Background

The negative impact of sustaining an injury on a military deployment on subsequent mental health is well-documented, however, the relationship between having an illness on a military operation and subsequent mental health is unknown.

Methods

Population based study, linking routinely collected data of attendances at emergency departments in military hospitals in Iraq and Afghanistan [Operational Emergency Department Attendance Register (OpEDAR)], with data on 3896 UK Army personnel who participated in a military health study between 2007 and 2009 and deployed to Iraq or Afghanistan between 2003 to 2009.

Results

In total, 13.8% (531/3896) of participants had an event recorded on OpEDAR during deployment; 2.3% (89/3884) were medically evacuated. As expected, those medically evacuated for an injury were at increased risk of post deployment probable PTSD (odds ratio 4.27, 95% confidence interval 1.80-10.12). Less expected was that being medically evacuated for an illness was also associated with a similarly increased risk of probable PTSD (4.39, 1.60-12.07) and common mental disorders (2.79, 1.41-5.51). There was no association between having an OpEDAR event and alcohol misuse. Having an injury caused by hostile action was associated with increased risk of probable PTSD compared to those with a non-hostile injury (3.88, 1.15 to 13.06).

Conclusions

Personnel sustaining illnesses on deployment are just as, if not more, at risk of having subsequent mental health problems as personnel who have sustained an injury. Monitoring of mental health problems should consider those with illnesses as well as physical injuries.

Background

There is no doubt that the perceived stigma of having a mental disorder acts as a barrier to help seeking. It is possible that personnel may be reluctant to admit to symptoms suggestive of poor mental health when such data can be linked to them, even if their personal details are only used to help them access further care. This may be particularly relevant because individuals who have a mental health problem are more likely to experience barriers to care and hold stigmatizing beliefs. If that is the case, then mental health screening programmers may not be effective in detecting those most in need of care. We aimed to compare mental health symptom reporting when using an anonymous versus identifiable questionnaire among UK military personnel on deployment in Iraq.

Methods

Survey among UK military personnel using two questionnaires, one was anonymous (n = 315) and one collected contact details (i.e. identifiable, n = 296). Distribution was by alternate allocation. Data were collected in Iraq during January-February 2009.

Results

No significant difference in the reporting of symptoms of common mental disorders was found (18.1% of identifiable vs. 22.9% of anonymous participants). UK military personnel were more likely to report sub-threshold and probable PTSD when completing questionnaires anonymously (sub-threshold PTSD: 2.4% of identifiable vs. 5.8% of anonymous participants; probable PTSD: 1.7% of identifiable vs. 4.8% of anonymous participants). Of the 11 barriers to care and perceived social stigma statements considered, those completing the anonymous questionnaire compared to those completing the identifiable questionnaire were more likely to endorse three statements: “leaders discourage the use of mental health services” (9.3% vs. 4.6%), “it would be too embarrassing” (41.6% vs. 32.5%) and “I would be seen as weak” (46.6% vs. 34.2%).

Conclusions

We found a significant effect on the reporting of sub-threshold and probable PTSD and certain stigmatizing beliefs (but not common mental disorders) when using an anonymous compared to identifiable questionnaire, with the anonymous questionnaire resulting in a higher prevalence of PTSD and increased reporting of three stigmatizing beliefs. This has implications for the conduct of mental health screening and research in the US and UK military.

Objective

The term ‘functional’ has a distinguished history, embodying a number of physiological concepts, but has increasingly come to mean ‘hysterical’. The DSM-V working group proposes to use ‘functional’ as the official diagnostic term for medically unexplained neurological symptoms (currently known as ‘conversion disorder’). This study aimed to explore the current neurological meanings of the term and to understand its resilience.

Design

Mixed methods were used, first interviewing the neurologists in a large UK region and then surveying all neurologists in the UK on their use of the term.

Results

The interviews revealed four dominant uses—‘not organic’, a physical disability, a brain disorder and a psychiatric problem—as well as considerable ambiguity. Although there was much dissatisfaction with the term, the ambiguity was also seen as useful when engaging with patients. The survey confirmed these findings, with a majority adhering to a strict interpretation of ‘functional’ to mean only ‘not organic’, but a minority employing it to mean different things in different contexts - and endorsing the view that ‘functional’ would one day be a neurological construct again.

Conclusions

‘Functional’ embodies real divisions in neurologists' conceptualisation of unexplained symptoms and, perhaps, between those of patients and neurologists: its diversity of meanings allows it to be a common term while meaning different things to different people, or at different times, and thus conceal some of the conflict in a particularly contentious area. This flexibility may help explain the term's longevity.

A new book that describes the changing responses of medical professionals to people who have been in a disaster represents a welcoming maturing of the field, finds Simon Wessely

Background

Chronic fatigue syndrome (CFS) is a complex multifactorial disorder. This paper reports the prevalence of chronic fatigue (CF) and CFS in an ethnically diverse population sample and tests whether prevalence varies by social adversity, social support, physical inactivity, anxiety and depression.

Methods

Analysis of survey data linking the Health Survey for England (1998 and 1999) and the Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC) study undertaken in 2000. The study population comprised a national population sample of 4,281 people ages 16 to 74 years. CF and CFS were operationally defined on the basis of an interview in the EMPIRIC study, alongside questions about psychosocial risk factors. Previous illnesses were reported in the Health Survey for England during 1998 and 1999, as was physical inactivity.

