Deployment of personnel to military operations: impact on mental health and social functioning.

This Campbell systematic review examines the effects of deployment on mental health. The review summarizes evidence from 185 studies. All studies used observational data to quantify the effect of deployment. This review includes studies that evaluate the effects of deployment on mental health. A total of 185 studies were identified. However, only 40 of these were assessed to be of sufficient methodological quality to be included in the final analysis. The studies spanned the period from 1993 to 2017 and were mostly carried out in the USA, UK and Australia. The studies all had some important methodological weaknesses. None of the included studies used experimental designs (random assignment). Deployment to military operations negatively affects the mental health functioning of deployed military personnel. For assessments taken more than 24 months since exposure, we consistently found adverse effects of deployment on all mental health domains (PTSD, depression, substance abuse/dependence, and common mental disorders), particularly on PTSD. For assessments taken less than 24 months (or a variable number of months since exposure) the evidence was less consistent and in many instances inconclusive. Plain language summary: Deployment to military operations negatively affects the mental health functioning of deployed military personnel: While additional research is needed, the current evidence strongly supports the notion that deployment negatively affects mental health functioning of deployed military personnel.What is this review about?: When military personnel are deployed to military operations abroad they face an increased risk of physical harm, and an increased risk of adverse shocks to their mental health.The primary condition under consideration is deployment to an international military operation. Deployment to a military operation is not a uniform condition; rather, it covers a range of scenarios. Military deployment is defined as performing military service in an operation at a location outside the home country for a limited time period, pursuant to orders.The review included studies that reported outcomes for individuals who had been deployed. This review looked at the effect of deployment on mental health outcomes. The mental health outcomes are: post-traumatic stress disorder (PTSD), major depressive disorder (MDD), common mental disorders (depression, anxiety and somatisation disorders) and substance-related disorders.By identifying the major effects of deployment on mental health and quantifying these effects, the review can inform policy development on deployment and military activity as well as post-deployment support for veterans. In this way the review enables decision-makers to prioritise key areas.What are the main findings of this review?: What studies are included?: This review includes studies that evaluate the effects of deployment on mental health. A total of 185 studies were identified. However, only 40 of these were assessed to be of sufficient methodological quality to be included in the final analysis. The studies spanned the period from 1993 to 2017 and were mostly carried out in the USA, UK and Australia. The studies all had some important methodological weaknesses. None of the included studies used experimental designs (random assignment).Does deployment have an effect on mental health?: Deployment to military operations negatively affects the mental health functioning of deployed military personnel. For assessments taken more than 24 months since exposure, we consistently found adverse effects of deployment on all mental health domains (PTSD, depression, substance abuse/dependence, and common mental disorders), particularly on PTSD. For assessments taken less than 24 months (or a variable number of months since exposure) the evidence was less consistent and in many instances inconclusive.What do the findings of this review mean?: The odds of screening positive for PTSD and depression were consistently high in the longer term. This suggests that efforts should be increased to detect and treat mental disorders, as effects may be long-lasting.Overall the risk of bias in the majority of included studies was high. While it is difficult to imagine a randomised study design to understand how deployment affects mental health, other matters such as changes to personnel policy, or unanticipated shocks to the demand for military personnel, could potentially be a rich source of quasi-experimental variation.How up-to-date is this review?: The review authors searched for studies up to 2017. This Campbell systematic review was published in March 2018. Executive summary: BACKGROUND: When military personnel are deployed to military operations abroad they face an increased risk of physical harm, and an increased risk of adverse shocks to their mental health. Research suggests that the increased risk to mental health is mainly due to the hazards of war, combat exposure: firing weapons, road side bombs, seeing fellow soldiers, friends, civilians, and enemies being injured, maimed or killed. These experiences may lead to severe mental stress. The adverse impact on mental health is the psychological cost of war, and it is of interest to policymakers to learn the magnitude of these effects. This review sets out to synthesise available evidence about the consequences of deployment for deployed military personnel in the mental health and social functioning domains.OBJECTIVES: The objective of this review isto synthesise the consequences of deployment to military operation on the mental health and social functioning of deployed military personnel.SEARCH METHODS: We searched