Sickness absence and associations with sociodemographic factors, health risk behaviours, occupational stressors and adverse mental health in 40,343 UK police employees

AIMS

Police employees may experience high levels of stress due to the challenging nature of their work which can then lead to sickness absence. To date, there has been limited research on sickness absence in the police. This exploratory analysis investigated sickness absence in UK police employees.

METHODS

Secondary data analyses were conducted using data from the Airwave Health Monitoring Study (2006-2015). Past year sickness absence was self-reported and categorised as none, low (1-5 days), moderate (6-19 days) and long-term sickness absence (LTSA, 20 or more days). Descriptive statistics and multinomial logistic regressions were used to examine sickness absence and exploratory associations with sociodemographic factors, occupational stressors, health risk behaviours, and mental health outcomes, controlling for rank, gender and age.

RESULTS

From a sample of 40,343 police staff and police officers, forty-six per cent had no sickness absence within the previous year, 33% had a low amount, 13% a moderate amount and 8% were on LTSA. The groups that were more likely to take sick leave were women, non-uniformed police staff, divorced or separated, smokers and those with three or more general practitioner consultations in the past year, poorer mental health, low job satisfaction and high job strain.

CONCLUSIONS

The study highlights the groups of police employees who may be more likely to take sick leave and is unique in its use of a large cohort of police employees. The findings emphasise the importance of considering possible modifiable factors that may contribute to sickness absence in UK police forces.

Risk and protective factors for self-harm and suicide behaviours among serving and ex-serving personnel of the UK Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force: A systematic review

BACKGROUND

Self-harm and suicide behaviours are a major public health concern. Several factors are associated with these behaviours among military communities. Identifying these factors may have important implications for policy and clinical services. The aim of this review was to identify the risk and protective factors associated with self-harm and suicide behaviours among serving and ex-serving personnel of the United Kingdom Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force.

METHODS

A systematic search of seven online databases (PubMed, Web of Science, Embase, Global Health, PsycINFO, PTSDpubs and CINAHL) was conducted alongside cross-referencing, in October 2022. Following an a priori PROSPERO approved protocol (CRD42022348867), papers were independently screened and assessed for quality. Data were synthesised using a narrative approach.

RESULTS

Overall, 28 papers were included: 13 from Canada, 10 from the United Kingdom, five from Australia and none from New Zealand. Identified risk factors included being single/ex-relationship, early service leavers, shorter length of service (but not necessarily early service leavers), junior ranks, exposure to deployment-related traumatic events, physical and mental health diagnoses, and experience of childhood adversity. Protective factors included being married/in a relationship, higher educational attainment, employment, senior ranks, and higher levels of perceived social support.

CONCLUSION

Adequate care and support are a necessity for the military community. Prevention and intervention strategies for self-harm and suicide behaviours may be introduced early and may promote social networks as a key source of support. This review found a paucity of peer-reviewed research within some populations. More peer-reviewed research is needed, particularly among these populations where current work is limited, and regarding modifiable risk and protective factors.

Re: investigating the impact of financial concerns on symptoms of depression in UK healthcare workers: data from the UK REACH nationwide cohort study

This editorial comments on the paper by Martin McBride and the UK REACH team (published in 2023) investigating financial concerns in UK healthcare workers and depressive symptoms. The research concludes that reporting future financial concerns at baseline increased the odds of depressive symptoms at follow-up around 18 months later. We discuss these findings in the context of the cost-of-living crisis and pay disputes within the NHS, important policy implications and directions for future research.

Ethnic inequalities among NHS staff in England: workplace experiences during the COVID-19 pandemic

OBJECTIVES

This study aims to determine how workplace experiences of National Health Service (NHS) staff varied by ethnicity during the COVID-19 pandemic and how these experiences are associated with mental and physical health at the time of the study.

METHODS

An online Inequalities Survey was conducted by the Tackling Inequalities and Discrimination Experiences in Health Services study in collaboration with NHS CHECK. This Inequalities Survey collected measures relating to workplace experiences (such as personal protective equipment (PPE), risk assessments, redeployments and discrimination) as well as mental health (Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder 7 (GAD-7)), and physical health (PHQ-15) from NHS staff working in the 18 trusts participating with the NHS CHECK study between February and October 2021 (N=4622).

RESULTS

Regression analysis of this cross-sectional data revealed that staff from black and mixed/other ethnic groups had greater odds of experiencing workplace harassment (adjusted OR (AOR) 2.43 (95% CI 1.56 to 3.78) and 2.38 (95% CI 1.12 to 5.07), respectively) and discrimination (AOR 4.36 (95% CI 2.73 to 6.96) and 3.94 (95% CI 1.67 to 9.33), respectively) compared with white British staff. Staff from black ethnic groups also had greater odds than white British staff of reporting PPE unavailability (AOR 2.16 (95% CI 1.16 to 4.00)). Such workplace experiences were associated with negative physical and mental health outcomes, though this association varied by ethnicity. Conversely, understanding employment rights around redeployment, being informed about and having the ability to inform redeployment decisions were associated with lower odds of poor physical and mental health.

CONCLUSIONS

Structural changes to the way staff from ethnically minoritised groups are supported, and how their complaints are addressed by leaders within the NHS are urgently required.

Is lifetime traumatic brain injury a risk factor for mild cognitive impairment in veterans compared to non-veterans?

Background: Traumatic brain injury (TBI) is prevalent in veterans and may occur at any stages of their life (before, during, or after military service). This is of particular concern, as previous evidence in the general population has identified TBI as a strong risk factor for mild cognitive impairment (MCI), a known precursor of dementia.Objectives: This study aimed to investigate whether exposure to at least one TBI across the lifetime was a risk factor for MCI in ageing UK veterans compared to non-veterans.Method: This cross-sectional study comprised of data from PROTECT, a cohort study comprising UK veterans and non-veterans aged ≥ 50 years at baseline. Veteran and TBI status were self-reported using the Military Service History Questionnaire (MSHQ) and the Brain Injury Screening Questionnaire (BISQ), respectively. MCI was the outcome of interest, and was defined as subjective cognitive impairment and objective cognitive impairment.Results: The sample population comprised of veterans (n = 701) and non-veterans (n = 12,389). TBI was a significant risk factor for MCI in the overall sample (OR = 1.21, 95% CI 1.11-1.31) compared to individuals without TBI. The prevalence of TBI was significantly higher in veterans compared to non-veterans (69.9% vs 59.5%, p < .001). There was no significant difference in the risk of MCI between veterans with TBI and non-veterans with TBI (OR = 1.19, 95% CI 0.98-1.45).Conclusion: TBI remains an important risk factor for MCI, irrespective of veteran status. The clinical implications indicate the need for early intervention for MCI prevention after TBI.

Evaluation of Community Reinforcement and Family Therapy in the UK military community

Background: Partners and family can play a key role in encouraging military service and ex-service personnel to seek help for their mental health. Community Reinforcement Approach and Family Training (CRAFT) was developed to equip concerned significant others (CSOs) of those experiencing substance use disorders with skills to encourage their loved one to enter treatment and improve their own well-being. It was adapted in the US for CSOs of ex-service personnel with post-traumatic stress disorder (PTSD) (VA-CRAFT).Objective: This study aimed to evaluate an adaptation of VA-CRAFT for use with CSOs of serving and ex-service personnel experiencing PTSD and Common Mental Disorders in the UK (UKV-CRAFT).Method: Acceptability of UKV-CRAFT was assessed with interviews with experts, namely key stakeholders (n = 15) working in support provision for serving and ex-service personnel. In addition, individuals who took part in a small-scale demonstrative trial of UKV-CRAFT (three CSOs and three facilitators who delivered UKV-CRAFT) provided feedback.Results: UKV-CRAFT was viewed positively, with interviewees highlighting that programmes like UKV-CRAFT filled a gap in provision for UK Armed Forces families as most services were only available to the serving or ex-service personnel. Interviewees praised how UKV-CRAFT enhanced CSO well-being and communication with their loved one. Concerns over the confidentiality of taking part in UKV-CRAFT were raised due to the perceived negative effects of highlighting a loved one's mental ill health, especially for CSOs of serving personnel. Ideas for improvement included broadening access to all CSOs regardless of whether their loved one was seeking treatment.Conclusion: Interviewees regarded UKV-CRAFT as a potentially useful intervention suggesting it could be proactively offered universally to support timely help-seeking if required. We recommend further evaluation of UKV-CRAFT on a wider scale, incorporating our recommendations, to assess its effectiveness accurately.

