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CRITICAL APPRAISAL
- ABRAHAM P. GEORGE, Paula Whittaker, Ed Pilling (4 August 2007)
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Is there a different peak for PTSD in armed forces reserves?
- Jude N Chukwuma (4 August 2007)
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Who needs Wars?
- David Richard Musa (24 September 2007)
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What about those who do not want to take part in research?
- Jelena Jankovic (26 September 2007)
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One year in a war zone is enough
- Anthony P Hall (28 September 2007)
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Mental health consequences of overstretch – what about hospital emergency departments?
- Martin Wiese (7 October 2007)
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ABRAHAM P. GEORGE, SpR Public Health Greater Manchester Health Protection Unit, Peel House, Eccles, Manchester M30 0NJ, Paula Whittaker, Ed Pilling
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We congratulate the authors in undertaking this difficult but important study. The results suggest a link between developing post- traumatic stress disorder and deployments of over 12 months or deployments that last longer than expected. This has major implications for the organisation of armed forces in long-term operations such as Iraq. These results support the need for deployments to fall within the harmony guidelines. Though this evidence may be used to support compensation claims for service personnel who have served longer postings, this should also prompt the armed services to invest in their counselling, support and psychiatric services. However, we would also like to raise a number of methodological issues: · In the Methods section, the authors stated a total 10,272 personnel (4722 deployed plus 5550 non deployed personnel) followed by sample of 5547 regulars. However, the results section states “ Overall 5547 (63.9%) out of 8686 regulars who completed the questionnaire had participated in at least one deployment in the past 3 years.” A flow chart describing the recruitment process of the study participants would have helped explain the inclusion, exclusion and response rate details. · No mention was made how the authors calculated the expected sample size of the study. · Considering that only two of the outcomes measured showed a marginal association with operational tempo, could it have been possible that sample size was found to be inadequate even though the overall response rate was good? · Under the Discussion section, the authors state that information bias is unlikely because the outcome measurements were objective. This in incorrect because self reported responses are subjective measures. Taken ethical, confidentiality and financial issues into consideration, if the medical records of the study participants were also available, outcome ascertainment and measurement could have more objective, and survival analysis could have been used to yield more accurate results. Competing interests: None declared |
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Jude N Chukwuma, Honorary Clinical Research Fellow School of Medicine, University of Wales, Singleton Park, Swansea SA2 8PP
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Deployment is an essential ingredient of military life, is considered a valuable feature of a military career, and for many is the reason for joining up.1 There is significant evidence to support the association between combat experience and mental health conditions particularly PTSD. The current study has introduced some equally significant new knowledge. The study population was substantial and the methodology was robust, the findings should therefore be taken very seriously. However, the exclusion of 953 reserves with deployment experience just because their deployments in the past 3 years were noticeably shorter than those in the regular services amounts to the exclusion of a potentially important study population. It might be that the reserve population would have a different peak for development of the identified mental health conditions; Given that most reserves have different primary occupations and may have different reasons for enrolling in the armed forces compared to regular service personnel, a different peak may be associated with the reasons for enrollment in the armed forces. This might have implications for recruitment protocol. 1. Rona R J, Fear N T, Hull L, Greenberg N, Earnshaw M, Hotopf M, and Wessely S Mental health consequences of overstretch in the UK armed forces: first phase of a cohort study BMJ 2007; Competing interests: None declared |
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David Richard Musa, Specialist Training Registrar. Barnet ,Enfield &Harringey NHS mental health Trust,St Anns Hospital, London N15 3TH
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What I find difficult to comprehend is how we self inflict catastrophies and then come around to marvel at the impact these have upon us.Far from it, I am not trying to belittle the superb research carried out by Rona et al. It is one thing to say ‘’war develops as a result of seemingly unaviodable circumstances emerging within a specific social context’’ but then, we are much the wiser as a result of the seemingly unaviodable circumstances of recent wars!
