Scotland concluded that their study ‘provides no evidence to support the assertion that early entry to military service is associated with adverse long-term mental health outcomes’ and that concerns about early enlistment are ‘misplaced’ (p. 5).

    This conclusion is justified on the grounds that junior entrants into the armed forces (below the age of 17.5) were found to have had a lower risk of developing a severe mental health disorder when compared to those recruited between the ages of 17.5 and 19; or between the ages of 20 and 24.

    However, all veterans, including those who joined as junior entrants, were significantly more likely to develop mental disorders (especially PTSD) when compared to matched non-veterans. In addition, for the cohort of veterans born between 1975 and 1984, the data suggests that junior entrants have a higher risk of presenting with mental health disorders when compared to older recruits, although this is not statistically significant (Table 1). This cohort is important because it is associated with the multiple major combat deployments to Bosnia, Kosovo, Afghanistan and Iraq.

    For these reasons, while modern day junior entrants to the armed forces in the UK are better protected when compared to ‘child soldiers’ in other countries, or to junior entrants from previous eras, concerns about their vulnerability to mental illness are...

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  • Enlistment of under-18s: Abiding concerns

    Dear Editor

    Margaret Jones and colleagues’ study of armed forces personnel concluded that, for the study cohort as a whole, those who had joined up under the age of 17.5 years (‘junior entrants’) were no more likely than those who enlisted at older ages to report symptoms of mental health disorders. However, the study also found that junior entrants who had enlisted since 2003 showed significantly higher rates of alcohol misuse, somatic symptoms, and a lifetime history of self-harm, relative to older recruits. The study’s data further suggests that PTSD and common mental disorders may also be more prevalent among younger enlistees since 2003, although this is not statistically significant.

    In recent decades, protections for armed forces recruits who are legally children have improved, including a legal prohibition on deployment to zones since 2002. Despite these developments, this study’s findings indicate continuing reason to be concerned about the impact of early enlistment on long-term mental health. It could be relevant that, as this study has shown, once junior entrants turn 18 and may be deployed, they are more likely to be in a combat role such as the frontline infantry.

    Furthermore, the study sample may not reflect the relevant population accurately. Comparing Table 1 with UK armed forces quarterly personnel statistics,(1) higher-ranked personnel appear to be over-represented in the study sample, while those with the lowest ranks are under-repr...

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  • Enlistment of under-18s: Abiding concerns - Authors' response

    Dear Editor,

    Thank you for publishing the Rapid Response to our paper by Cooper et al. The authors agree with our findings that junior entrants to the Armed Forces have a lower risk of developing a severe mental health disorder compared with older entrants, but have noted that we found that all veterans were more likely to develop mental disorders (especially PTSD) then matched non-veterans.
    The increased risk of mental health disorders in veterans overall compared with non-veterans is not a new observation. In our 2016 paper(1) we showed that overall, veterans were at 21% overall increased risk of having experienced mental ill-health compared with matched non-veterans, whilst Goodwin et al.(2) showed that serving personnel had more than double the odds of common mental disorders compared with a general population sample. In our 2016 paper we showed that the risk in veterans is highest in those with the shortest service; Early Service Leavers (ESL) were at 51% increased risk, whilst those with more than 9 years’ service were at no greater risk than the comparison population. ESL who did not complete training, and who could not have deployed operationally, had the highest risk; it is likely that their mental health outcomes (including PTSD) arose predominantly from pre-service vulnerabilities. In our new study, we showed that junior entrants were less likely to be ESL (a finding supported by a House of Commons Written Answer on length of service of junior...

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  • Enlistment of under-18s: Abiding concerns – Authors’ response

    Dear Editor
    We read with interest the comments made by Cooper et al to our paper comparing experiences and mental health of personnel who joined service as junior entrants compared to adult entrants. Participants in the King's Centre for Military Health Research (KCMHR) cohort study were sampled from the trained and, consequently, deployable strength of the UK Armed Forces (UKAF) since the primary purpose of the cohort study was to measure the health consequences of deployment to Iraq and Afghanistan[1]. The participants were not sampled from personnel at recruitment but on the basis of their deployment to Iraq or Afghanistan. We had no data about individuals who joined service at the same time but who did not remain in service until the time of sampling and this is a fully acknowledged limitation in the paper. We have no evidence that there may have been differential attrition on the basis of mental health between the comparison groups. Those who joined before 2003 could represent a sub sample of particularly successful personnel (both those who joined as Junior Entrants and those who joined as adults). That is why we carried out a subgroup analysis of the smaller number of participants who had joined the trained strength after 2003 (the replenishment samples). In that analysis there were some significant associations that are of concern, but PTSD and common mental disorders were not, as suggested, among them as they were far from being statistically significan...

