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

BMJ 2006; 333 doi: (Published 09 November 2006) Cite this as: BMJ 2006;333:991
  1. Roberto J Rona, professor of public health1,
  2. Richard Hooper, lecturer in medical statistics2,
  3. Margaret Jones, research associate1,
  4. Lisa Hull, study coordinator1,
  5. Tess Browne, research assistant1,
  6. Oded Horn, data manager1,
  7. Dominic Murphy, research assistant1,
  8. Matthew Hotopf, professor of general hospital psychiatry1,
  9. Simon Wessely, professor of epidemiology and liaison psychiatry1
  1. 1King's College London, King's Centre for Military Health Research, Weston Education Centre, London SE5 9RJ
  2. 2Imperial College London, National Heart and Lung Institute, Respiratory Epidemiology and Public Health, London SW3 6LR
  1. Correspondence to: R J Rona Roberto.rona{at}
  • Accepted 23 August 2006


Objective To assess whether screening for mental disorder before the start of the 2003 Iraq war would have predicted subsequent mental disorders.

Design Longitudinal cohort study of the United Kingdom armed forces.

Participants 2820 of 2873 personnel of the three services who completed an initial questionnaire in 2002 were asked to complete a second questionnaire between June 2004 and 2 March 2006.

Setting Regiments, air stations, bases, ships, and homes for those who had left the services.

Main outcome measures Positive and negative likelihood ratios, and positive and negative predictive value of first assessment compared with assessment two to three years later of post-traumatic stress disorder, general health questionnaire, physical symptoms, self perception of health, and alcohol misuse for the entire group and for those deployed to the Iraq war.

Results The response rate to the follow-up questionnaire was 69%, adjusted for return to senders. The positive likelihood ratio of post-traumatic stress disorder was high (13.1, 95% confidence interval 7.2 to 23.8), but the negative likelihood ratio was close to 1 (0.78, 0.67 to 0.91). The positive predictive values were low because of the low prevalence of post-traumatic stress disorder in the period before the Iraq war. The positive likelihood ratios for the other psychological assessments varied between 2.7 and 5.6, and the negative likelihood ratios were slightly lower than for post-traumatic stress disorder, indicating that these were not good candidates for screening. Results were the same for the analyses restricted to those who were deployed.

Conclusions Screening for common mental disorders before deployment in this cohort would not have reduced subsequent morbidity or predicted post-traumatic stress disorder, but this may change if there is a considerable increase in the prevalence of the disorder.


  • We thank the UK Ministry of Defence for their cooperation; in particular we thank the Defence Medical Services Department, the Defence Analytical Services Agency, the Armed Forces Personnel Administration Agency, and the Veterans Policy Unit.

  • Contributors: RJR was principal investigator, planned and sought funding for the study, supervised data collection, designed the analysis, was the lead author, and is guarantor. RH collected and processed data collection, discussed and carried out the analysis, wrote the paper, and is guarantor. MJ and LH participated in the conduct of the research, analysis, and the writing of the paper. TB participated in the conduct of the study. OH was responsible for data management and participated in the planning and conduct of the study. DM participated in the planning and conduct of the study. MH was a principal investigator, sought funding, and participated in the planning, supervision of data collection, and writing of the paper. SW was principal investigator, sought funding, led the planning of the study and supervision of data collection, and made comments on the analysis and writing of the paper.

  • Funding: The initial study was funded by the Defence Science and Technology Laboratory (Dstl), part of the Ministry of Defence. The second survey was funded by the UK Ministry of Defence.

  • Competing interests: SW is honorary civilian consultant adviser to the British army.

  • Ethical approval: The initial survey was approved by the Defence Medical Services clinical research committee. The second study received approval from the Ministry of Defence (Navy) personnel research ethics committee and the King's College Hospital local research ethics committee.

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