The mental health of the UK Armed Forces in the 21st century: resilience in the face of adversity

Full text

The mental health of the UK Armed Forces in the
21st century: resilience in the face of adversity
Deirdre MacManus,
1,2
N Jones,
3
S Wessely,
1
N T Fear,
1,3
E Jones,
4
N Greenberg
1,3
1
King’s Centre for Military
Health Research, King’s
College London, Weston
Education Centre, London, UK
2
Department of Forensic and
Neurodevelopmental Sciences,
Institute of Psychiatry, King’s
College London, London, UK
3
Academic Centre for Defence
Mental Health (ACDMH),
Weston Education Centre,
London, UK
4
Department of War Studies,
King’s College London, Weston
Education Centre, London, UK
Correspondence to
Dr Deirdre MacManus,
Department of Forensic and
Neurodevelopmental Sciences,
King’s College London,
Institute of Psychiatry PO 23,
De Crespigny Park,
London SE5 8AF, UK;
Deirdre.macmanus@kcl.ac.uk
Received 20 November 2013
Accepted 10 December 2013
To cite: MacManus D,
Jones N, Wessely S, et al.
J R Army Med Corps
Published Online First:
[please include Day Month
Year] doi:10.1136/jramc-
2013-000213
ABSTRACT
The recent conflicts in Iraq and Afghanistan have
attracted considerable political and media interest in the
mental health of UK military personnel. As a result of
the close operational collaboration between US and UK
forces, there have inevitably been many comparisons
drawn between the mental health status of the two
forces. Considerable research activity suggests that the
mental health of UK forces appear to have remained
relatively resilient in spite of their considerable exposure
to traumatic events; one stark exception to this is the
high rates of alcohol misuse which seem to be related to
deployment. This paper explores the recently published
literature relating to UK military forces and attempts to
draw conclusions about the reasons for the apparent
resilience shown by the majority of the regular forces.
INTRODUCTION
The prolonged combat missions in Iraq and
Afghanistan have been the most significant burden
on the mental health of the UK Armed Forces in
the 21st Century. Evidence from past conflicts has
established a relationship between the rate of phys-
ical casualties (killed and wounded) and levels of
psychiatric morbidity.
1
It is indisputable that
deployment exposes servicemen and women to
stressful and traumatic events that will not be
encountered by the majority of the general UK
population. Military personnel, especially those in
combat roles, are a high-risk group for developing
a range of mental health disorders including, but
not limited to, post-traumatic stress disorder
(PTSD).
2
Other studies have shown that, compared
with the general population, military personnel are
also at an increased risk of mental health and
behaviour problems such as depression, anxiety dis-
orders, alcohol misuse and aggressive behaviour.
3
In addition to the recognition that deployment
increases the risk of mental health problems, con-
cerns about the mental health of troops returning
from Iraq and Afghanistan were very likely to have
been exacerbated by the legacy of 1990–1991 Gulf
War. It has been estimated that 25% of military
personnel returning from the first Gulf War
reported symptoms of physical ill-health, some-
times severe, which became colloquially known as
‘Gulf War Syndrome’.
4
When UK forces deployed
to the Gulf region once again and in comparable
circumstances to the first Gulf War, it was feared
that the conflict would give rise to similar health
problems among deployed troops.
Since 2002, UK troops have been involved in a
number of highly challenging military operations in
Iraq and Afghanistan. In Iraq, a difficult counterin-
surgency and reconstruction phase followed from
the initial combat operations of 2003. As a result,
the period of troop deployment and the number of
casualties were both greater than had been antici-
pated. Furthermore, over this same period the
intensity and scope of the conflict in Afghanistan
increased: UK troops encountered a violent and
protracted insurgency, especially in Helmand prov-
ince, along with the challenges of dealing with the
widespread use of improvised explosive devices
and other forms of asymmetric threat such as
snipers and suicide bombers.
Inevitably, these operations resulted in a number
of psychological casualties and a wealth of research
activity. Not since Vietnam has so much research
been directed towards the mental health of service
personnel. However, contrary to many people’s
expectations, deployment to Iraq and Afghanistan
has not led to an overall increase in mental health
problems among UK personnel.
5
The overall
number of personnel with symptoms of probable
PTSD, considered a signature injury of these con-
flicts, has remained low. There have, however, been
some groups who have been found to be at greater
risk of developing mental health symptoms:
deployed Reservists and combat personnel have
greater levels of mental health symptoms upon
return home, while alcohol misuse
6
continues to be
a common concern among Regulars and to a lesser
degree among Reservists.