There are other factors which are equally important in terms of the impact combat actions have on the mental state of soldiers;as we know,the magnitude of the assault ,rather than the length of the duration, can play an important role in the post event mental state of the individual involved:a soldier who was caught up in a roadside bomb and escaped with minor injuries but, at the same time, whose colleagues were blown into smithereens, would have a more enduring mental impact not least in the form of flashbacks.It is also known that there is a genetic personality template in terms of vulnerability as evidenced by the twin studies carried out on the Vietnam veterans. When we are talking of multiple redeployments even of soldiers who have recently finished a tour of campaign because the armed forces are overstretched, how do we marry that with the "avoidance of cues that remind the sufferers of the original trauma"? The last point I would like to draw our attention to is that, the effect military conflicts have is not only on the soldiers but, on the civilians in the community and this manifests not only psychological but, financial and social ramifications that transcend beyond the present. 1.Rona et al Mental health consequences of overstretch in the UK armed forces:first phase of a cohort study BMJ 2007;335:603-7 2.Ursano et al Mental illness in deployed soldiers BMJ 2007;335:571-2 3.ICD-10 .1992 C .WHO 147-9 4.Gelder et al ,Oxford core texts of psychiatry 2nd edition 93-4 Competing interests: None declared |
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Jelena Jankovic, Speciality Registrar ST4 in General Adult Psychiatry St Michael's Hospital, Warwick, CV34 5QW
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Rona et al. study provides valuable results about correlation between duration of deployment and mental health consequences. Association of posttraumatic stress disorder and a mismatch between expectations about the duration of deployment and reality is particularly interesting. It has been hypothesised that uncontrollable and unpredictable aversive events may be more ‘traumatogenic’, and experiencing a mismatch between expectations and reality of the duration of deployment may have those characteristics. Number of previous studies on trauma-related mental health consequences had difficulties in obtaining a random sample with high response rate. Therefore a response rate in this sample (approx. 60%) is very acceptable. However it is still important to acknowledge that a significant number of military personnel who were randomised did not participate in the research as some of the studies show that those individuals who did not want to take part in the research can have higher avoidance symptoms (Schwartz and Kowalski, 1992). If possible (practically and ethically) it would be interesting to know whether the group who did not take part in the research was significantly different from the one who did in terms of type of deployment and socioeconomic characteristics. 1. Rona, J.R. et al. (2007). Mental health consequences of overstretch in the UK armed forces: first phase of a cohort study. British Medical Journal, 335, 603-607. 2. Schwarz, E.D., & Kowalski, J.M. (1992) Malignant memories: Reluctance to utilize mental health services after a disaster. Journal of Nervous and Mental Disease, 180, 767 -772. j.jankovic@qmul.ac.uk Competing interests: Author is actively involved in a multicentre study on posttraumatic stress following war and migration in the Balkans |
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Anthony P Hall, retired Consultant in Tropical Medicine and Infectious Diseases 5 Manland Avenue, Harpenden, Herts. AL5 4RE
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Sir, Rona and colleagues found that troops deployed for more than 12 months in a war zone were more likely to have mental problems(1). I agree because I served as a physician in the US Army in Vietnam for one year (1969-70). Like most troops, I was drafted and the maximum assignment was one year. We could have volunteered for further years, but very few did. I was the Chief Physician at a 1000 bed hospital and heard of troops who volunteered for a second year and were then killed. Obviously, the longer troops spend in a war zone, the more likely they are to be killed or injured. I realize that the current British and American troops are volunteers, but the Americans have also found an increase in mental health problems in relation to the length of duty(2). So, I advise both governments to limit mandatory assignments to a war zone to one year. This would mean that we would need to withdraw from Iraq and Afghanistan which would probably be wise anyway. Yours faithfully, Dr. Tony Hall References (1) Rona, RJ, Fear NT, Hull l, Greenberg N, Earnshaw M, Hotopf M, et al. Mental health consequences of overstretch in the UK armed forces: first phase of a cohort study. BMJ 2007 doi:10. 1136/bmj.39274.585752.BE. (2) Mental Health Advisory Team IV. Operation Iraqi freedom. 2007. Final Report. www.armymedicine.army.mil/news.mhat/mhat_iv/mhat-iv.cfm
Competing interests: None declared |
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Martin Wiese, Consultant in emergency medicine Leicester Royal Infirmary, LE1 5WW
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Rona and colleagues have suggested that a relationship might exist between the incidence of mental health problems in UK armed forces and the duration of their deployment. [1] These findings might well be relevant to non-military settings in which employees are exposed to the stress of working under emergency conditions for prolonged periods of time. Hospital emergency departments (EDs) are likely to be one of them. The presence of high levels of psychological distress among ED consultants compared with other groups of doctors has previously been recognized. [2] Several factors have probably led to further increases of stress in health care professionals working in these units. Emergency departments have to comply with government targets introduced under the NHS plan to complete patient management within 4 hours. The recent Wanless review of NHS funding and performance has highlighted that ED attendances across the board have risen by more than 37% between 2002 and 2005, a trend that is still continuing. The report postulates that this has been due to the combined effects of reduced waiting times in emergency departments and the opt-out of general practitioners from out-of-hours care provision. [3] While most trusts have initially invested in increased staff and improved facilities in order to meet the 4-hour target, funding has in many places not kept up with the ever-increasing patient numbers. The resulting pressure on staff to deal with the rising workload has been compounded by the EWTD controls on junior doctors’ working hours and, most recently, by the changes to postgraduate training under the umbrella of ‘Modernising Medical Careers’. ED staff in the UK therefore routinely find themselves to be not only dealing with emergency conditions but working under emergency conditions. The same mental health consequences affecting consultants are likely to be present in nursing staff and higher emergency medicine trainees similarly exposed to the stress of ‘prolonged deployment’ in the ED. More junior doctors working in emergency departments, such as those in their second foundation year (FY2) or first two specialist training years (ST1 and 2) might be relatively protected thanks to the shorter duration of their ‘exposure’. Further research providing the evidence base for strategies to improve the working lives of health care professionals dedicated to the delivery of front line emergency hospital care is urgently required. References 1. Rona RJ, Fear NT, Hull L et al. Mental health consequences of overstretch in the UK armed forces: first phase of a cohort study. BMJ 2007;335:603. 2. Burbeck R, Coomber S, Robinson SM et al. Occupational stress in consultants in accident and emergency medicine: a national survey of levels of stress at work. EMJ 2002;19:234. http://emj.bmj.com/cgi/content/abstract/19/3/234 3. Wanless D, Appleby J, Harrison A, Patel D. Our future health secured? London: King's Fund, 2007. www.kingsfund.org.uk/publications/kings_fund_publications/our_future.html Competing interests: None declared |
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