Gender differences in structural and attitudinal barriers to mental healthcare in UK Armed Forces personnel and veterans with self-reported mental health problems

PURPOSE

Structural and attitudinal barriers often hinder treatment-seeking for mental health problems among members of the Armed Forces. However, little is known about potential gender differences in structural and attitudinal barriers among members of the UK Armed Forces. The current study aimed to explore how men and women differ in terms of these barriers to care among a sample of UK Armed Forces personnel and veterans with self-reported mental health problems.

METHODS

Currently serving and ex-serving members of the UK Armed Forces who self-reported a mental health problem were invited to participate in a semi-structured phone interview on mental health and treatment-seeking. The final sample included 1448 participants (1229 men and 219 women). All participants reported on their current mental health, public stigma, self-stigma, and barriers to mental healthcare.

RESULTS

Overall, men and women reported similar levels of both structural and attitudinal barriers, with no significant differences detected. The highest scores for both men and women were observed in attitudinal barriers relating to self-stigma domains, which encapsulate internalised attitudes and beliefs about mental illness and treatment.

CONCLUSIONS

Findings suggest that anti-stigma campaigns can be targeted simultaneously at both men and women within the Armed Forces. In particular, targeting self-stigma may be beneficial for health promotion campaigns.

Adjustment disorder in the Armed Forces: a systematic review

BACKGROUND

In the UK military, adjustment disorder (AjD) is reported as one of the most diagnosed mental disorders, alongside depression, in personnel presenting to mental health services. Despite this, little is understood about what may predict AjD, common treatment or outcomes for this population.

AIM

The systematic review aimed to summarise existing research for AjD in Armed Forces (AF) populations, including prevalence and risk factors, and to outline clinical and occupational outcomes.

METHOD

A literature search was conducted in December 2020 to identify research that investigated AjD within an AF population (serving or veteran) following the PRISMA guidelines.

RESULTS

Eighty-three studies were included in the review. The AjD prevalence estimates in AF populations with a mental disorder was considerably higher for serving AF personnel (34.9%) compared to veterans (12.8%). Childhood adversities were identified as a risk factor for AjD. AjD was found to increase the risk of suicidal ideation, with one study reporting a risk ratio of 4.70 (95% Confidence Interval: 3.50-6.20). Talking therapies were the most common treatment for AjD, however none reported on treatment effectiveness.

CONCLUSION

This review found that AjD was commonly reported across international AF. Despite heterogeneity in the results, the review identifies several literature gaps.

Risk factors for the progression to multimorbidity among UK urban working-age adults. A community cohort study

OBJECTIVES

The progression of long-term conditions (LTCs) from zero-to-one (initiation), and from one-to-many (progression)are common trajectories that impact a person's quality of life including their ability to work. This study aimed to explore the demographic, socioeconomic, psychosocial, and health-related determinants of LTC initiation and progression, with a focus on work participation.

METHODS

Data from 622 working-age adults who had completed two waves (baseline and follow-up) of the South-East London Community Health survey were analysed. Chi square tests and multinomial logistic regression were used to describe the associations between self-reported demographic, socioeconomic, psychosocial, and health-related variables, and the progression of LTCs.

RESULTS

Small social networks, an increased number of stressful life events, low self-rated health, functional impairment, and increased somatic symptom severity were all associated with both the progression from zero-to-one LTC and from one LTC to multimorbidity (two or more LTCs). Renting accommodation (RRR 1.73 [95% CI 1.03-2.90]), smoking (RRR 1.91 [95% CI 1.16-3.14]) and being overweight (RRR 1.88 [95% CL 1.12-3.16]) were unique risk factors of developing initial LTCs, whereas low income (RRR 2.53 [95% CI 1.11-5.80]), working part-time (RRR 2.82 ([95% CL 1.12-7.10]), being unemployed (RRR 4.83 [95% CI 1.69-13.84]), and making an early work exit (RRR 16.86 [95% CI 3.99-71.30]) all increased the risk of progressing from one LTC to multimorbidity compared to being employed full-time. At follow-up, depression was the most prevalent LTC in the unemployed group whereas musculoskeletal conditions were the most prevalent in those working.

CONCLUSIONS

The journey to multimorbidity is complex, with both common and unique risk factors. Non-full-time employment was associated with an increased risk of progression to multimorbidity. Future research should explore the risk and benefit pathways between employment and progression of LTCs. Interventions to prevent progression of LTCs should include mitigation of modifiable risk factors such as social isolation.

Evaluating a Smartphone App (MeT4VeT) to Support the Mental Health of UK Armed Forces Veterans: Feasibility Randomized Controlled Trial

BACKGROUND

Previous research demonstrates that less than 50% of military veterans experiencing mental health difficulties seek formal support. Veterans often struggle to identify problems as mental health difficulties. In addition, they may fail to recognize the need for support before reaching a crisis point and face difficulties navigating care pathways to access support.

OBJECTIVE

A feasibility trial was conducted to assess a novel digital smartphone app (Mental Health Toolkit for Veterans Project [MeT4VeT]) for UK Armed Forces (UKAF) veterans experiencing mental health difficulties. The trial aimed to explore the feasibility and acceptability of trial procedures for a later randomized controlled trial (RCT) and to assess the acceptability of the MeT4VeT app.

METHODS

Participants were recruited at UK military medical centers, by advertising on social media, and through veteran third-sector organizations between February and November 2021, and assessed for eligibility (male, owned a smartphone, served at least 2 years in the UKAF, left the UKAF within the last 2 years, not undertaking formal mental health treatment). Eligible participants were assigned, on a 1:1 ratio, to either the intervention group (full app) or a control group (noninteractive app with signposting information). Three key objectives were determined a priori to assess the practicality of running an RCT including an assessment of recruitment and retention, evaluation of the technical app delivery and measurement processes, and acceptability and usability of the intervention.

RESULTS

In total, 791 individuals completed the participant information sheet, of which 261 (33%) were ineligible, 377 (48%) declined or were unable to be contacted for consent, and 103 (13%) did not download the app or complete the baseline measures. Of this, 50 participants completed baseline measures and were randomly assigned to the intervention group (n=24) or the control group (n=26). The trial was effective at enabling both the technical delivery of the intervention and collection of outcome measures, with improvements in mental health demonstrated for the intervention group from baseline to the 3-month follow-up. Recruitment and retention challenges were highlighted with only 50 out of the 530 eligible participants enrolled in the trial. The acceptability and usability of the MeT4VeT app were generally supported, and it was reported to be a useful, accessible way for veterans to monitor and manage their mental health.

CONCLUSIONS

The results highlighted that further work is needed to refine recruitment processes and maintain engagement with the app. Following this, an RCT can be considered to robustly assess the ability of the app to positively affect mental health outcomes indicated within this trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05993676; https://clinicaltrials.gov/ct2/show/NCT05993676.

Post-traumatic growth amongst UK armed forces personnel who were deployed to Afghanistan and the role of combat injury, mental health and pain: the ADVANCE cohort study

BACKGROUND

Post-traumatic growth (PTG) is a positive psychological consequence of trauma. The aims of this study were to investigate whether combat injury was associated with deployment-related PTG in a cohort of UK military personnel who were deployed to Afghanistan, and whether post-traumatic stress disorder (PTSD), depression and pain mediate this relationship.

METHODS

521 physically injured (n = 138 amputation; n = 383 non-amputation injury) and 514 frequency-matched uninjured personnel completed questionnaires including the deployment-related Post-Traumatic Growth Inventory (DPTGI). DPTGI scores were categorised into tertiles of: no/low (score 0-20), moderate (score 21-34) or a large (35-63) degree of deployment-related PTG. Analysis was completed using generalised structural equation modelling.

RESULTS

A large degree of PTG was reported by 28.0% (n = 140) of the uninjured group, 36.9% (n = 196) of the overall injured group, 45.4% (n = 62) of amputee and 34.1% (n = 134) of the non-amputee injured subgroups. Combat injury had a direct effect on reporting a large degree of PTG [Relative risk ratio (RRR) 1.59 (95% confidence interval (CI) 1.17-2.17)] compared to sustaining no injury. Amputation injuries also had a significant direct effect [RRR 2.18 (95% CI 1.24-3.75)], but non-amputation injuries did not [RRR 1.35 (95% CI 0.92-1.93)]. PTSD, depression and pain partially mediate this relationship, though mediation differed depending on the injury subtype. PTSD had a curvilinear relationship with PTG, whilst depression had a negative association and pain had a positive association.

CONCLUSIONS

Combat injury, in particular injury resulting in traumatic amputation, is associated with reporting a large degree of PTG.