7
In light of evidence of significant mental health
morbidity among, for example, US Iraq and
Afghanistan veterans,
89
this article aims to review
studies into the mental health of UK Armed Forces
Key messages
▸UK military regular personnel have remained
resilient in spite of prolonged combat missions
in Iraq and Afghanistan.
▸Deployment can have a detrimental effect on
specific sub-groups, such as reserves and
combat personnel.
▸There appears to be evidence that good
training, leadership and unit cohesion promote
resilience to mental health problems among
service personnel.
▸Access to high quality mental health services
and a number of evidence based mitigation
measures such as Decompression and Trauma
Risk Management is also important.
▸Future research will explore the nature of
resilience in service personnel exposed to
extreme or prolonged stress in the longer term.
MacManus D, et al.J R Army Med Corps 2014;0:1–6. doi:10.1136/jramc-2013-000213 1
Review

in the 21st Century, to appraise the evidence and possible expla-
nations for seemingly greater resilience among UK troops.
METHODS
Articles were retrieved by one of the authors (DM) on 15
August 2013 by performing a literature search of Google
Scholar, PsychINFO, MEDLINE, PubMed and Web of Science
from 2003 to 2010 (Figure 1). Searches included key words:
(‘military’or ‘Armed Forces’or ‘army’or ‘combat’) and (‘UK’
or ‘British’) and (‘mental health’or ‘psychological’or
‘well-being’).
Studies were included if they reported data on UK Armed
Forces pertaining to recent deployments in Iraq and
Afghanistan, had at least one measure of psychological health or
well-being, were peer-reviewed, and were reported in English.
The search was limited to UK papers concerning operations in
the last 10 years in order to ensure that they would coincide
with the start of UK deployments to Iraq and increased levels of
operational activity in Afghanistan. Other suitable non-UK
papers were chosen for comparison by the authors and these
were not limited to the last 10 years.
MENTAL HEALTH OF REGULAR UK MILITARY PERSONNEL
The bulk of research into the mental health of the UK Armed
Forces in the last 15 years has been undertaken by the research
group based at King’s Centre for Military Health Research
(KCMHR) at King’s College London. They set up a large pro-
spective cohort study coinciding with the beginning of the 2003
Iraq War to follow-up the health and well-being of those
deployed compared with those who were not deployed. The
first phase of the KCMHR cohort study did not demonstrate
any evidence of a new ‘Iraq War Syndrome’in Regulars.
10
However, evidence of high and rising rates of mental disorder
among American troops deployed to Iraq
11
reinforced the
importance of continuing monitoring the psychological health
of UK military personnel. In contrast to US research findings,
over the period following initial data collection, the overall rates
of mental health problems in UK personnel deployed to Iraq or
Afghanistan were found to remain stable.
12
Indeed, as is out-
lined below, the follow-up phase of the cohort study found no
increase in most mental health problems among regular person-
nel who had served in Iraq or Afghanistan, compared with
regular personnel not deployed to Iraq or Afghanistan.
12
It is
import to note, however, that the rates of presentation for help
by service personnel with mental health problems vary, depend-
ing on the nature of the presentation (initial or repeat atten-
dances) and to which service it was made (primary or secondary
care); nevertheless, the KCMHR data have shown that the back-
ground prevalence rate has remained stable.
In comparison with US research findings, the prevalence of
symptoms of probable PTSD among UK Regulars following
return from deployment remained low with estimates ranging
between 1.3% and 4.8%.
713
A study of mental health among
UK Regulars during deployment found 3.8% reported symp-
toms of probable PTSD.
14
These figures were not as high as
expected, considering that PTSD rates in the UK general popu-
lation are approximately 3%.
15
Symptoms of common mental disorders (such as depression
and anxiety) were the most frequently reported mental health
problems among UK military personnel deployed to Iraq or
Figure 1 Flow diagram illustrating the retrieval, selection and exclusion of articles.
2 MacManus D, et al.J R Army Med Corps 2014;0:1–6. doi:10.1136/jramc-2013-000213
Review

Afghanistan. Based on the 12-item General Health
Questionnaire, 16.7%–19.6% reported symptoms of common
mental disorders,
12 16 17
and 27.2% when using the Patient
Health Questionnaire.
7
However, there was no evidence that
deployment to Iraq or Afghanistan increased the risk of
common mental disorder among regular personnel, when com-
pared with regular personnel not deployed to Iraq or
Afghanistan.
12 16
Indeed, similar rates of common mental disor-
ders are found in the general UK population.
