Upward trends in symptom reporting in the UK Armed Forces.

Several reports have shown increases in the prevalence of non-specific symptoms in the general population. Research in the military tends to focus on comparisons between deployed and non-deployed personnel and does not examine trends over time. 4,257 and 4,295 male participants of the Gulf war and Iraq war studies not deployed to either of these wars were randomly sampled and surveyed in 1997/1998 and 2004/2006 in two independent cross-sectional studies. Information was collected on 50 symptoms and the General Health Questionnaire (GHQ-12). Factor analysis was performed to identify an underlying pattern of symptom dimensions, and multivariate regressions were carried out to examine changes in symptom dimensions between the two surveys and the possible role of psychological morbidity. Factor analysis identified a robust pattern of eight symptom dimensions. An increase in the prevalence of symptoms was evident across all symptom dimensions. Adjustment for demographic and service characteristics revealed increases in the odds of scoring highly on symptom dimensions, varying from odds ratios 1.57, 95% CI 1.36-1.81 (cardio-respiratory dimension) to 2.24, 95% CI 1.93-2.60 (fatigue dimension). Unexpectedly, increases were even greater when adjusting for psychological morbidity. There is clear evidence of an increase in the reporting of non-specific symptoms over a 7 year period in the UK Armed Forces. It suggests that the threshold for reporting symptoms has decreased and cannot be explained by psychological distress. The possible implication of this trend for medical practice in the wider population deserves close scrutiny.

The patient's photograph in the medical record as a diagnostic tool.

Two case reports are presented: one of acromegaly and the other of hyperthyroidism. Previous photographs of the patients that appeared in their military medical record were of considerable assistance in making the correct diagnoses. When "smart cards" are issued in the future, inclusion of a photograph as an integral part of the patient's medical information should be considered.

Influence of childhood adversity on health among male UK military personnel.

BACKGROUND: Exposure to childhood adversity may explain why only a minority of combatants exposed to trauma develop psychological problems. AIMS: To examine the association between self-reported childhood vulnerability and later health outcomes in a large randomly selected male military cohort. METHOD: Data are derived from the first stage of a cohort study comparing Iraq veterans and non-deployed UK military personnel. We describe data collected by questionnaire from males in the regular UK armed forces (n=7937). RESULTS: Pre-enlistment vulnerability is associated with being single, of lower rank, having low educational attainment and serving in the Army. Pre-enlistment vulnerability is associated with a variety of negative health outcomes. Two main factors emerge as important predictors of ill health: a 'family relationships' factor reflecting the home environment and an 'externalising behaviour' factor reflecting behavioural disturbance. CONCLUSIONS: Pre-enlistment vulnerability is an important individual risk factor for ill health in military men. Awareness of such factors is important in understanding post-combat psychiatric disorder.

Patterns of drinking in the UK Armed Forces.

AIMS: To examine patterns of drinking in the UK Armed Forces, how they vary according to gender and other demographics, and to make comparisons with the general population. DESIGN: Large cross-sectional postal questionnaire study (response rate 60%). SETTING: United Kingdom. PARTICIPANTS: A random representative sample of the regular UK Armed Forces who were in service in March 2003 (n = 8686; 7937 men, 749 women). Comparisons were made with the general population of Great Britain. MEASUREMENTS: Alcohol consumption was assessed using the Alcohol Use Disorders Identification Test (AUDIT). FINDINGS: Sixty-seven per cent of men and 49% of women in the UK Armed Forces had an AUDIT score of 8+ (defined as hazardous drinking), compared to 38% of men and 16% of women in the general population. In both sexes, for all ages, the military have a higher prevalence of hazardous drinking. Binge drinking was associated with being younger, being in the Army, being single, being a smoker and being white. Among military men, heavy drinking (AUDIT score 16+) was associated with holding a lower rank, being younger, being single, being in the Naval Service or Army, being deployed to Iraq, not having children, being a smoker, having a combat role and having a parent with a drink or drug problem. CONCLUSIONS: Excessive alcohol consumption is more common in the UK Armed Forces than in the general population. There are certain socio-demographic characteristics associated with heavy drinking within the military; for example, young age, being single and being a smoker, which may allow the targeting of preventive interventions.

Anthrax vaccination in a military population before the war in Iraq: side effects and informed choice.

BACKGROUND: To assess any health consequences of the anthrax vaccination programme in UK Armed Forces deployed to Iraq. METHODS: Data were collected from two samples simultaneously. The first was 5302 randomly selected UK service personnel. The second was 607 service personnel involved in a longitudinal study, where pre-vaccination health had previously been collected. Both samples were offered the anthrax vaccination before they deployed to Iraq in 2003 and subsequently following their service in Iraq. Participants completed a detailed questionnaire, including a range of health outcomes, receipt of the anthrax vaccination and quality of choice. RESULTS: Seventy-two percent of the combined sample had the anthrax vaccination. Being a member of the Army, a commissioned officer or a reservist was associated with higher uptake. No differences in self-reported health were observed between those who did and did not receive the vaccination. For participants who accepted the vaccination, we found an association between making an uninformed choice and adverse health. After adjustment for baseline health in the longitudinal cohort these associations remained significant. CONCLUSIONS: Anthrax vaccination used by the UK Armed Forces in preparation for the Iraq War has not resulted in adverse health outcomes. However, of those who did accept the vaccination, reported side effects were related to whether acceptance of vaccination was perceived to be informed. Improving the quality of choice may improve self-reported ill health.