Linking electronic mental healthcare and benefits records in South London: design, procedure and descriptive outcomes

OBJECTIVES

To describe the process and outcomes of a data linkage between electronic secondary mental healthcare records from the South London and Maudsley (SLaM) NHS Foundation Trust with benefits records from the Department for Work and Pensions (DWP). We also describe the mental health and benefit profile of patients who were successfully linked.

DESIGN

A deterministic linkage of routine records from health and welfare government service providers within a secure environment.

SETTING AND PARTICIPANTS

Adults aged≥18 years who were referred to or accessed treatment at SLaM services between January 2007 and June 2019, including those who were treated as part of Improving Access to Psychological Therapies (IAPT) services between January 2008 and June 2019 (n=448 404). Benefits data from the DWP from January 2005 to June 2020.

OUTCOME MEASURES

The linkage rate and associated sociodemographic, diagnostic and treatment factors. Recorded primary psychiatric diagnosis based on International Classification of Diseases (ICD)-10 codes and type of benefit receipt.

RESULTS

A linkage rate of 92.3% was achieved. Women, younger patients and those from ethnic minority groups were less likely to be successfully linked. Patients who had subsequently died, had a recorded primary psychiatric diagnosis, had also engaged with IAPT and had a higher number of historical postcodes available were more likely to be linked. Overall, 83% of patients received benefits at some point between 2005 and 2020. Benefit receipt across the psychiatric diagnosis spectrum was high, over 80% across most ICD-10 codes.

CONCLUSIONS

This data linkage is the first of its kind in the UK demonstrating the use of routinely collected mental health and benefits data. Benefit receipt was high among patients accessing SLaM services and varied by psychiatric diagnosis. Future areas of research are discussed, including exploring the effectiveness of interventions for helping people into work and the impact of benefit reforms.

Identifying Military Service Status in Electronic Healthcare Records from Psychiatric Secondary Healthcare Services: A Validation Exercise Using the Military Service Identification Tool

Electronic healthcare records (EHRs) are a rich source of information with a range of uses in secondary research. In the United Kingdom, there is no pan-national or nationally accepted marker indicating veteran status across all healthcare services. This presents significant obstacles to determining the healthcare needs of veterans using EHRs. To address this issue, we developed the Military Service Identification Tool (MSIT), using an iterative two-staged approach. In the first stage, a Structured Query Language approach was developed to identify veterans using a keyword rule-based approach. This informed the second stage, which was the development of the MSIT using machine learning, which, when tested, obtained an accuracy of 0.97, a positive predictive value of 0.90, a sensitivity of 0.91, and a negative predictive value of 0.98. To further validate the performance of the MSIT, the present study sought to verify the accuracy of the EHRs that trained the MSIT models. To achieve this, we surveyed 902 patients of a local specialist mental healthcare service, with 146 (16.2%) being asked if they had or had not served in the Armed Forces. In total 112 (76.7%) reported that they had not served, and 34 (23.3%) reported that they had served in the Armed Forces (accuracy: 0.84, sensitivity: 0.82, specificity: 0.91). The MSIT has the potential to be used for identifying veterans in the UK from free-text clinical documents and future use should be explored.

A comparison of probable post-traumatic stress disorder and alcohol consumption among active female members of the UK Police Service and UK Armed Forces

BACKGROUND

The British Police Service and Armed Forces are male-dominated occupations, characterised by frequent trauma exposure and intensive demands. Female police employees and military personnel may have unique experiences and face additional strains to their male counterparts. This analysis compared the levels of post-traumatic stress disorder (PTSD), hazardous/harmful alcohol consumption, and comorbidity in female police employees and military personnel.

METHODS

Police data were obtained from the Airwave Health Monitoring Study (N = 14,145; 2007-2015) and military data from the Health and Wellbeing Cohort Study (N = 928; phase 2: 2007-2009 and phase 3: 2014-2016). Multinomial/logistic regressions analysed sample differences in probable PTSD, hazardous (14-35 units per week) and harmful (35 + units per week) alcohol consumption, and comorbid problems. We compared covariate adjustment and entropy balancing (reweighting method controlling for the same covariates) approaches.

RESULTS

There were no significant differences in probable PTSD (police: 3.74% vs military: 4.47%) or hazardous drinking (police: 19.20% vs military: 16.32%). Female military personnel showed significantly higher levels of harmful drinking (4.71%) than police employees (2.42%; Adjusted Odds Ratios [AOR] = 2.26, 95% Confidence Intervals [CIs] = 1.60-3.21), and comorbidity (1.87%) than police employees (1.00%, AOR = 2.07, 95% CI = 1.21-3.54). Entropy balancing and covariate-adjustments obtained the same results.

CONCLUSIONS

Comparable levels of probable PTSD were observed, which are slightly lower than estimates observed in the female general population. Future research should explore the reasons for this. However, female military personnel showed higher levels of harmful drinking than police employees, emphasising the need for alcohol interventions in military settings.

Prevalence of post-traumatic stress disorder and common mental disorders in health-care workers in England during the COVID-19 pandemic: a two-phase cross-sectional study

BACKGROUND

Previous studies on the impact of the COVID-19 pandemic on the mental health of health-care workers have relied on self-reported screening measures to estimate the point prevalence of common mental disorders. Screening measures, which are designed to be sensitive, have low positive predictive value and often overestimate prevalence. We aimed to estimate prevalence of common mental disorders and post-traumatic stress disorder (PTSD) among health-care workers in England using diagnostic interviews.

METHODS

We did a two-phase, cross-sectional study comprising diagnostic interviews within a larger multisite longitudinal cohort of health-care workers (National Health Service [NHS] CHECK; n=23 462) during the COVID-19 pandemic. In the first phase, health-care workers across 18 NHS England Trusts were recruited. Baseline assessments were done using online surveys between April 24, 2020, and Jan 15, 2021. In the second phase, we selected a proportion of participants who had responded to the surveys and conducted diagnostic interviews to establish the prevalence of mental disorders. The recruitment period for the diagnostic interviews was between March 1, 2021 and Aug 27, 2021. Participants were screened with the 12-item General Health Questionnaire (GHQ-12) and assessed with the Clinical Interview Schedule-Revised (CIS-R) for common mental disorders or were screened with the 6-item Post-Traumatic Stress Disorder Checklist (PCL-6) and assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) for PTSD.

FINDINGS

The screening sample contained 23 462 participants: 2079 participants were excluded due to missing values on the GHQ-12 and 11 147 participants due to missing values on the PCL-6. 243 individuals participated in diagnostic interviews for common mental disorders (CIS-R; mean age 42 years [range 21-70]; 185 [76%] women and 58 [24%] men) and 94 individuals participated in diagnostic interviews for PTSD (CAPS-5; mean age 44 years [23-62]; 79 [84%] women and 15 [16%] men). 202 (83%) of 243 individuals in the common mental disorders sample and 83 (88%) of 94 individuals in the PTSD sample were White. GHQ-12 screening caseness for common mental disorders was 52·8% (95% CI 51·7-53·8). Using CIS-R diagnostic interviews, the estimated population prevalence of generalised anxiety disorder was 14·3% (10·4-19·2), population prevalence of depression was 13·7% (10·1-18·3), and combined population prevalence of generalised anxiety disorder and depression was 21·5% (16·9-26·8). PCL-6 screening caseness for PTSD was 25·4% (24·3-26·5). Using CAPS-5 diagnostic interviews, the estimated population prevalence of PTSD was 7·9% (4·0-15·1).

INTERPRETATION

The prevalence estimates of common mental disorders and PTSD in health-care workers were considerably lower when assessed using diagnostic interviews compared with screening tools. 21·5% of health-care workers met the threshold for diagnosable mental disorders, and thus might benefit from clinical intervention.

FUNDING

UK Medical Research Council; UCL/Wellcome; Rosetrees Trust; NHS England and Improvement; Economic and Social Research Council; National Institute for Health and Care Research (NIHR) Biomedical Research Centre at the Maudsley and King's College London (KCL); NIHR Protection Research Unit in Emergency Preparedness and Response at KCL.

Military veterans and civilians' mental health diagnoses: an analysis of secondary mental health services

PURPOSE

Healthcare provision in the United Kingdom (UK) falls primarily to the National Health Service (NHS) which is free at the point of access. In the UK, there is currently no national marker to identify military veterans in electronic health records, nor a requirement to record it. This study aimed to compare the sociodemographic characteristics and recorded mental health diagnoses of a sample of veterans and civilians accessing secondary mental health services.

METHODS

The Military Service Identification Tool, a machine learning computer tool, was employed to identify veterans and civilians from electronic health records. This study compared the sociodemographic characteristics and recorded mental health diagnoses of veterans and civilians accessing secondary mental health care from South London and Maudsley NHS Foundation Trust, UK. Data from 2,576 patients were analysed; 1288 civilians and 1288 veterans matched on age and gender.