15
Mild Traumatic Brain Injury (mTBI) is characterised by short-
term loss of consciousness and/or altered mental state as a result
of a head injury or blast explosions. mTBI has emerged as an
important concern in the US military
18 19
and, indeed, has been
described in the USA as a ‘signature injury’of the current con-
flicts in Iraq and Afghanistan.
20
A prevalence of 15% was found
in a large survey of US infantry deployed to Iraq.
18
Other US
studies have reported estimates from 12% to 23%,
21–23
rising to
around 40% among injured personnel who had been exposed
to a blast.
24
The prevalence of mTBI in UK military was found
to be lower than that in the US military. Based on a large repre-
sentative sample of UK regular personnel, Rona et al
25
found a
prevalence of 4.4%, though those who had been deployed in a
combat role had a higher rate of 9.5%. Therefore, while some
impact of combat role on the prevalence of mTBI was observed
among UK personnel, rates were still shown to be less that in
the USA.
Alcohol misuse (drinking at a level likely to cause physical or
psychological harm) is one of the most frequently reported
mental health problem of UK troops deployed to Iraq or
Afghanistan. In the study by KCMHR, between 16% and 20%
of troops reported alcohol misuse.
12 17
It is the only mental dis-
order which has been shown to be increased in prevalence
among all deployed compared with non-deployed regular mili-
tary personnel.
12
Although rates of alcohol misuse are particu-
larly high among young men, who make up the majority of the
UK Armed Forces (especially the combat troops), this alone did
not account for the high rates of alcohol misuse in service per-
sonnel. Comparison of alcohol misuse in the same age and
gender groups in the general population in England and Wales
and the UK Armed Forces shows that both servicemen and
women are more likely to misuse alcohol than their general
population counterparts.
6
Thus, the resilience exhibited in
terms of mental health to the impact of deployment has not
been replicated in terms of alcohol misuse.
MENTAL HEALTH STATUS OF COMBAT TROOPS
While regular personnel in general do not appear to have been
affected by the potential negative impact of deployment, the
role undertaken by deployed personnel has been shown to be
an important risk factor for mental health outcomes. Combat
exposure has been consistently identified as a risk factor for
PTSD, and the risk has been found to increase with more
intense combat experiences.
12
The intensity of traumatic expo-
sures experienced in theatre has been shown to have a greater
effect than most pre-trauma risk factors, such as a history of
childhood adversity.
26
Therefore, when analysing data from the
KCMHR cohort study, the effect on subsequent mental health
of the participants’role when on deployment was taken into
account. Unsurprisingly, combat troops deployed to Iraq and
Afghanistan show a small but significant increase in the risk of
symptoms of PTSD compared with non-combat troops:
12 16
approximately 7% of combat troops were found to have symp-
toms of PTSD following deployment to Iraq and Afghanistan.
However, not all combat troops are at increased risk of
PTSD. Elite forces such as Royal Marines and Airborne person-
nel report fewer mental health problems compared with other
infantry after deployment to Iraq.
27 28
The exact reasons for
this reduced risk are not fully understood but might be due to
differences in selection and training. Compared with other
infantry, elite forces have been found to have fewer pre-
deployment risk factors, such as a history of childhood adver-
sity, as well as higher levels of unit cohesion, which has been
found to protect against mental health problems.
28
In addition and reflecting the pattern observed for PTSD, an
increase in the rate of alcohol misuse was observed among
combat troops deployed to Iraq
12 16
and, as above, although
young men predominate combat forces, age did not fully
account for this increase in alcohol use among those deployed
in combat roles.
VIOLENT OFFENDING
Post-deployment aggression and violence in soldiers recently
returned from combat missions have been a long-standing
issue.
29
Research from the Vietnam era in the USA was the first
to show a statistical association with combat exposure and such
behaviour among returning troops.
30 31
MacManus et al
32
found that self-reported aggressive and violent behaviour was
prevalent among UK troops on return from deployment in Iraq
with almost 13% reporting having assaulted someone in the
weeks following return. Similar to other mental health problems
reported thus far, they did not find that this was associated with
deployment per se; troops deployed in a combat, rather than in
another role, were more likely to report physical assaults follow-
ing their return. The authors explored this in greater depth by
linking the KCMHR cohort (almost 14 000 participants) with
their official criminal records.