Explanations for the increase in mental health problems in UK reserve forces who have served in Iraq.

BACKGROUND: Deployment to the 2003 Iraq War was associated with ill health in reserve armed forces personnel. AIMS: To investigate reasons for the excess of ill health in reservists. METHOD: UK personnel who were deployed to the 2003 Iraq War completed a health survey about experiences on deployment to Iraq. Health status was measured using self-report of common mental disorders, post-traumatic stress disorder (PTSD), fatigue, physical symptoms and well-being. RESULTS: Reservists were older and of higher rank than the regular forces. They reported higher exposure to traumatic experiences, lower unit cohesion, more problems adjusting to homecoming and lower marital satisfaction. Most health outcomes could be explained by role, experience of traumatic events or unit cohesion in theatre. PTSD symptoms were the one exception and were paradoxically most powerfully affected by differences in problems at home rather than events in Iraq. CONCLUSIONS: The increased ill-health of reservists appears to be due to experiences on deployment and difficulties with homecoming.

Mental health screening in armed forces before the Iraq war and prevention of subsequent psychological morbidity: follow-up study.

OBJECTIVE: To assess whether screening for mental disorder before the start of the 2003 Iraq war would have predicted subsequent mental disorders. DESIGN: Longitudinal cohort study of the United Kingdom armed forces. PARTICIPANTS: 2820 of 2873 personnel of the three services who completed an initial questionnaire in 2002 were asked to complete a second questionnaire between June 2004 and 2 March 2006. SETTING: Regiments, air stations, bases, ships, and homes for those who had left the services. MAIN OUTCOME MEASURES: Positive and negative likelihood ratios, and positive and negative predictive value of first assessment compared with assessment two to three years later of post-traumatic stress disorder, general health questionnaire, physical symptoms, self perception of health, and alcohol misuse for the entire group and for those deployed to the Iraq war. RESULTS: The response rate to the follow-up questionnaire was 69%, adjusted for return to senders. The positive likelihood ratio of post-traumatic stress disorder was high (13.1, 95% confidence interval 7.2 to 23.8), but the negative likelihood ratio was close to 1 (0.78, 0.67 to 0.91). The positive predictive values were low because of the low prevalence of post-traumatic stress disorder in the period before the Iraq war. The positive likelihood ratios for the other psychological assessments varied between 2.7 and 5.6, and the negative likelihood ratios were slightly lower than for post-traumatic stress disorder, indicating that these were not good candidates for screening. Results were the same for the analyses restricted to those who were deployed. CONCLUSIONS: Screening for common mental disorders before deployment in this cohort would not have reduced subsequent morbidity or predicted post-traumatic stress disorder, but this may change if there is a considerable increase in the prevalence of the disorder.

Uptake of screening for breast cancer in patients with mental health problems.

OBJECTIVES: Mental illness is associated with physical illness and mortality from a variety of causes including cancer. There is little information on screening attendance among the mentally ill population. An audit was conducted of a breast screening service in inner London to determine uptake rates in women with mental illness. DESIGN: Cross sectional data linkage study of the local screening register and patients of the local psychiatric units. Screening uptake rates in all patients, those with a history of multiple detention in hospital, and those with psychosis were compared with the local reference population. SETTING: Women in three inner London boroughs. PARTICIPANTS: Screening records for 933 psychiatric patients and 44 195 women without mental health problems aged 50 to 64 years. MAIN RESULTS: Overall, psychiatric patients were as likely as the reference group to attend breast screening. Patients with a history of multiple detention were significantly less likely to attend (OR = 0.40, 0.29 to 0.55; p<0.001), as were patients with a diagnosis of psychosis (OR = 0.33, 0.18 to 0.61; p<0.01). Increasing age, a history of detention in hospital, and social deprivation remained independent predictors for non-attendance. CONCLUSION: Women with severe mental health problems may be less likely to attend national screening programmes such as breast screening, and action should be taken to overcome the barriers to attendance.

The health of UK military personnel who deployed to the 2003 Iraq war: a cohort study.

BACKGROUND: Concerns have been raised about the mental and physical health of UK military personnel who deployed to the 2003 war in Iraq and subsequent tours of duty in the country. METHODS: We compared health outcomes in a random sample of UK armed forces personnel who were deployed to the 2003 Iraq war with those in personnel who were not deployed. Participants completed a questionnaire covering the nature of the deployment and health outcomes, which included symptoms of post-traumatic stress disorder, common mental disorders, general wellbeing, alcohol consumption, physical symptoms, and fatigue. FINDINGS: The participation rate was 62.3% (n=4722) in the deployed sample, and 56.3% (n=5550) in the non-deployed sample. Differences in health outcomes between groups were slight. There was a modest increase in the number of individuals with multiple physical symptoms (odds ratio 1.33; 95% CI 1.15-1.54). No other differences between groups were noted. The effect of deployment was different for reservists compared with regulars. In regulars, only presence of multiple physical symptoms was weakly associated with deployment (1.32; 1.14-1.53), whereas for reservists deployment was associated with common mental disorders (2.47, 1.35-4.52) and fatigue (1.78; 1.09-2.91). There was no evidence that later deployments, which were associated with escalating insurgency and UK casualties, were associated with poorer mental health outcomes. INTERPRETATION: For regular personnel in the UK armed forces, deployment to the Iraq war has not, so far, been associated with significantly worse health outcomes, apart from a modest effect on multiple physical symptoms. There is evidence of a clinically and statistically significant effect on health in reservists.