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  • RE: Efficacy of mirror therapy and virtual reality therapy in alleviating phantom limb pain

    With great interest, I have read the review article entitled “Efficacy of mirror therapy and virtual reality therapy in alleviating phantom limb pain: a meta-analysis and systematic review” written by Rajendram et al (1). The authors conducted a meta-analysis to evaluate the effects of mirror therapy (MT) and virtual reality (VR) therapy on phantom limb pain (PLP). Both therapies led to a reduction of visual analogue scale (VAS) scores on PLP, and there was no statistically significant difference in pain alleviation between two therapies. The authors recommended that factors such as gender, cause of amputation, site of limb loss or length of time from amputation should be considered for the analysis. I present additional information regarding the effect of MT on PLP.
    Wang et al. also conducted a meta-analysis, handling randomized controlled trials (RCTs) (2). The pooled standardized mean difference (SMD) (95% confidence interval [CI]) of MT group was -0.81 (-1.36 to -0.25), which was compared with other 6 methods (four covered mirror, one phantom exercise, three mental visualization, one sensorimotor exercise, one transcutaneous electrical nerve stimulation, and one tactile stimuli). They concluded that MT was beneficial for reducing phantom limb pain. There is a fact that the authors did not consider follow-up intervals, and a control group was consisted a complex of traditional treatments for patients with PLP. I suppose that heterogeneous treatments may have diff...

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  • Statistical problems in the vitamin C and common cold trial with South Korean army recruits

    The report on vitamin C for preventing the common cold in the Republic of South Korea army recruits by Kim et al. [1] has several statistical problems.

    First, Kim et al. did not follow the intention-to-treat [ITT] approach. Figure 1 shows that 49 participants were excluded because they “stopped intake of vitamin C”, and 84 participants were excluded because they “stopped intake of placebo” [1]. The CONSORT recommendation for ITT analysis states as follows [2, Box 6]: “participants who … did not take all the intended treatment ... exclusion of any participants for such reasons is incompatible with intention-to-treat analysis”.

    Second, Altman et al. pointed out that “The odds ratio should not be interpreted as an approximate relative risk [RR] unless the events are rare in both groups (say, less than 20-30%)”[3]. The common cold is not rare. Over 50% of the participants in the Kim et al. trial had the common cold during the trial period which greatly exceeds the 20-30% limit. Furthermore, there is no need to use the OR as the approximation for RR, because the RR can be calculated from the trial data in Table 1, RR = 0.916 (= 0.538/0.587) [1].

    Third, in their abstract, Kim et al. wrote “the vitamin C group had a 0.80-fold lower risk of getting a common cold” implying that vitamin C decreased the incidence of colds by 20%. However, the correct effect estimate is given by the RR above, which indicates only 8.4% lower risk of colds in the vitamin C group....

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  • Advice on how to navigate the MODREC process for junior researchers in the Defence Medical Services

    Dear Sir,

    The paper by Dr Schmidt details the history of the first independent Research Ethics Committee (REC) at Porton Down in the 1960’s. This REC was created to address ethical and legal concerns about research on human subjects. Since the 1960’s the emphasis has rightly shifted from “the doctor/scientist is always right” to “the participants must be protected from any unnecessary harms”. This has led to an expansion of the ethics review process and level of scrutiny, which has left many junior researchers feeling frustrated when their plans are criticised or delayed.

    This letter will list some advice for junior researchers in the Defence Medical Services on how to navigate the process and improve the quality of their research and the chance of a successful ethical approval for research involving human participants:
    1. First, use the NHS Health Research Authority tool to confirm that your study design is research and that it requires ethical approval.
    2. Read JSP 536 Pt 1 (48 pages) and 2 (64 pages).
    3. Be familiar with the main tenets of medical ethics - respect for autonomy, beneficence, non-maleficence, justice and equipoise.
    4. Involve patients and other stakeholders in the design of the study.
    5. Do not underestimate the time required, it may take six to 12 months.
    6. Be resilient and ensure you have support. It will be stressful.
    7. The REC process is a combination of prestigious journal submission and viv...

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