33
The findings confirmed that the
risk of increased violent offending was associated with having
served in a combat role on deployment and also highlighted
that male military personnel had a greater lifetime risk of
violent offending than a similarly aged sample of men from the
general population. However, this study also found that military
personnel were less likely to have committed a non-violent
offence in their lifetime than a similarly aged sample from the
general population. This implies that while military service, in
particular serving in a combat role, can increase propensity for
violent offending, it may also serve to lower the risk of non-
violent offending. Unfortunately, we do not have similar data
from the USA to draw a comparison.
SELF-HARM AND SUICIDE
Suicide has been a much publicised problem among US military
personnel. Despite universal access to healthcare services, man-
datory suicide prevention training and other preventive efforts,
suicide has become one of the leading causes of death in the US
military in recent years.
34–36
Reported rates have risen sharply
since 2005 with the highest rates reported in recent months
alleged to exceed combat and deployment deaths.
37
Fear and colleagues examined suicide rates in the UK Armed
Forces using mortality statistics from Defence Statistics between
1984 and 2007, a period which included the initial years of
deployments to Iraq and Afghanistan.
38
The UK Armed Forces
had statistically significantly fewer suicides than expected com-
pared with the UK general population. This was evident for
each of the three Services (Naval Service, Army and Royal Air
Force). For each age group, the number of suicides in each
Service was lower than the number expected based on UK
general population rates, except for Army males under 20 years
MacManus D, et al.J R Army Med Corps 2014;0:1–6. doi:10.1136/jramc-2013-000213 3
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of age, where there were 1.5 times more deaths than expected
(standardised mortality rate (SMR)=150, 95% CI 118 to 190,
based on 68 deaths). Given that, in the latter years of this study
period the UK Armed Forces were subject to a number of
unique occupational stressors, it is of interest that they contin-
ued to experience lower than expected numbers of suicides in
comparison with the UK general population. This was true for
each Service and all age groups except young males in the army.
It is important to note that the data in the Fear et al study
ended in 2007, and also concerns only serving personnel, and
in addition does not differentiate between deployed and non-
deployed. It is only very recently that all those who have served
in Iraq/Afghanistan have had their records ‘flagged’with the
Office of National Statistics. Until such data are analysed one
should be cautious about any statements regarding the impact of
deployment, particularly mindful of the flawed anecdotal state-
ments made over the years about the number of Falklands
suicides.
39
In a subsequent study of self-harming behaviour, which used
KCMHR cohort data, Hines and colleagues estimated self-harm
in the UK military to vary between 1% and 5.6% compared
with 4.9% in the general UK population.
40
They also found that
contrary to predictions, self-harm in the UK military was not
associated with deployment, but rather was linked to available
social support in childhood and adulthood.
40
However, a tele-
phone interview study by Pinder et al
41
found that ex-Service
personnel reported a lifetime prevalence of self-harm more than
double that of serving personnel (10.5% vs 4.2%, respectively)
and that younger personnel and those who had experienced
more childhood adversity and psychological injury were more
likely to report self-harming behaviour. Similar to other mental
health and behaviour problems, it appears that suicide and self-
harm in the UK military has not been directly linked to deploy-
ment experiences and raised suicide rates among younger men
and elevated self-harming among young and ex-serving person-
nel may have more to do with pre-military risk factors and diffi-
culties associated with post-service life.
MENTAL HEALTH OF RESERVE FORCES PERSONNEL
Reserve forces, which comprise volunteer reserves and those
with a post-regular service residual commitment, have been
widely used in recent overseas conflicts. Initial studies into the
impact of deployment to Iraq and Afghanistan on the mental
health of UK Reservists found that they were more vulnerable
to negative outcomes than deployed regular personnel being
twice as likely to report common mental disorders and probable
PTSD after deployment compared with regular personnel.
16
UK
Reservists who deployed to the 2003 Iraq War were more than
twice as likely to report symptoms of common mental disorders
and probable PTSD compared with those who did not deploy.
16
The same study did not find any such impact of deployment
among Regulars. Empirical studies based in both the USA and
UK have repeatedly demonstrated that, compared with regular
military personnel, Reservists have an increased prevalence of
mental illness post-deployment.
8121642
There have been a number of speculative views about the
reasons for the high rates of mental illness among Reservists
returning from deployment to Iraq and Afghanistan. One sug-
gestion is that the finding may be due to the challenge of reinte-
grating into civilian life. A number of UK studies have explored
the reasons for UK Reservists’apparent vulnerability to mental
health problems and have suggested that it is related to their
homecoming experiences.
