Chilcot: physical and mental legacy of Iraq war on UK service personnelBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3842 (Published 12 July 2016) Cite this as: BMJ 2016;354:i3842
- Neil Greenberg, professor1,
- Anthony Bull, professor2,
- Simon Wessely, chair of psychological medicine3
- 1King’s Centre for Military Health Research, Institute of Psychiatry, Psychology and Neurosciences, King’s College London, London, UK
- 2Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK
- 3Institute of Psychiatry, Psychology and Neurosciences, King’s College London
- Correspondence to: S Wessely
The much awaited Chilcot report focused on the legitimacy of the UK going to war in Iraq.1 But the UK citizens most directly affected by the war were members of the armed forces and their families. A total of 179 British service personnel were killed in the conflict, and many more received life changing physical and mental injuries. The Ministry Of Defence reports a total of 5970 casualties, including deaths up to July 2009.2
In April 2003 the UK Ministry of Defence commissioned an independent study of the health and wellbeing of Iraq war veterans (Chilcot, 16.2, 58-). This study, now completing its third wave of data collection, compared military personnel who had or had not been to Iraq, and found no new “Iraq war syndrome”3; no significant increase in probable post-traumatic stress disorder (PTSD) or common mental health disorders; and only a modest increase in alcohol misuse. There were, however, specific increases in mental health problems, including PTSD and alcohol misuse, among men who had been in combat roles.4 Likewise, reports of probable PTSD were more common among reservists who served in Iraq (6%) than those who did not (3%).5 This was associated more with difficulties experienced on returning home than the deployment itself, and remained evident five years later 6 As the Ministry of Defence intends to increase the use of reservists in future, this is a concerning finding.
Although there were many reasons for the apparent resilience of UK forces,7 Chilcot highlights some “major developments in mental health care” as possible contributors: psychological decompression when personnel returned home, a specific reservists mental health programme, NHS community mental health programmes for veterans, and the rolling out of the trauma risk management (TRIM) programme (Chilcot 16.4, 45).1
Despite these improvements in care, deployment had behavioural consequences for returning veterans and their families. For example, more than 20% of recent returnees exhibit risky driving,8 linked to higher death rates from motor vehicle crashes; and increases in both self reported violence9 and official convictions for violent offences10 are strongly linked to probable PTSD and alcohol misuse. Chilcot notes that mental health remains an important future concern and will require vigilance in future deployments (Chilcot 16.4, 43).1
Turning to physical care, the extensive use of improvised explosive devices in the Iraq and Afghanistan conflicts led to a different pattern of injury from that seen in previous wars. Explosions accounted for 79% of troops killed or wounded in action from 2003 to 2008; 87%11 of casualties sustained extremity injuries, including traumatic amputations and loss of multiple limbs.12 Chilcot accepts that many survived because of advances in care made during the conflicts, noting an increase in the number of “unexpected survivors” who might have died from their severe injuries only a few years earlier.
Progress was made in many areas, including improved personal protective equipment for troops, innovations in prehospital care, expedited casualty evacuation, and new in-hospital resuscitation protocols optimised for battlefield trauma.13 But long term outcomes for these unexpected survivors remain unknown.
The Royal British Legion Centre for Blast Injury Studies at Imperial College London and the King’s Centre for Military Health Research, together with military colleagues at Headley Court, are now collaborating on the Armed Services Trauma Rehabilitation Outcome Study (ADVANCE) study,14 which will assess the physical, social, and psychological challenges faced by survivors of the most serious injuries over 20 years.
Chilcot concluded that the “Ministry of Defence planned and prepared effectively to provide medical care in support of Operation Telic” and substantially improved the provision of medical, mental health, and rehabilitative care during the course of the conflict. But no matter how good the short term care, nothing will remove the enduring effects of the deaths and the physical and psychological injuries. The true legacy of the conflict for individuals and wider society in both the UK and Iraq may not be evident for many years to come.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: SW is a trustee of Combat Stress, the leading charity providing mental health care to former service personnel, and is honorary civilian consultant adviser in psychiatry to the British army (unpaid). His unit receives grant support from the UK Ministry of Defence and other sources. AB’s unit also receives grant support from the UK Ministry of Defence, veterans’ charities, and other sources. NG is the veterans lead for the Royal College of Psychiatrists and a trustee for two military charities. He also prepares legal reports on former service personnel in respect of their mental health.
Provenance and peer review: Commissioned; not externally peer reviewed.