RESULTS

Depressive disorder was the most prevalent across both groups in the sample (26.2% veterans, 15.5% civilians). The present sample of veterans accessing support for mental health conditions were significantly more likely to have diagnoses of anxiety, depressive, psychosis, personality, and stress disorders (AORs ranging 1.41-2.84) but less likely to have a drug disorder (AOR = 0.51) than age- and gender-matched civilians.

CONCLUSION

Veterans accessing secondary mental health services in South London had higher risks for many mental health problems than civilians accessing the same services. Findings suggest that military career history is a key consideration for probable prognosis and treatment, but this needs corroborating in other geographical areas including national population-based studies in the UK.

Long-term health conditions in UK working-age adults: a cross-sectional analysis of associations with demographic, socioeconomic, psychosocial and health-related factors in an inner-city population

OBJECTIVES

To study the overall disease prevalence, and associations between demographic, socioeconomic, psychosocial, and health-related factors, and self-reporting one or more long-term health conditions (LTCs) in a working-age inner-city population.

DESIGN

Cross-sectional household-based survey with a follow-up timepoint.

SETTING

South-East London Community Health survey data.

PARTICIPANTS

893 adults aged 16-64 years living in Lambeth and Southwark, London.

OUTCOME MEASURES

Prevalence estimates of individual and multiple LTCs. Multinomial logistic regression was used to analyse the association of demographic, socioeconomic, psychosocial and health-related indicators with having one and multiple LTCs at two timepoints.

RESULTS

More than one third of participants reported at least one LTC, with the most prevalent being musculoskeletal conditions and asthma. The prevalence of one LTC at both timepoints was 20.6% and 21.4%, and of multimorbidity was 14.0% and 16.4%. At both timepoints, the 35-44 age group showed the largest increase in prevalence of one LTC compared with the preceding age group (16-34). After adjusting for age and gender, small social networks and a larger number of stressful life events were associated with increased risk of having both one and multiple LTCs. The risk of multimorbidity was greater than for initial LTCs for small social networks (3.8 (95% CI: 1.8 to 7.8) compared with 2.0 (95% CI: 1.0 to 3.9)), and three to five stressful life events (3.0 (95% CI: 1.7 to 5.3) compared with 1.5 (95% CI 1.0 to 2.2)).

CONCLUSIONS

In this study, the prevalence of multimorbidity increased more than the prevalence of one LTC between the two timepoints, indicating a progression of the overall disease prevalence over time. The 35-44 age group showed the greatest increase in the number of initial LTCs which support health-promotion interventions targeting younger age groups. Focusing on increasing social support networks and treating the psychological impact of stressful life events may also be of benefit.

Capturing the experiences of UK healthcare workers during the COVID-19 pandemic: A structural topic modelling analysis of 7,412 free-text survey responses

BACKGROUND

Healthcare workers (HCWs) have provided vital services during the COVID-19 pandemic, but existing research consists of quantitative surveys (lacking in depth or context) or qualitative interviews (with limited generalisability). Structural Topic Modelling (STM) of large-scale free-text survey data offers a way of capturing the perspectives of a wide range of HCWs in their own words about their experiences of the pandemic.

METHODS

In an online survey distributed to all staff at 18 geographically dispersed NHS Trusts, we asked respondents, "Is there anything else you think we should know about your experiences of the COVID-19 pandemic?". We used STM on 7,412 responses to identify topics, and thematic analysis on the resultant topics and text excerpts.

RESULTS

We identified 33 topics, grouped into two domains, each containing four themes. Our findings emphasise: the deleterious effect of increased workloads, lack of PPE, inconsistent advice/guidance, and lack of autonomy; differing experiences of home working as negative/positive; and the benefits of supportive leadership and peers in ameliorating challenges. Themes varied by demographics and time: discussion of home working decreasing over time, while discussion of workplace challenges increased. Discussion of mental health was lowest between September-November 2020, between the first and second waves of COVID-19 in the UK.

DISCUSSION

Our findings represent the most salient experiences of HCWs through the pandemic. STM enabled statistical examination of how the qualitative themes raised differed according to participant characteristics. This relatively underutilised methodology in healthcare research can provide more nuanced, yet generalisable, evidence than that available via surveys or small interview studies, and should be used in future research.

Post-traumatic growth among UK military personnel deployed to Iraq or Afghanistan: data from phase 3 of a military cohort study

BACKGROUND

Post-traumatic growth (PTG) refers to beneficial psychological change following trauma.

AIMS

This study explores the sociodemographic, health and deployment-related factors associated with PTG in serving/ex-serving UK armed forces personnel deployed to military operations in Iraq or Afghanistan.

METHOD

Multinomial logistic regression analyses were applied to retrospective questionnaire data collected 2014-2016, stratified by gender. PTG scores were split into tertiles of no/very low PTG, low PTG and moderate/large PTG.

RESULTS

A total of 1447/4610 male personnel (30.8%) and 198/570 female personnel (34.8%) reported moderate/large PTG. Male personnel were more likely to report moderate/large PTG compared with no/very low PTG if they reported a greater belief of being in serious danger (relative risk ratio (RRR) 2.47, 95% CI 1.68-3.64), were a reservist (RRR 2.37, 95% CI 1.80-3.11), reported good/excellent general health (fair/poor general health: RRR 0.33, 95% CI 0.24-0.46), a greater number of combat experiences, less alcohol use, better mental health, were of lower rank or were younger. Female personnel were more likely to report moderate/large PTG if they were single (in a relationship: RRR 0.40, 95% CI 0.22-0.74), had left military service (RRR 2.34, 95% CI 1.31-4.17), reported better mental health (common mental disorder: RRR 0.37, 95% CI 0.17-0.84), were a reservist, reported a greater number of combat experiences or were younger. Post-traumatic stress disorder had a curvilinear relationship with PTG.

CONCLUSIONS

A moderate/large degree of PTG among the UK armed forces is associated with mostly positive health experiences, except for post-traumatic stress disorder.

Indicators of recent COVID-19 infection status: findings from a large occupational cohort of staff and postgraduate research students from a UK university

BACKGROUND

Researchers conducting cohort studies may wish to investigate the effect of episodes of COVID-19 illness on participants. A definitive diagnosis of COVID-19 is not always available, so studies have to rely on proxy indicators. This paper seeks to contribute evidence that may assist the use and interpretation of these COVID-indicators.

METHODS

We described five potential COVID-indicators: self-reported core symptoms, a symptom algorithm; self-reported suspicion of COVID-19; self-reported external results; and home antibody testing based on a 'lateral flow' antibody (IgG/IgM) test cassette. Included were staff and postgraduate research students at a large London university who volunteered for the study and were living in the UK in June 2020. Excluded were those who did not return a valid antibody test result. We provide descriptive statistics of prevalence and overlap of the five indicators.

RESULTS

Core symptoms were the most common COVID-indicator (770/1882 participants positive, 41%), followed by suspicion of COVID-19 (n = 509/1882, 27%), a positive symptom algorithm (n = 298/1882, 16%), study antibody lateral flow positive (n = 124/1882, 7%) and a positive external test result (n = 39/1882, 2%), thus a 20-fold difference between least and most common. Meeting any one indicator increased the likelihood of all others, with concordance between 65 and 94%. Report of a low suspicion of having had COVID-19 predicted a negative antibody test in 98%, but positive suspicion predicted a positive antibody test in only 20%. Those who reported previous external antibody tests were more likely to have received a positive result from the external test (24%) than the study test (15%).

CONCLUSIONS

Our results support the use of proxy indicators of past COVID-19, with the caveat that none is perfect. Differences from previous antibody studies, most significantly in lower proportions of participants positive for antibodies, may be partly due to a decline in antibody detection over time. Subsequent to our study, vaccination may have further complicated the interpretation of COVID-indicators, only strengthening the need to critically evaluate what criteria should be used to define COVID-19 cases when designing studies and interpreting study results.

Trajectories of mental health among UK university staff and postgraduate students during the pandemic

OBJECTIVES

The COVID-19 pandemic has disrupted the social and working lives of many. Past studies have highlighted worsening mental health during the pandemic, but often rely on small samples or infrequent follow-up. This study draws on fortnightly assessments from a large occupational cohort to describe differing trajectories of mental health between April 2020 and April 2021 and individual characteristics associated with these trajectory types.

