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Is more likely as traumatic exposures increase, and this is often related to length of deployment
More than 29 armed conflicts involving 25 countries are now occurring around the globe.1 For people in the United Kingdom and United States the situation in Iraq and Afghanistan is a constant reminder of the cost of war. The price that soldiers, sailors, airmen, marines, and their families pay is always considerable.
In this week's BMJ, Rona and colleagues assess the effect of the frequency and duration of deployment on the mental health of 5547 randomly chosen military personnel with experience in deployment.2 They found that people who were deployed for more than 12 months in the past three years were more likely to have mental health problems (odds ratio for post-traumatic stress disorder 1.55, 95% confidence interval 1.07 to 2.32), although exposure to combat partly accounted for these associations. Post-traumatic stress disorder was more likely when a mismatch occurred between the expected and actual lengths of deployment.
The study could help identify those at high risk of long term disability and guide policy.3 Deployment is a strange term. Few people would suggest that deployment itself is a substantial cause of psychiatric disorder or distress. Many nations deploy soldiers around the globe. The US and UK have deployed soldiers for decades to overseas assignments, both with and without their families, and without substantially increased risk of post-traumatic stress disorder.4 However, it is the nature of the deployment experience—the “toxic” exposures—including traumatic events, loss of attachments, and psychological and physical demands that increase the risk of mental illness.
Another example of how the nature of the deployment affects the risk of mental illness is seen in US military veteran prisoners of war repatriated at the end of the Vietnam war. Duration of solitary confinement and weight loss were the most robust independent predictors of poor psychiatric outcome because they were strongly related to various “toxic” exposures.5 If the length of deployment corresponds with the amount of combat trauma and related experiences, it can be a strong predictor of the risk of mental illness. But this is not always the case, as deployments vary greatly in the frequency, intensity, and type of exposures encountered. In real time, wars change in days, weeks, and months, and so may the exposures that comprise a deployment. The length of deployment is just one measure of these factors—remembering this is important for healthcare planning as well as for protecting forces in war.
The incidence of mental illness is usually only measured after soldiers return from deployment, often well after the trauma. The challenge is to assess the risk of mental illness in real time. This would enable risk to be assessed, so that soldiers identified to be at high risk or those diagnosed with mental illness could be treated at the battlefront. We must, therefore, move towards measuring relevant exposures in real time. Exposure to traumatic events and loss of coping and social support must be assessed in real time by commanders to protect the health of their personnel. Decisions about how long soldiers should be deployed must take into account how stressful the combat is likely to be. In addition, decisions on length of deployment must consider the stress of rotation home and return (for example, the transition from “battle mind” to “home front mind” and back to “battle mind”) and the ability of soldiers to sustain skills and mental and physical strength while home.
Perhaps most importantly, Rona and colleagues have shown that the Iraq war is not without its costs—both to the health of those deployed and eventually to the healthcare system—and that these same costs are related to duration of exposure. To date, the US army surgeon general has set up four mental health advisory teams to assess the mental health of deployed US soldiers via anonymous surveys. In 2006, the fourth team collected data from surveys and qualitative interviews from more than 1300 soldiers and nearly 450 marines.6 The report noted that the length of deployment and uncertainty about the date of return home were the top two concerns of soldiers. Morale among soldiers deployed several times was lower than that among those deployed for the first time. Similarly, soldiers deployed several times to Iraq were more likely to fulfil criteria for acute stress, post-traumatic stress disorder, depression, or any mental disorder than those who were deployed once. Soldiers deployed several times were 1.6 times more likely to screen positive for post-traumatic stress disorder than those who were deployed once, 1.2 times more likely to screen positive for anxiety, and 1.7 times more likely to have depression. Importantly, no specific cut off for duration of deployment eliminated risk. Soldiers deployed for longer than six months were also between 1.5 and 1.6 times more likely to screen positive for acute stress than those deployed for less than six months.
War develops as a result of seemingly unavoidable circumstances emerging within a specific social context. Similarly, the ability to adapt to normal life after war is shaped by the specific social circumstances and contexts of the conflict.7 Rona and colleagues' finding that unmet expectations for a shorter deployment are associated with post-traumatic stress disorder shows how our hopes and beliefs about the future, a part of our changing social context, affect health and disease.
For the practitioner and the health planner, soldiers with the longest deployments will be among those most likely to need care, both at the battlefront and after their return home. Length of deployment is but one measure, not the most direct, of the exposures and risks when they return home. Providing continuity of care across time and space is a challenge for providers and health systems.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.