43 44
Harvey et al
44
found that, com-
pared with regular personnel, Reservists were more likely to feel
unsupported by the military, and to have difficulties with social
functioning, in the post-deployment period. Perceived lack of
support from the military was associated with increased report-
ing of probable PTSD and alcohol misuse. Additionally, low
levels of non-military, post-deployment social support and par-
ticipation were associated with increased reporting of common
mental disorder, probable PTSD, and alcohol misuse.
Until recently, the pattern of longer term post-deployment
psychological morbidity for UK Reservists was unknown.
Harvey et al
45
conducted a longitudinal analysis of 552 UK
Reservists deployed to Iraq in 2003 and 391 non-deployed
Reservists who served during the same period. Measures of
mental health and social functioning were collected around
16 months and approximately 5 years after potential and actual
deployment. At the first follow-up, deployment was associated
with increased common mental disorder, PTSD and poorer
general health. By the second follow-up, those who had
deployed were no longer at increased risk for common mental
disorder or poor general health and reported good levels of
social functioning. However, those who deployed continued to
have over twice the odds of PTSD and were more likely to
report actual or serious consideration of separation from their
partner. In conclusion, the authors found that the majority of
mental health and social problems among Reservists following
deployment are transient. However, they remain at increased
risk of PTSD and relationship problems 5 years after their tour
of duty.
RESILIENCE AMONG UK MILITARY PERSONNEL
COMPARED WITH INTERNATIONAL COUNTERPARTS?
Research to date has overwhelmingly found that the rates of
mental health problems reported by UK military personnel,
especially following return from recent deployment, have been
lower than predicted by the media and some military charities.
There are some exceptions to this, however, most importantly
alcohol misuse and violence. Research has also highlighted the
vulnerability of certain groups of at-risk personnel, namely,
those deployed in a combat role and reserve personnel. It has
also revealed certain groups who demonstrate increased resili-
ence such as the elite forces.
While it is difficult to compare rates between nations, a con-
sistent finding of the last 20 years is that reported mental health
problems tend to be higher among service personnel and veter-
ans of the USA compared with the UK, Canada, Germany and
Denmark.
46
Hoge and Castro
47
reported PTSD rates among
returning US troops of between 5% and 10%, and recent
studies based on Department of Veteran Affairs data have
recorded PTSD rates between 21% and 29%,
48
at a time when
UK researchers reported rates of between 2% and 7%.
512
Explanations for these international differences have been
various. Research has shown that US personnel tend to be
younger and of lower socio-economic background than their
UK counterparts and also have, to date, undertaken longer tours
of duty (US troops routinely undertake 12 month deployments,
and often longer, compared with 6 months for UK forces). The
US military also deploys a greater proportion of Reservists.
There are considerable international differences in the entitle-
ment to healthcare and benefits for veterans with marked differ-
ences in the way both are delivered. Earlier US studies that
found an increased prevalence of PTSD compared with UK
troops were undertaken when US troops were engaged in more
dangerous duties than UK troops and thus combat exposure,
prior to the recent operations in Afghanistan, may have
explained US and UK differences. However, since 2006 combat
4 MacManus D, et al.J R Army Med Corps 2014;0:1–6. doi:10.1136/jramc-2013-000213
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exposure has been similar for troops from both nations, this is
unlikely to be a major explanatory factor. Furthermore, US
culture may be more receptive to psychological disorder (eg, see
the high rates of PTSD recorded by the National Vietnam
Veterans’Readjustment Study
49
). Another potential impediment
to assessing the true prevalence of mental disorder symptoms is
the unwillingness of military personnel to declare symptoms as
a consequence of stigmatising beliefs about mental health.
While psychiatric stigma among UK forces is reducing with
time,
50
it persists as a potential barrier to help-seeking.
51
However, a recent study which compared US and UK troops,
along with troops from Australia and Canada, who had just left
Afghanistan found comparable rates of reported stigma.
52
CAN MILITARY LEADERSHIP AND MANAGEMENT-RELATED
FACTORS INCREASE THE RESILIENCE OF MILITARY
PERSONNEL?