METHODS

King's College London Coronavirus Health and Experiences of Colleagues at King's is an occupational cohort study at a large university in London, UK. Participants (n=2241) completed online questionnaires fortnightly between April 2020 and April 2021. Symptoms of anxiety and depression were assessed using Generalised Anxiety Disorder (GAD-7) and Patient Health Questionnaire (PHQ-9).

RESULTS

On average, participants reported low levels of anxiety and depression (GAD-7 and PHQ-9 scores of 0-9, consistent with 'none', 'minimal' or 'mild' symptoms) throughout the year, with symptoms highest in April 2020 and decreasing over the summer months when no lockdown measures were in place. However, we observed more severe and variable symptoms among subgroups of participants. Four trajectory types for anxiety and depression were identified: 'persistent high severity' (6%-7% of participants), 'varying symptoms, opposing national cases' (4%-8%), 'varying symptoms, consistent with national cases' (6%-11%) and 'persistent low severity' (74%-84%). Younger age, female gender, caring responsibilities and shielding were associated with higher severity trajectory types.

CONCLUSIONS

These data highlight differing individual responses to the pandemic and underscore the need to consider individual circumstances when assessing and treating mental health. Aggregate trends in anxiety and depression may hide greater variation and symptom severity among subgroups.

Mental health outcomes of male UK military personnel deployed to Afghanistan and the role of combat injury: analysis of baseline data from the ADVANCE cohort study

BACKGROUND

The long-term psychosocial outcomes of UK armed forces personnel who sustained serious combat injuries during deployment to Afghanistan are largely unknown. We aimed to assess rates of probable post-traumatic stress disorder (PTSD), depression, anxiety, and mental health-associated multimorbidity in a representative sample of serving and ex-serving UK military personnel with combat injuries, compared with rates in a matched sample of uninjured personnel.

METHODS

This analysis used baseline data from the ADVANCE cohort study, in which injured individuals were recruited from a sample of UK armed forces personnel who were deployed to Afghanistan and had physical combat injuries, according to records provided by the UK Ministry of Defence. Participants from the uninjured group were frequency-matched by age, rank, regiment, deployment, and role on deployment. Participants were recruited through postal, email, and telephone invitations. Participants completed a comprehensive health assessment, including physical health assessment and self-reported mental health measures (PTSD Checklist, Patient Health Questionnaire-9, and Generalised Anxiety Disorder-7). The mental health outcomes were rates of PTSD, depression, anxiety, and mental health-associated multimorbidity in the injured and uninjured groups. The ADVANCE study is ongoing and is registered with the ISRCTN registry, ISRCTN57285353.

FINDINGS

579 combat-injured participants (161 with amputation injuries and 418 with non-amputation injuries) and 565 uninjured participants were included in the analysis. Participants had a median age of 33 years (IQR 30-37 years) at the time of assessment. 90·3% identified as White and 9·7% were from all other ethnic groups. The rates of PTSD (16·9% [n=89] vs 10·5% [n=53]; adjusted odds ratio [AOR] 1·67 [95% CI 1·16-2·41], depression (23·6% [n=129] vs 16·8% [n=87]; AOR 1·46 [1·08-2·03]), anxiety (20·8% [n=111] vs 13·5% [n=71]; AOR 1·56 [1·13-2·24]) and mental health-associated multimorbidity (15·3% [n=81] vs 9·8% [n=49]; AOR 1·62 [1·12-2·49]) were greater in the injured group than the uninjured group. Minimal differences in odds of reporting any poor mental health outcome were noted between the amputation injury subgroup and the uninjured group (AOR range 0·77-0·97), whereas up to double the odds were noted for the non-amputation injury subgroup compared with the uninjured group (AOR range 1·74-2·02).

INTERPRETATION

Serious physical combat injuries were associated with poor mental health outcomes. However, the type of injury sustained influenced this relationship. Regardless of injury, this cohort represents a group who present with greater rates of PTSD than the general population, as well as increased psychological burden from multimorbidity.

FUNDING

The ADVANCE Charity.

Prevalence of at-risk drinking recognition: A systematic review and meta-analysis

BACKGROUND

There is a prominent "treatment gap" in relation to at-risk drinking (ARD), whereby a minority of at-risk drinkers ever access treatment. Research suggests that recognition of problem drinking is a necessary precursor for help-seeking and treatment.

OBJECTIVE

This systematic review and meta-analysis aimed to estimate the prevalence of ARD recognition within those meeting criteria for ARD.

METHOD

PsycINFO, Web of Science, Scopus, and MEDLINE were searched using the terms: problem* AND (recogni* OR perceive* OR perception OR self-identif*) AND alcohol - to identify studies published in English between 2000 and 2022. Studies reported the frequency (weighted or unweighted) of participants meeting ARD criteria that also directly identified ARD, perceived a need for help, or endorsed a readiness to change. The prevalence of ARD recognition was estimated using a random-effects meta-analysis with 95% confidence intervals (CIs).

RESULTS

17 studies were included which provided data for 33,349 participants with ARD. Most (n = 14) were US studies. ARD was self-identified via a single indicator in 7 studies, whereas recognition was assessed via stages of change in 4 studies and need for help in 6 studies. The pooled prevalence of ARD recognition was 31% (95% CI: 25%-36%), and subgroup analyses indicated alcohol use severity, measure of recognition, and population type to be significant sources of heterogeneity.

CONCLUSIONS

Most individuals with ARD fail to recognise their drinking problem so preventive approaches that promote recognition may be helpful. However, we must be cautious of how inconsistency in question framing affects self-reported problem recognition.

Chronic fatigue syndrome and occupational status: a retrospective longitudinal study

BACKGROUND

Few studies into chronic fatigue syndrome (CFS) have emphasized work-related consequences, including return to work after illness.

AIMS

This paper explores socio-demographic, work and clinical characteristics that are associated with occupational status among patients who were assessed at baseline and a follow-up point.

METHODS

Longitudinal data were assessed from patients affected by CFS who attended an outpatient CFS treatment service between 2007 and 2014. Employment status at baseline and follow-up was available for 316 patients. Data were also included on gender, age, duration of CFS, fatigue severity, type and number of treatment sessions, coping strategies, functional impairment, common mental disorders and physical functioning.

RESULTS

Most patients were female (73%) and had been affected by CFS for longer than 2 years (66%). Patients were followed up for an average of 285 days and over this period 53% of patients who were working remained in employment. Of the patients who were not working at baseline, 9% had returned to work at follow-up. However, of those working at baseline, 6% were unable to continue to work at follow-up. Age, fatigue severity, functional impairment, cognitive and behavioural responses, and depressive symptoms impacted on a patients' work status at follow-up.

CONCLUSIONS

The findings indicated that it is possible for people with CFS to remain in work or return to work, despite having had a disabling illness. Work-related outcomes should be targeted in all people of working age.

Multimorbidity and fit note receipt in working-age adults with long-term health conditions

BACKGROUND

Research on sickness absence has typically focussed on single diagnoses, despite increasing recognition that long-term health conditions are highly multimorbid and clusters comprising coexisting mental and physical conditions are associated with poorer clinical and functional outcomes. The digitisation of sickness certification in the UK offers an opportunity to address sickness absence in a large primary care population.

METHODS

Lambeth Datanet is a primary care database which collects individual-level data on general practitioner consultations, prescriptions, Quality and Outcomes Framework diagnostic data, sickness certification (fit note receipt) and demographic information (including age, gender, self-identified ethnicity, and truncated postcode). We analysed 326 415 people's records covering a 40-month period from January 2014 to April 2017.

RESULTS

We found significant variation in multimorbidity by demographic variables, most notably by self-defined ethnicity. Multimorbid health conditions were associated with increased fit note receipt. Comorbid depression had the largest impact on first fit note receipt, more than any other comorbid diagnoses. Highest rates of first fit note receipt after adjustment for demographics were for comorbid epilepsy and rheumatoid arthritis (HR 4.69; 95% CI 1.73-12.68), followed by epilepsy and depression (HR 4.19; 95% CI 3.60-4.87), chronic pain and depression (HR 4.14; 95% CI 3.69-4.65), cardiac condition and depression (HR 4.08; 95% CI 3.36-4.95).

CONCLUSIONS

Our results show striking variation in multimorbid conditions by gender, deprivation and ethnicity, and highlight the importance of multimorbidity, in particular comorbid depression, as a leading cause of disability among working-age adults.

Mental health among UK university staff and postgraduate students in the early stages of the COVID-19 pandemic

OBJECTIVES

To characterise the baseline King's College London Coronavirus Health and Experiences of Colleagues at King's cohort and describe patterns of probable depression and anxiety among staff and postgraduate research students at a large UK university in April/May 2020.