electronic databases, grey literature, and references from primary studies and related reviews. No language or date restrictions were applied to the searches. We searched the following electronic databases: Academic Search Elite, Cochrane Library, EMBASE, ERIC, MEDLINE, PsycINFO, Science Citation Index, Social Science Citation Index, SocINDEX, as well as the Nordic platforms: bibliotek.dk, BIBSYS, and LIBRIS. The conclusions of this review are based on the most recent searches performed. The last search was performed in April 2017.SELECTION CRITERIA: Primary studies had to meet the following inclusion criteria: Participants: The participants should be military personnel.Intervention: The condition should be deployment to a military operation.Comparison: The relevant comparisons were either comparing a) deployed military personnel to non-deployed military personnel, b) deployed military personnel to military personnel deployed elsewhere, for example personnel deployed to non-combat operations, c) military personnel deployed to the same operation but stratified by combat exposure.Outcomes: The study should report on one or more mental health outcomes, and/or social functioning for the deployed participants. In particular studies should report on one or more of the following mental health outcomes: PTSD, major depression, substance abuse or dependence (including alcohol), and common mental disorders (depression and anxiety disorders). The following social functioning outcomes were relevant: employment, and homelessness.Study Designs: Both experimental and quasi-experimental designs with a comparison group were eligible for inclusion in the review. Studies were excluded if they: Reported on deployments taking place before 1989.Used a within group pre-post study design.Did not report on at least one of the mental health or social functioning outcomes. DATA COLLECTION AND ANALYSIS: The total number of potentially relevant studies constituted31,049records. A total of 185 studies met the inclusion criteria and were critically appraised by the review authors. The final selection of 185 studies was from 13 different countries.Forty eight of the 185 studies did not report effect estimates or provide data that would allow the calculation of an effect size and standard error. Fifty four studies were excluded because of overlapping samples. The majority of those studies were from USA but the main reason for not using studies from USA in the synthesis was lack of information to calculate an effect size. Nearly half the studies from the UK could not be used in the synthesis due to overlap of data samples. Forty three studies were judged to have a very high risk of bias (5 on the scale) and, in accordance with the protocol, we excluded these from the data synthesis on the basis that they would be more likely to mislead than inform., Thus a total of 40 studies, from five different countries, were included in the data synthesis.Random effects models were used to pool data across the studies. We used the odds ratio. Pooled estimates were weighted with inverse variance methods, and 95% confidence intervals were calculated. The meta-analyses were carried out by time since exposure (short, medium, long, and other time since exposure) and by type of comparison (deployed versus non-deployed, all deployed but stratified by either combat operations versus non-combat operations, or stratified by combat exposure). We performed single factor subgroup analysis. The assessment of any difference between subgroups was based on 95% confidence intervals. Funnel plots were used to assess the possibility of publication bias. Sensitivity analysis was used to evaluate whether the pooled effect sizes were robust across components of methodological quality.MAIN RESULTS: The findings were mixed, depending on the outcome, the time since exposure and the approach (deployed versus non-deployed termed absolute or stratified by extent of combat termed relative) used to investigate the effect. It was not possible to analyse the outcomes homelessness and employment. All studies that could be used in the data synthesis reported on the impact of deployment on mental health; PTSD, depression, substance use or common mental disorder.For assessments taken less than 24months since exposure the evidence was inconclusive either because too few studies reported results in the short and medium term and/or the degree of heterogeneity between studies was large.For assessments taken at other time points (a variable number of months since exposure) the evidence was inconclusive for the relative comparisons due to either too few studies or a substantial degree of heterogeneity between studies. For the absolute comparison the analysis of common mental disorder was inconclusive, whereas the average effects of PTSD and depression were positive and statistically significant (PTSD odds ratio (OR) was 1.91 (95% confidence interval (CI): 1.28 to 2.85) and OR=1.98 (95% CI: 1.05 to 3.70) for depression). The analysis concerning substance use indicated that deployed participants did not have higher odds of screening positive for substance use compared to non-deployed participants (OR=1.15 (95% CI: 0.98 to 1.36)).For assessments taken more than 24 months post exposure, meta-analyses indicated that the odds of screening positive for PTSD, depression, substance use and common mental disorder were higher for participants in the deployed group compared to participants in the group that were not deployed (PTSD OR=3.31 (95% CI: 2.69 to 4.07), OR=2.19 (95% CI: 1.58 to 3.03) for depression, OR=1.27 (95% CI: 1.15 to 1.39) for substance use, and OR=1.64 (95% CI: 1.38 to 1.96) for common mental disorder). Likewise, participants reporting high combat