Is there an Iraq war syndrome? Comparison of the health of UK service personnel after the Gulf and Iraq wars.

BACKGROUND: UK armed forces personnel who took part in the 1991 Gulf war experienced an increase in symptomatic ill health, colloquially known as Gulf war syndrome. Speculation about an Iraq war syndrome has already started. METHODS: We compared the health of male regular UK armed forces personnel deployed to Iraq during the 2003 war (n=3642) with that of their colleagues who were not deployed (n=4295), and compared these findings with those from our previous survey after the 1991 war. Data were obtained by questionnaire. FINDINGS: Graphs comparing frequencies of 50 non-specific symptoms in the past month in deployed and non-deployed groups did not show an increase in prevalence of symptoms equivalent to that observed after the Gulf war. For the Iraq war survey, odds ratios (ORs) for self-reported symptoms ranged from 0.8 to 1.3. Five symptoms were significantly increased, and two decreased, in deployed individuals, whereas prevalence greatly increased for all symptoms in the Gulf war study (ORs 1.9-3.9). Fatigue was not increased after the 2003 Iraq war (OR 1.08; 95% CI 0.98-1.19) but was greatly increased after the 1991 Gulf war (3.39; 3.00-3.83). Personnel deployed to the Gulf war were more likely (2.00, 1.70-2.35) than those not deployed to report their health as fair or poor; no such effect was found for the Iraq war (0.94, 0.82-1.09). INTERPRETATION: Increases in common symptoms in the 2003 Iraq war group were slight, and no pattern suggestive of a new syndrome was present. We consider several explanations for these differences.

UK armed forces responses to an informed consent policy for anthrax vaccination: a paradoxical effect?

BACKGROUND: In recognition of concerns that anthrax vaccination might be a trigger for "Gulf war syndrome", anthrax vaccinations were offered to UK armed forces in the 2003 Iraq conflict using explicit as opposed to implicit consent, as is the policy for all other vaccinations. This paper examines responses of personnel to this policy. METHODS: Qualitative analysis of free text responses to a question inviting comments on any concerns about the anthrax vaccination, asked in the context of a questionnaire assessing military health amongst 1000 members of the UK armed forces following the invasion of Iraq in 2003. RESULTS: Two hundred and two (20.2%) respondents made comments reflecting concerns about the vaccine's effectiveness and its safety. These appeared to be magnified by suspicions about the motives behind the informed consent policy for anthrax but not other vaccinations. CONCLUSION: While the informed consent policy for anthrax vaccinations was intended to decrease concern, it may inadvertently have had the opposite effect.

How effective is St John's wort? The evidence revisited.

BACKGROUND: St. John's wort (Hypericum perforatum) has been identified as an effective treatment for depression in controlled studies and subsequent meta-analyses. However, 3 recently published large studies failed to demonstrate robust efficacy. Updated meta-analysis and assessment of publication bias may help determine the true effect of St. John's wort. METHOD: Meta-analysis to reevaluate the effectiveness of St. John's wort as an antidepressant, funnel plot analysis, and meta-regression to assess the impact of publication bias, small-study effects, and variation in trial characteristics were performed. We conducted 2 analyses: a reproduction of a recent meta-analysis including 15 studies (Meta-15) and a meta-analysis extended by the 3 studies published since then (Meta-18). The studies in Meta-15 were identified through MEDLINE and EMBASE searches conducted in June 2000. The search terms used were St. John's wort, hypericum, hypericin, depression, and antidepressant, and no language restrictions were applied. For both meta-analyses, we compared funnel plots, Begg's rank correlation, Egger's regression, trim and fill method, and meta-regression. RESULTS: In both analyses, effect sizes in recent studies were smaller than those reported in earlier studies; the addition of more recent studies into the analyses resulted in reduced effect size. In Meta-15, St. John's wort was significantly more effective than placebo with a risk ratio (RR) of 1.97 (CI = 1.54 to 2.53). In Meta-18, the RR was reduced to 1.73 (CI = 1.40 to 2.14). On funnel plot analysis, the Meta-18 plot proved to be much more skewed than the Meta-15 plot. Meta-regression showed that increase in effect size was associated with smaller sample size only. The impact of baseline severity of depression could not be evaluated as the studies used different versions of the Hamilton Rating Scale for Depression. CONCLUSION: St. John's wort may be less effective in the treatment of depression than previously assumed and may finally be shown to be ineffective if future trials confirm this trend.