METHODS

An online survey was sent to current staff and postgraduate research students via email in April 2020 (n=2590). Primary outcomes were probable depression and anxiety, measured with the Patient Health Questionnaire-9 and Generalised Anxiety Disorder-7, respectively. Secondary outcomes were alcohol use and perceived change in mental health. Outcomes were described using summary statistics and multivariable Poisson regression was used to explore associations with six groups of predictors: demographics and prior mental health, living arrangements, caring roles, healthcare, occupational factors and COVID-19 infection. All analyses were weighted to account for differences between the sample and target population in terms of age, gender, and ethnicity.

RESULTS

Around 20% of staff members and 30% of postgraduate research students met thresholds for probable depression or anxiety on the questionnaires. This doubled to around 40% among younger respondents aged <25. Other factors associated with probable depression and anxiety included female gender, belonging to an ethnic minority group, caregiving responsibilities and shielding or isolating. Around 20% of participants were found to reach cut-off for hazardous drinking on Alcohol Use Disorders Identification Test, while 30% were drinking more than before the pandemic.

CONCLUSIONS

Our study shows worrying levels of symptoms of depression, anxiety and alcohol use disorder in an occupational sample from a large UK university in the months following the outbreak of the COVID-19 pandemic.

'It hurts your heart': frontline healthcare worker experiences of moral injury during the COVID-19 pandemic

Background: Moral injury is defined as the strong emotional and cognitive reactions following events which clash with someone's moral code, values or expectations. During the COVID-19 pandemic, increased exposure to Potentially Morally Injurious Events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this. Objective: We sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19. Methods: We recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) [Nash et al., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine, 178(6), 646-652] at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis. Results: HCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients. Conclusion: These results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement. HIGHLIGHTS Clinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patients.HCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbance.Most HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress.

Psychosocial impact of the COVID-19 pandemic on 4378 UK healthcare workers and ancillary staff: initial baseline data from a cohort study collected during the first wave of the pandemic

OBJECTIVES

This study reports preliminary findings on the prevalence of, and factors associated with, mental health and well-being outcomes of healthcare workers during the early months (April-June) of the COVID-19 pandemic in the UK.

METHODS

Preliminary cross-sectional data were analysed from a cohort study (n=4378). Clinical and non-clinical staff of three London-based NHS Trusts, including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire. Secondary outcomes are probable anxiety (seven-item Generalised Anxiety Disorder), depression (nine-item Patient Health Questionnaire), post-traumatic stress disorder (PTSD) (six-item Post-Traumatic Stress Disorder checklist), suicidal ideation (Clinical Interview Schedule) and alcohol use (Alcohol Use Disorder Identification Test). Moral injury is measured using the Moray Injury Event Scale.

RESULTS

Analyses showed substantial levels of probable CMDs (58.9%, 95% CI 58.1 to 60.8) and of PTSD (30.2%, 95% CI 28.1 to 32.5) with lower levels of depression (27.3%, 95% CI 25.3 to 29.4), anxiety (23.2%, 95% CI 21.3 to 25.3) and alcohol misuse (10.5%, 95% CI 9.2 to 11.9). Women, younger staff and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one's moral code) was strongly associated with increased levels of probable CMDs, anxiety, depression, PTSD symptoms and alcohol misuse.

CONCLUSIONS

Our findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic.

The impact of moral injury on the wellbeing of UK military veterans

BACKGROUND

Experiences of potentially morally injurious events (PMIEs) have been found to negatively impact the mental health of US personnel/veterans, yet little is known about the effect of PMIEs on the mental health of the UK Armed Forces (AF). This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of UK AF veterans.

METHOD

Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an online questionnaire to 204 UK veterans. Subjects were classified as having experienced a morally injurious event (n = 66), a non-morally injurious traumatic event (n = 57), a 'mixed' event (n = 31), or no event (n = 50).

RESULTS

Potentially morally injurious experiences were associated with adverse mental health outcomes, including likely anxiety disorders and suicidal ideation, compared to those who reported no event exposure. The likelihood of meeting criteria for probable PTSD was greatest in those who had experienced a non-morally injurious trauma. No statistically significant association between alcohol misuse and experiencing a PMIE or traumatic event was observed.

CONCLUSIONS

The results provide preliminary evidence that potentially morally injurious experiences are associated with adverse mental health outcomes in UK AF veterans. Further work is needed to better understand the interplay between morally injurious events and threat-based trauma in order to design effective pathways for prevention and intervention for people exposed to highly challenging events.

Probable post-traumatic stress disorder and harmful alcohol use among male members of the British Police Forces and the British Armed Forces: a comparative study

Background: British Armed Forces' and Police Forces' personnel are trained to operate in potentially traumatic conditions. Consequently, they may experience post-traumatic stress disorder (PTSD), which is often comorbid with harmful alcohol use. Objective: We aimed to assess the proportions, and associations, of probable PTSD and harmful alcohol use among a covariate-balanced sample of male military personnel and police employees. Methods: Proportions of probable PTSD, harmful alcohol use, and daily binge drinking, were explored using data from the police Airwave Health Monitoring Study (2007-2015) (N = 23,826) and the military Health and Wellbeing Cohort Study (phase 2: 2007-2009, phase 3: 2014-2016) (N = 7,399). Entropy balancing weights were applied to the larger police sample to make them comparable to the military sample on a range of pre-specified variables (i.e. year of data collection, age and education attainment). Multinomial and logistic regression analyses determined sample differences in outcome variables, and associated factors (stratified by sample). Results: Proportions of probable PTSD were similar in military personnel and police employees (3.67% vs 3.95%), although the large sample size made these borderline significant (Adjusted Odds Ratio (AOR): 0.84; 95% Confidence Intervals (CI): 0.72 to 0.99). Clear differences were found in harmful alcohol use among military personnel, compared to police employees (9.59% vs 2.87%; AOR: 2.79; 95% CI: 2.42 to 3.21). Current smoking, which was more prevalent in military personnel, was associated with harmful drinking and binge drinking in both samples but was associated with PTSD in military personnel only. Conclusions: It is generally assumed that both groups have high rates of PTSD from traumatic exposures, however, low proportions of PTSD were observed in both samples, possibly reflecting protective effects of unit cohesion or resilience. The higher level of harmful drinking in military personnel may relate to more prominent drinking cultures or unique operational experiences.

Probable PTSD, depression and anxiety in 40,299 UK police officers and staff: Prevalence, risk factors and associations with blood pressure

INTRODUCTION

Police employees undertake challenging duties which may adversely impact their health. This study explored the prevalence of and risk factors for probable mental disorders amongst a representative sample of UK police employees. The association between mental illness and alterations in blood pressure was also explored.

METHODS

Data were used from the Airwave Health Monitoring Study which was established to monitor the possible physical health impacts of a new communication system on police employees. Data included sociodemographic characteristics, lifestyle habits, depression, anxiety, and post-traumatic stress disorder (PTSD) symptoms and blood pressure. Descriptive statistics were used to explore the prevalence of probable mental disorders and associated factors. Stepwise linear regression was conducted, controlling for confounding variables, to examine associations between mental disorders and blood pressure.

RESULTS

The sample included 40,299 police staff, police constable/sergeants and inspectors or above. Probable depression was most frequently reported (9.8%), followed by anxiety (8.5%) and PTSD (3.9%). Groups at risk for probable mental disorders included police staff, and police employees who reported drinking heavily. Police employees exposed to traumatic incidents in the past six months had a doubling in rates of anxiety or depression and a six-fold increase in PTSD compared to those with no recent trauma exposure. Adjusted logistic regression models did not reveal any significant association between probable mental disorders and systolic blood pressure but significantly elevated diastolic blood pressure (≈1mmHg) was found across mental disorders.

CONCLUSIONS

These results show lower rates of probable mental disorders, especially PTSD, than reported in other studies focusing on police employees. Although mental ill health was associated with increased diastolic blood pressure, this was unlikely to be clinically significant. These findings highlight the importance of continued health monitoring of members of the UK police forces, focusing on employees recently exposed to traumatic incidents, heavy drinkers and police staff.