exposure had higher odds of screening positive for PTSD and depression than participants reporting lower exposure for long term assessments (PTSD OR=3.05 (95% CI: 1.94 to 4.80) and OR=1.81 (95% CI: 1.28 to 2.56) for depression). The analyses of substance use and common mental disorder were inconclusive due to too few studies.On the basis of the prevalence of mental health problems in pre-deployed or non-deployed population based comparison sampleswe would therefore expect the long term prevalence of PTSD in post-deployed samples to be in the range 6.1 - 14.9%, the long term prevalence of depression to be in the range from 7.6% to 18%, the long term prevalence of substance use to be in the range from 2.4% to 17.5% and the prevalence of common mental disorder to be in the range from 10% to 23%.Sensitivity analyses resulted in no appreciable change in effect size, suggesting that the results are robust.It was only possible to assess the impact of two types of personnel characteristics (branch of service and duty/enlistment status) on the mental health outcomes. We found no evidence to suggest that the effect of deployment on any outcomes differ between these two types of personnel characteristics.AUTHORS' CONCLUSIONS: Deployment to military operations negatively affects the mental health functioning of deployed military personnel. We focused on the effect of deployment on PTSD (post-traumatic stress disorder), depression, substance abuse/dependence, and common mental disorders (depression and anxiety disorders). For assessments taken less than 24 months (or a variable number of months since exposure) the evidence was less consistent and in many instances inconclusive. For assessments taken more than 24 months since exposure, we consistently found adverse effects of deployment on all domains, particularly on PTSD. There is increased political awareness of the need to address post deployment mental health problems. The odds of screening positive for PTSD and depression were consistently high in the longer term. This suggests that efforts should be increased to detect and treat mental disorders, as effects may be long lasting. Mental illness is of particular concern in the military for operational reasons, but they may be hard to detect in the military setting because a military career is intimately linked with mental and physical strength.It was not possible to examine a number of factors which we had reason to expect would impact on the magnitude of the effect. This would have been particularly relevant from a policy perspective because these are direct parameters that one could use to optimally "organize" deployment in order to minimize impacts on mental health functioning.While additional research is needed, the current evidence strongly supports the notion that deployment negatively affects mental health functioning of deployed military personnel. The next step is to begin to examine preventive measures and policies for organizing deployment, in order to minimize the effects on mental health.

Reducing unemployment benefit duration to increase job finding rates: a systematic review.

This Campbell systematic review examines the impact of reducing the maximum duration of unemployment benefits on job-finding rates. Seven studies were included in the review, all of which are from European countries. Included studies had to examine the effect of a reduction in the maximum duration of entitlement of any kind of unemployment benefits on employment using a well-defined control group. Whilst 41 studies were identified, after allowing for study quality and data issues, only seven studies were included in the review. The included studies covered Austria (2 studies), France, Germany (3 studies) and Slovenia. Maximum entitlement ranged between 26 and 209 weeks. The studies analyzed reductions between 9 and 179 weeks, with an average of 43 weeks. The studies analyze data from 1,154,090 unemployment spells. Reducing the duration of unemployment benefits increases the exit rate from unemployment. Data from seven studies show that the exit rate from unemployment for those with reduced duration of benefit entitlement on average is 10 per cent. This corresponds to a 52% chance that those with reduced duration will find a job before an unemployed person with the existing, longer duration (no effect corresponds to a 50% chance). There is not enough evidence to determine effects on the exit rate from re-employment or on the wage rate in the job found. There are insufficient high-quality studies to allow an examination of variation of effects. Plain language summary: Reducing the maximum duration of unemployment benefits increases the job finding rate of the unemployed: Reducing the maximum duration of unemployment benefits is one strategy used to reduce unemployment. Evidence from seven studies confirms such an effect. However, the effect is small and more studies of higher quality are needed to give more detailed findings to inform policy.The review in brief: Evidence from seven studies shows shortening the maximum duration of unemployment benefit entitlement has a small effect on the job finding rate of the unemployed.What is this review about?: Policymakers may wish to reduce the generosity of the unemployment benefits system in order to reduce unemployment levels. Reducing benefit levels may be politically more difficult than shortening the length of the unemployment benefit eligibility period to create work incentives for the unemployed.This review summarizes studies that measure the effects of shortening the maximum duration of unemployment benefit entitlement on job finding rates.What are the main findings of this review?: What studies are included?: Included studies had to examine