Insight into factors that may increase resilience among UK
troops was provided by Jones et al
53
who carried out a study
into the potential mitigating effects of cohesion, morale and
leadership on the risk of developing mental health problems. To
assess the possible impact of these factors on PTSD symptoms
and common mental disorders resulting from combat exposure,
a sample of UK personnel serving in Afghanistan in 2010 were
asked to complete a self-report survey about aspects of their
current deployment, including perceived levels of cohesion,
morale, leadership, combat exposure and their mental health
status. Outcomes were symptoms of common mental disorder
and symptoms of PTSD. Combat exposure was associated with
both PTSD symptoms and symptoms of common mental dis-
order. Of the 1431 participants, 17.1% reported caseness levels
of common mental disorder, and 2.7% were classified as prob-
able PTSD cases. Greater self-reported levels of unit cohesion,
morale and perceived good leadership were all associated with
lower levels of common mental disorder and PTSD. Although
the authors accepted the limitations of assessing cause in a cross-
sectional study, there was some tentative evidence that these
factors may help to modulate the effects of combat exposure
and mental health symptoms among UK Armed Forces person-
nel deployed to Afghanistan. This study thus provides support
for the hypothesis that within organisations, such as the military
which rely on cohesive teams, resilience is best thought of as a
social construct, being an interaction between individuals.
Unlike the majority of the US military, the UK Armed Forces
require personnel to spend around 36 h attending third location
decompression (TLD) before they return to their home bases.
TLD is a social, supportive and educational intervention follow-
ing prolonged operational deployment which aims to smooth
the transition between operations and returning home. The UK
Academic Centre for Defence Mental Health assessed whether
TLD impacted upon both mental health and post-deployment
readjustment. Jones et al
54 55
suggested that TLD had a positive
impact upon mental health outcomes (PTSD and multiple phys-
ical symptoms) and levels of harmful alcohol use. However,
when the samples were stratified by combat exposure, post-
deployment readjustment was similar for all exposure levels,
and personnel experiencing low and moderate levels of combat
exposure experienced the greatest positive mental health effects.
Although the Jones et al paper
59
used a strategy that allowed
for pseudorandomisation (propensity scores were used which
allowed for the analyses of observational data so that some of
the particular characteristics of a randomised controlled trial are
mimicked), the true value or otherwise of TLD can only be
properly ascertained via a randomised controlled trial, the
opportunity for which has probably now passed.
The UK military has also invested considerably in ensuring
that personnel within deployed units are able to support each
other after traumatic events. The Trauma Risk Management
(TRiM) programme has been widely used by the Royal Marines
since the late 1990s
56
and has been in widespread use by the
rest of the Armed Forces since 2007.
57
TRiM is a peer support
programme which aims to provide units with an integral peer
support process which is designed to assess the psychological
risk in trauma exposed personnel and engage them with helping
services when and if needed. TRiM has been the subject of a
number of studies which have shown that it is highly acceptable
to military personnel, capable of detecting changes in post inci-
dent mental health, helps to mobilise social support
58
and
improves organisational function while not causing harm.
59
TRiM, which is not routinely used by the US military, although
their senior command are considering whether it might be
useful for their personnel, is thus another potential pro-
resilience factor which works to ensure that military personnel
operating in highly challenging environments can properly
support each other.
CONCLUSIONS
The evidence presented in this paper shows that, in the main,
UK military personnel have remained resilient in spite of having
suffered significant numbers of fatalities and casualties and
having undertaken prolonged combat missions in Iraq and
Afghanistan. However, the many scientific publications discussed
in the paper suggest that deployment can have a detrimental
effect on specific sub-groups, such as reserves and combat per-
sonnel. Given the large number of Service personnel who have
deployed to Iraq and Afghanistan over recent years, there is
likely to be a small, but important group of veterans with
mental health conditions attributable to their service who will
require specialist mental healthcare provision in the years ahead.
While it is not possible to be certain about the likely vast range
of factors which are associated with resilience in UK troops,
there appears to be some evidence that the considerable efforts
the UK Armed Forces have made to ensure that deployed per-
sonnel are well trained, well led, cohesive, have access to high
quality mental health services and a number of evidence based
mitigation measures such as TLD and TRiM are important.
However, the longer term psychological effects of these deploy-
ments remain to be seen and research opportunities exist to
explore the nature of resilience in service personnel exposed to
extreme or prolonged stress in the longer term.
Contributors DM conducted the literature search and wrote the review. NG
conceived of the idea and contributed to the writing of the review. SW, NTF, EJ and
NJ contributed informed and constructive comments on the drafted review which
significantly shaped the final product.
Competing interests NG is an ex-serving full-time member of the UK Armed
Forces, and is currently employed by King’s College London. NTF and SW are
employed by the Academic Centre for Defence Mental Health, based at King’s
College London which receives funding from the UK Ministry of Defence. SW is also
honorary civilian consultant advisor in psychiatry to the British Army and a trustee of
Combat Stress, a UK charity that provides service and support for veterans with
mental health problems.
Provenance and peer review Not commissioned; externally peer reviewed.
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