The mental health of emergency services personnel in the UK Biobank: a comparison with the working population

Background: There is evidence that mental disorders are more frequently reported among emergency services personnel due to the stressful nature of the job in combination with a high exposure to traumatic events. However, most of this research is based on occupational surveys that may lead to a contextual bias in the prevalence estimates or lack an adequate comparison group. Objectives: To investigate mental health outcomes and associations with individual, job and trauma related characteristics among emergency services personnel compared to other workers. Method: Participants were identified from the UK Biobank, a large study that collected a variety of genetic, physical and health data on individuals from across the UK. UK Biobank participants were aged between 40-69 years at recruitment. Those employed in the emergency services were identified based on job titles. A comparison sample of other workers was selected and matched to the gender composition of emergency services personnel. Results: 5052 participants were included, and 842 were currently working in the emergency services. The majority were male (77.4%) and the mean age at Biobank enrolment was 52.5 years. Alcohol misuse was reported in 32.8% of emergency services personnel compared to 29.2% in non-emergency services personnel, followed by PTSD (9.2% vs 6.0%), depression (6.8% vs 5.1%) and anxiety (3.9% vs 3.6%). An increased risk of PTSD was found among emergency services personnel compared to other workers (odds ratio 1.58, 95% confidence interval 1.21-2.06), but this association was no longer significant after adjustment for exposure to traumatic events and job characteristics. Conclusions: The substantial levels of alcohol misuse and increased risk of PTSD, possibly as a result of traumatic exposures in the line of duty in combination with job stressors such as shift work, call for continued monitoring of the health and wellbeing of emergency services personnel.

Confidentiality and psychological treatment of moral injury: the elephant in the room

Morally injurious incidents may present ethical or legal quandaries, yet how military or civilian clinicians should manage such disclosures is poorly understood. Individuals who experience moral injury may be reluctant to seek help due to concerns about the legal ramifications of disclosure. Guidance on breaching patient confidentiality differs by regulatory body but also by profession, geography and context. As moral injury continues to become recognised in clinical practice, in the military and elsewhere, clarity is needed regarding best practice in managing moral injury cases and the dilemmas they present.

The Development of the Military Service Identification Tool: Identifying Military Veterans in a Clinical Research Database Using Natural Language Processing and Machine Learning

Background

Electronic health care records (EHRs) are a rich source of health-related information, with potential for secondary research use. In the United Kingdom, there is no national marker for identifying those who have previously served in the Armed Forces, making analysis of the health and well-being of veterans using EHRs difficult.

Objective

This study aimed to develop a tool to identify veterans from free-text clinical documents recorded in a psychiatric EHR database.

Methods

Veterans were manually identified using the South London and Maudsley (SLaM) Biomedical Research Centre Clinical Record Interactive Search—a database holding secondary mental health care electronic records for the SLaM National Health Service Foundation Trust. An iterative approach was taken; first, a structured query language (SQL) method was developed, which was then refined using natural language processing and machine learning to create the Military Service Identification Tool (MSIT) to identify if a patient was a civilian or veteran. Performance, defined as correct classification of veterans compared with incorrect classification, was measured using positive predictive value, negative predictive value, sensitivity, F1 score, and accuracy (otherwise termed Youden Index).

Results

A gold standard dataset of 6672 free-text clinical documents was manually annotated by human coders. Of these documents, 66.00% (4470/6672) were then used to train the SQL and MSIT approaches and 34.00% (2202/6672) were used for testing the approaches. To develop the MSIT, an iterative 2-stage approach was undertaken. In the first stage, an SQL method was developed to identify veterans using a keyword rule–based approach. This approach obtained an accuracy of 0.93 in correctly predicting civilians and veterans, a positive predictive value of 0.81, a sensitivity of 0.75, and a negative predictive value of 0.95. This method informed the second stage, which was the development of the MSIT using machine learning, which, when tested, obtained an accuracy of 0.97, a positive predictive value of 0.90, a sensitivity of 0.91, and a negative predictive value of 0.98.

Conclusions

The MSIT has the potential to be used in identifying veterans in the United Kingdom from free-text clinical documents, providing new and unique insights into the health and well-being of this population and their use of mental health care services.

Demographic variation in fit note receipt and long-term conditions in south London

Objectives

Introduced in the UK in 2010, the fit note was designed to address the problem of long-term sickness absence. We explored (1) associations between demographic variables and fit note receipt, ‘maybe fit’ use and long-term conditions, (2) whether individuals with long-term conditions receive more fit notes and are more likely to have the ‘maybe fit’ option selected and (3) whether long-term conditions explained associations between demographic variables and fit note receipt.

Methods

Data were extracted from Lambeth DataNet, a database containing electronic medical records of all 45 general practitioner (GP) practices within the borough of Lambeth. Individual-level anonymised data on GP consultations, prescriptions, Quality and Outcomes Framework diagnostic data and demographic information were analysed using survival analysis.

Results

In a sample of 326 415 people, 41 502 (12.7%) received a fit note. We found substantial differences in fit note receipt by gender, age, ethnicity and area-level deprivation. Chronic pain (HR 3.7 (95% CI 3.3 to 4.0)) and depression (HR 3.4 (95% CI 3.3 to 3.6)) had the highest rates for first fit note receipt. ‘Maybe fit’ recommendations were used least often in patients with epilepsy and serious mental illness. The presence of long-term conditions did not explain associations between demographic variables and fit note use.

Conclusions

For the first time, we show the relationships between fit note use and long-term conditions using individual-level primary care data from south London. Further research is required in order to evaluate this relatively new policy and to understand the needs of the population it was designed to support.

The journey to professional mental health support: a qualitative exploration of the barriers and facilitators impacting military veterans' engagement with mental health treatment

Background: It is often claimed that military veterans are reticent to seek help for mental disorders, even though delayed treatment may impair recovery and impact the wellbeing of those close to the veteran. Objective: This paper aims to explore the barriers and facilitators to accessing professional mental health support for three groups of veterans who met criteria for a probable mental health disorder and: (1) do not recognize a probable mental disorder; (2) recognize they are affected by a mental disorder but are not seeking professional support; or (3) are currently seeking professional mental health support. Method: Qualitative telephone interviews were conducted with 62 UK military veterans. Thematic analysis identified core themes along an illustrative journey towards professional mental health support. Results: Distinct barriers and facilitators to care were discussed by each group of veterans depicting changes as veterans moved towards accessing professional mental health support. In contrast to much of the literature, stigma was not a commonly reported barrier to care; instead care-seeking decisions centred on a perceived need for treatment, waiting until a crisis event occurred. Whilst the recognition of treatment need represented a pivotal moment, our data identified numerous key steps which had to be surmounted prior to care-seeking. Conclusion: As care-seeking decisions within this sample appeared to centre on a perceived need for treatment future efforts designed to encourage help-seeking in UK military veterans may be best spent targeting the early identification and management of mental health disorders to encourage veterans to seek support before reaching a crisis event.

The impact of trauma exposure and moral injury on UK military veterans: a qualitative study

Background: Exposure to a potentially morally injurious event (PMIE) has been found to be associated with a range of adverse mental health outcomes. However, how the psychological consequences following PMIEs compare to those encountered after a traumatic, but not a PMIE, remain poorly understood. Objective: The aim was to qualitatively explore UK military veterans' responses to experiences of trauma and moral injury and the impact of such events on psychological wellbeing. Method: Thirty male veterans who reported exposure to traumatic and/or morally injurious events were recruited. Semi-structured qualitative interviews were conducted, and data were analysed using thematic analysis. Results: Six veterans described exposure to a non-morally injurious traumatic event, 15 reported experiencing a PMIE, and 9 described exposure to a 'mixed' event which was simultaneously morally injurious and traumatic. Veterans who encountered a PMIE described experiencing moral dissonance, or a clash between concurrently held sets of values (e.g. military values versus civilian values), which provoked considerable psychological distress. Veterans' cognitions and responses were found to differ following a PMIE compared to a traumatic, but not PMIE, which could have negative implications for daily functioning. Several risk and protective factors for experiencing distress following a PMIE were described. Conclusions: This study provides some of the first evidence that events experienced by UK veterans can simultaneously be morally injurious and traumatic or life-threatening as well as highlighting the process by which moral injury may occur in UK veterans. These findings illustrate the need to examine effective pathways for prevention and intervention for veterans who have experienced a morally injurious event.

Pre-service Military-related and Mental Disorder Factors Associated with Leaving the UK Armed Forces

Background: The UK Armed Forces (UKAF) have a substantial manning deficit as more personnel leave than join. This article identified pre-service, military, and mental health factors giving rise to leaving the UKAF and estimated the contributions to leaving of those factors which are potentially amenable to modification. Methods: This study utilized data from a three-phase cohort study (2004-2006, 2007-2009 and 2014-2016), commencing while respondents were serving in the UKAF (n = 10,836; 6,046 (55.8%) had left service). Associations between leaving the services and socio-demographics, military career and experiences, and mental health were determined using Cox regression. Contribution to leaving was based on population attributable fractions (PAF) from Cox regression. Analyses were stratified by rank due to the different career structures of Commissioned Officers and enlisted personnel. Results: Leaving the UKAF was associated with joining when older, being a woman with a child/children, Army service, combat role, lower education level, and poor mental health. Factors contributing a significant proportion of leaving among enlisted personnel were joining over the age of 17, history of externalizing behavior, being female, common mental disorders, and alcohol misuse. Among Commissioned Officers only age at joining and sex contributed significant proportions to leaving. Conclusions: The key factors for leaving are education and higher age at recruitment. These are not amenable to intervention, for policy, equity, and legal reasons. Heavy drinking and common mental disorder symptoms may be more amenable to modification and hence reduce rates of leaving the UKAF. Women are more likely to leave due to childbearing.