the effect of a reduction in the maximum duration of entitlement of any kind of unemployment benefits on employment using a well-defined control group.Whilst 41 studies were identified, after allowing for study quality and data issues, only seven studies were included in the review. The included studies covered Austria (2 studies), France, Germany (3 studies) and Slovenia. Maximum entitlement ranged between 26 and 209 weeks. The studies analyzed reductions between 9 and 179 weeks, with an average of 43 weeks. The studies analyze data from 1,154,090 unemployment spells.What are the main results of this review?: Reducing the duration of unemployment benefits increases the exit rate from unemployment. Data from seven studies show that the exit rate from unemployment for those with reduced duration of benefit entitlement on average is 10 per cent. This corresponds to a 52% chance that those with reduced duration will find a job before an unemployed person with the existing, longer duration (no effect corresponds to a 50% chance).There is not enough evidence to determine effects on the exit rate from re-employment or on the wage rate in the job found. There are insufficient high-quality studies to allow an examination of variation of effects.What do the findings of this review mean?: On the basis of this limited number of studies, shortening the maximum duration of unemployment benefit entitlement has a small effect on the job finding rate of the unemployed. Whether unemployed workers responding to a shorter potential benefit entitlement may be worse off, in the sense that they accept "lower quality" jobs, has not yet been fully investigated.But the review finds a surprisingly low number of studies with a sufficiently low risk of bias to be used for synthesis to determine the effect size of shortening the maximum duration of unemployment benefit entitlement. Many studies had to be excluded as they had a high risk of bias. This is a finding in its own right.There is a need for future studies to more thoroughly discuss the assumptions of the study design and justify the choice of method by considering and reporting all relevant data and tests. Future studies should also use data with all relevant information, in particular, information on whether eligible individuals actually received unemployment benefits and information on individual maximum entitlement duration.How up-to-date is this review?: The review authors searched for studies published up to December 2016. This Campbell Systematic Review was published in February 2018. Executive Summary/Abstract: BACKGROUND: Unemployment benefit programmes protect individuals against loss of income and provide unemployed individuals with the possibility of finding a better match between their qualifications and job vacancies. However, unemployment benefits may also distort incentives by subsidizing long and unproductive job searches. In order to reduce unemployment levels, policymakers may wish to reduce the generosity of the unemployment system. While it may be politically intractable to lower the monetary amount of unemployment benefits available, the length of the unemployment benefit eligibility period is often used as a political instrument to create work incentives for the unemployed. If a shorter benefit period results in a significantly increased incentive for finding work, shortening the benefit eligibility period may reduce the share of long and unproductive job searches and thereby decrease the overall unemployment level.OBJECTIVES: The purpose of this review is to systematically uncover relevant studies in the literature that measure the effects of shortening the maximum duration of unemployment benefit entitlement on job finding rates, and to synthesize the effects in a transparent manner. As a secondary objective we will, where possible, investigate the extent to which the effects differ among different groups of unemployed people, such as those with high/low levels of education or men/women, and further explore from which point in the unemployment spell unemployed individuals react to the length of benefit entitlement.SEARCH METHODS: The search was concluded in March 2016. Relevant studies were identified through electronic searches of bibliographic databases, government policy databanks, internet search engines and hand searching of core journals. We searched to identify both published and unpublished literature. The searches were international in scope. Reference lists of included studies and relevant reviews were also searched.SELECTION CRITERIA: The intervention of interest was a reduction (change) in the maximum duration of entitlement of any kind of unemployment benefits. We included unemployed individuals who received any type of time-limited benefit during their unemployment spell. All study designs that used a well-defined control group were eligible for inclusion in this review. Studies that utilised qualitative approaches were not included in the review due to the absence of adequate control group conditions.DATA COLLECTION AND ANALYSIS: Random effects models were used to pool data across the studies. We used the point estimate of the hazard ratio. Pooled estimates were weighted with inverse variance methods, and 95% confidence intervals were used. A sensitivity analysis was performed to evaluate whether the pooled effect sizes were robust across components of methodological quality, in relation to the quality of data and whether the study analysed an extension of entitlement duration.RESULTS: The initial search for potentially relevant studies resulted in a total number of 34,930 hits. A total of 41 studies, consisting of 66 papers, from 15 different countries, met the inclusion criteria and were vetted