Suicidal Ideation, Suicidal Attempts, and Self-Harm in the UK Armed Forces

INTRODUCTION

In the UK military, suicide is infrequent and studies of self-harm behavior in this population are rare.

OBJECTIVES

To compare lifetime self-harm rates estimated on three occasions between 2004 and 2016 and to explore the associates of lifetime self-harm.

METHOD

Three phases of a UK AF cohort study (n = 10,272, 9,990, and 8,581, respectively) provided data. Telephone interviews assessed associates of self-harm among cohort members who reported subjective mental health problems in the past 3 years (n = 1,448). Validated measures of mental health and related stigmatization, social support, and help-seeking were obtained.

RESULTS

Lifetime self-harm increased significantly (p < .001) from 1.8% among serving personnel and 3.8% among veterans in 2004/06 to 1.9% and 4.5% in 2007/09 and to 4.2% and 6.6% in 2014/16 in the two groups, respectively. Veterans were consistently significantly more likely to report lifetime self-harm than serving personnel. Significant determinants of lifetime self-harm included current mental disorder symptoms, stigmatization, poor social support, suicidal ideation, and seeking help from formal medical sources.

CONCLUSION

Self-harm has increased over time in the UK serving and veteran community. Suicide prevention should focus on ameliorating mental disorder by encouraging engagement with health care, reducing negative views of mental illness, and fostering social support.

Perceived stigma and barriers to care in UK Armed Forces personnel and veterans with and without probable mental disorders

Background

Previous studies have found that perceptions of mental health related stigma can negatively impact help-seeking, particularly in military samples. Moreover, perceptions of stigma and barriers to care can vary between individuals with different psychiatric disorders. The aim of this study was to examine whether perceptions of stigma and barriers to care differed in a UK military sample between those with and without a current likely mental health diagnosis.

Method

Structured telephone interviews were carried out with 1432 service personnel and veterans who reported recent subjective mental ill health in the last 3 years. Participants completed self-reported measures relating to perceived stigma, barriers to care and psychological wellbeing.

Results

Those meeting criteria for probable common mental disorders (CMD) and PTSD were significantly more likely to report concerns relating to perceived and internalised stigma and barriers to care compared to participants without a likely mental disorder. Compared to individuals with likely CMD and alcohol misuse, those with probable PTSD reported higher levels of stigma-related concerns and barriers to care – although this difference was not significantly different.

Conclusions

These results indicate that perceptions of stigma continue to exist in UK serving personnel and military veterans with current probable mental disorders. Efforts to address particular concerns (e.g. being seen as weak; difficulty accessing appointments) may be worthwhile and, ultimately, lead to improvements in military personnel and veteran wellbeing.

Health consequences of bullying in the healthcare workplace: A systematic review

AIMS

To review both mental and physical health consequences of bullying for healthcare employees.

DESIGN

Systematic literature review.

DATA SOURCES

EMBASE, MEDLINE, PsycINFO, PUBMED and Web of Science Core Collection were searched for articles published between 2005 - January 2017.

REVIEW METHODS

This review was conducted using the framework described by Khan and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two independent reviewers performed systematic data extraction and appraised the methodological quality of included articles. A pooled mean prevalence of bullying was estimated.

RESULTS

Forty-five papers met inclusion criteria. Bullying prevalence ranged from 3.9% to 86.5%, with a pooled mean estimate of 26.3%. Perceived bullying was associated with mental health problems including psychological distress, depression and burnout, and physical health problems including insomnia and headache. Bullied staff took more sick leave.

CONCLUSION

Bullying occurs frequently amongst healthcare staff and is deleterious to health and occupational functionality.

Factors associated with work status in chronic fatigue syndrome

BACKGROUND

Work status in people with chronic fatigue syndrome (CFS) has not been extensively researched.

AIMS

To explore occupational outcomes in patients with CFS by socio-demographic, well-being and disease characteristics.

METHODS

We assessed cross-sectional data from patients attending a UK specialist CFS treatment service between 1 January 2007 and 31 December 2014. The main outcome was self-reported current employment status: currently in employment, temporarily interrupted employment or permanently interrupted employment. Other variables included sex, age, ethnicity, education, marital status, CFS duration, fatigue severity, anxiety, depression, activity limitations and functional impairment. We used multinominal logistic regression models to identify factors associated with current work status.

RESULTS

Two hundred and seventy-nine (55%) patients were currently working, with 83 (16%) reporting temporarily interrupted employment and 146 (29%) stopping work altogether. Factors strongly associated with permanently interrupted employment were older age (adjusted odds ratio (AOR) 5.24; 95% CI 2.67-10.28), poorer functioning (AOR 6.41; 95% CI 3.65-11.24) and depressive symptoms (AOR 2.89; 95% CI 1.82-4.58) compared to patients currently working. Higher educated patients (AOR 0.60; 95% CI 0.37-0.97) and being in a relationship (AOR 0.34; 95% CI 0.21-0.54) were associated with being currently employed. Anxiety symptoms were common; 230 patients (45%) met caseness criteria.

CONCLUSIONS

Many patients with CFS were not working. This was exacerbated by high levels of depressive symptoms. Health professionals should assess co-morbid mental health conditions and consider treatment options when patients with CFS present themselves. The early involvement of occupational health practitioners is recommended to maximize the chances of maintaining employment.

The impact of military service on the mental health of older UK veterans: A qualitative study

BACKGROUND

There may be ongoing psychological problems associated with military service later in life; yet as the elderly in the general population also suffer from mental health problems, whether such issues can be attributed to military service or are a feature of ageing remains unclear. This study aimed to explore veteran and nonveteran perceptions of the impact of their occupation on their psychological well-being later in life.

METHODS

Twenty-five veterans (≥65 y); 25 nonveterans (≥65 y); 10 veterans with diagnoses of mental health issues (≥65 y); and a close companion of all participants (≥18 y, spouse, child, and close friend) were recruited. Using a qualitative approach, participants completed semistructured qualitative interviews with measures of psychological adjustment used to describe the sample.

RESULTS

Veterans were found to experience higher levels of workplace stress and trauma exposure compared with nonveterans. When such challenges were positively appraised, veterans described increased confidence and resilience. Social support in response to occupational stress was central to veteran and nonveteran well-being, especially for those with mental health problems. Nonetheless, providing support was challenging for close companions, with many feeling overwhelmed and requiring additional guidance from the veteran's clinical care team.

CONCLUSIONS

The findings delineate the impact of occupation on the well-being of older veterans and nonveterans. The results illustrated the psychological support needs and formal guidance desired by veterans, nonveterans, and their families, which could ultimately improve coping of both the individual and family.

Impact of military service on physical health later in life: a qualitative study of geriatric UK veterans and non-veterans

OBJECTIVES

Military veterans often experience physical health problems in later life; however, it remains unclear whether these problems are due to military service or are a feature of the ageing process. This study aimed to explore veteran and non-veteran perceptions of the impact of their occupation on their physical well-being later in life.

DESIGN

Semi-structured qualitative interviews analysed using thematic analysis.

SETTING

Interviews were conducted face-to-face in participants' homes or via telephone.

PARTICIPANTS

35 veterans (≥65 years), 25 non-veterans (≥65 years) were recruited, as well as a close companion of all participants for triangulation (n=60).

RESULTS

Most veterans reported good physical health later in life which they attributed to the fitness they developed during military service. However, several veterans described challenges in maintaining their desired level of physically activity due to new commitments and limited sports facilities when they left service. Fewer non-veterans had experienced work-related fitness activities or exercise in their civilian jobs. Ongoing physical health difficulties, such as deafness, were perceived to be due to exposure to workplace hazards and appeared more common in veterans compared with non-veterans. Veterans also described greater reluctance than non-veterans to seek medical treatment for physical health difficulties, which could be challenging for close companions who had to provide informal care.

CONCLUSIONS

Military service was largely perceived to be beneficial for physical well-being; although when occupation-related physical health problems were experienced, many veterans were unwilling to seek treatment. These findings may inform clinicians of the needs of older veterans and highlight potential barriers to care.