by the review authors. Only 38 studies provided data that permitted the calculation of an effect size for the primary outcome. Of these 38 studies, 28 studies could not be used in the data synthesis due to a too high risk of bias. A further 3 studies could not be used in the data synthesis due to overlapping of data samples. As a result, only 7 studies were included in the data synthesis and one of these studies only provided results on the secondary outcome. In total, 6 studies provided data that permitted the calculation of an effect size for the primary outcome and 3 studies provided data that permitted the calculation of secondary outcome. The sample size used in the studies ranged from 5,017 spells of unemployment to 509,355 spells. The total number of unemployment spells was 1,154,090, implying an average sample size of 164,870 spells of unemployment per study.The seven studies covered Austria, France, Germany and Slovenia. There was a high degree of variation in maximum entitlement, ranging between 26 and 209 weeks. On average the studies analysed a reduction of 43 weeks in maximum entitlement; the smallest being a reduction of 9 weeks and the largest a reduction of 179 weeks. Four studies restricted the analysis to a specific age group and three studies restricted the analysis to specific work experience levels. All studies used non-randomised designs. In the majority of studies the risk of bias was high.This review found a statistically significant effect of shortening the maximum duration of unemployment benefitentitlement. The overall impact of shortening the maximum duration of unemployment benefit entitlement, obtained using hazard ratios, was estimated at 1.10 (95% CI 1.03 to 1.17, p=0.0005), which translates into an increase of approximately 10% in the exit rate from unemployment into employment and corresponds to a 52% chance that a treated unemployed person will find a job before a non-treated unemployed person.Thus, although small, the available evidence associated with a sufficiently low risk of bias supports the hypothesis of an incentive effect of shortening the maximum duration of unemployment benefit entitlement. There was a lack of evidence to conclude that shortening the maximum duration of unemployment benefit entitlement has an impact on the quality of the job obtained.Only three studies provided data on the exit rate from re-employment and three studies provided data on the log wage ratio in the re-employment job.The overall impact of shortening the maximum duration of unemployment benefit entitlement on the exit rate from the re-employment job, obtained using hazard ratios, was 0.99 (95% CI 0.97 to 1.02, p=0.64) and the overall wage ratio was 1.00 (95% CI 0.99 to 1.01, p=0.089).We did not find any adverse effects.Sensitivity analyses resulted in no appreciable change in effect size, suggesting that the results are robust. The limited number of studies used in the meta-analysis should, however, be considered when interpreting the results.Due to having an insufficient number of studies available for moderator analysis to be performed, it was not possible to examine whether the effect of reducing the maximum potential benefit duration on job-finding differs for men and women, for particular age groups or educational groups, or if factors such as good or bad labour market conditions, the type of unemployment benefit, the availability of alternative benefits, or whether compulsory activation is part of the institutional system, have an impact on the effect.AUTHORS' CONCLUSIONS: To the best of our knowledge, this is the first systematic review analysing the magnitude of the effect of shortening the maximum duration of unemployment benefit entitlement on the job finding rate. The review finds a surprisingly low number of studies with a sufficiently low risk of bias to enter a synthesis of the effect size of shortening the maximum duration of unemployment benefit entitlement. On the basis of this limited number of studies, shortening the maximum duration of unemployment benefit entitlement displays a limited potential for altering the employment prospects of the unemployed individuals. The available evidence does suggest an effect on the job finding rate of shortening the maximum duration of unemployment benefit entitlement, but the effect is small. Further, whether unemployed workers responding to a shorter potential benefit entitlement may be worse off, in the sense that they accept "lower quality"" jobs, has not yet been fully investigated.The number of studies used in the data synthesis (7) is relatively low compared to the large number of studies (41) meeting the inclusion criteria for the review. The reduction in studies eligible for inclusion in the data synthesis was primarily caused by a judgment of too high a risk of bias. Thus, the process of excluding studies with too high risk of bias from the meta-analysis applied in this review left us with only seven studies to synthesize. This is a finding in its own right, entailing important information for stakeholders on the degree of confidence to place on the expected gains from changing the maximum potential unemployment benefit duration; fewer studies with too high risk of bias would have provided a more robust literature on which to base conclusions. There is a need for future studies to more thoroughly discuss the identifying assumptions of the study design and justify the choice of method by considering and reporting all relevant data and tests. Further, future studies should rely on data where all relevant information is available, in particular information on whether eligible individuals actually received unemployment benefits and information on individual maximum entitlement duration.