Results

All ethnic minority groups had a higher prevalence of CFS than the White group. The lowest prevalence was 0.8% in the White group, and it was highest at 3.5% in the Pakistani group (odds ratio (OR), 4.1; 95% confidence interval (95% CI), 1.6 to 10.4). Anxiety (OR, 1.8; 95% CI, 1.4 to 2.2), depression (OR, 1.4; 95% CI, 1.1 to 1.8), physical inactivity (OR, 2.0; 95% CI, 1.1 to 3.8), social strain (OR, 1.24; 95% CI, 1.04 to 1.48) and negative aspects of social support (OR, 2.12; 95% CI, 1.4 to 3.3) were independent risk factors for CFS in the overall sample. Together these risk factors explained ethnic differences in the prevalence of CFS, but no single risk factor could explain a higher prevalence in all ethnic groups.

Conclusions

The prevalence of CFS, but not CF, varies by ethnic group. Anxiety, depression, physical inactivity, social strain and negative aspects of social support together accounted for prevalence differences of CFS in the overall sample.

The novel human gammaretrovirus xenotropic murine leukemia virus-related virus (XMRV), originally described in prostate cancer, has also been implicated in chronic fatigue syndrome (CFS). When later reports failed to confirm the link to CFS, they were often criticised for not using the conditions described in the original study. Here, we revisit our patient cohort to investigate the XMRV status in those patients by means of the original PCR protocol which linked the virus to CFS. In addition, sera from our CFS patients were assayed for the presence of xenotropic virus envelope protein, as well as a serological response to it. The results further strengthen our contention that there is no evidence for an association of XMRV with CFS, at least in the UK.

Background

Conversion disorder is largely managed by neurologists, for whom it presents great challenges to understanding and management. This study aimed to quantify these challenges, examining how neurologists understand conversion disorder, and what they tell their patients.

Methods

A postal survey of all consultant neurologists in the UK registered with the Association of British Neurologists.

Results

349 of 591 practising consultant neurologists completed the survey. They saw conversion disorder commonly. While they endorsed psychological models for conversion, they diagnosed it according to features of the clinical presentation, most importantly inconsistency and abnormal illness behaviour. Most of the respondents saw feigning as entangled with conversion disorder, with a minority seeing one as a variant of the other. They were quite willing to discuss psychological factors as long as the patient was receptive but were generally unwilling to discuss feigning even though they saw it as their responsibility. Those who favoured models in terms of feigning were older, while younger, female neurologists preferred psychological models, believed conversion would one day be understood neurologically and found communicating with their conversion patients easier than it had been in the past.

Discussion

Neurologists accept psychological models for conversion disorder but do not employ them in their diagnosis; they do not see conversion as clearly different from feigning. This may be changing as younger, female neurologists endorse psychological views more clearly and find it easier to discuss with their patients.

Background

As with the general population, a proportion of military personnel with mental health problems do not seek help. As the military is a profession at high risk of occupational psychiatric injury, understanding barriers to help-seeking is a priority.

Method

Participants were drawn from a large UK military health study. Participants undertook a telephone interview including the Patient Health Questionnaire (PHQ); a short measure of PTSD (Primary Care PTSD, PC-PTSD); a series of questions about service utilisation; and barriers to care. The response rate was 76% (821 participants).

Results

The most common barriers to care reported are those relating to the anticipated public stigma associated with consulting for a mental health problem. In addition, participants reported barriers in the practicalities of consulting such as scheduling an appointment and having time off for treatment. Barriers to care did not appear to be diminished after people leave the Armed Forces. Veterans report additional barriers to care of not knowing where to find help and a concern that their employer would blame them for their problems. Those with mental health problems, such as PTSD, report significantly more barriers to care than those who do not have a diagnosis of a mental disorder.

Conclusions

Despite recent efforts to de-stigmatise mental disorders in the military, anticipated stigma and practical barriers to consulting stand in the way of access to care for some Service personnel. Further interventions to reduce stigma and ensuring that Service personnel have access to high quality confidential assessment and treatment remain priorities for the UK Armed Forces.

Objectives To discover the content of enduring beliefs held by first world war veterans about their experience of having been gassed.

Design Collection and thematic analysis of written and reported statements from a sample of veterans about gassing.

Subjects 103 veterans with a war pension.

Results Twelve themes were identified, which were related to individual statements. The systemic nature of chemical weapons played a key part in ideas and beliefs about their capacity to cause enduring harm to health. Unlike shrapnel or a bullet that had a defined physical presence, gas had unseen effects within the body, while its capacity to cause damage was apparent from vesicant effects to skin and eyes. The terror inspired by chemical weapons also served to maintain memories of being gassed, while anti-gas measures were themselves disconcerting or a source of discomfort.

Conclusions Chronic symptoms and work difficulties maintained beliefs about the potency of chemical weapons. In the period after the war, gas continued to inspire popular revulsion and was associated with a sense of unfairness.

Background

while low response rates need not introduce bias into research, having a lower percentage of responders does increase the potential for this to occur. This is of particular concern given the decline that has been occurring in response rates since the 1950s. However, there are various methods that can be incorporated into the study design, which can assist in increasing levels of participation.

Objective

To outline the methods used by the King's Centre for Military Health Research (KCMHR) when conducting a recent telephone survey of serving and ex-Service military personnel.

Design

Using participants who had already taken part in a questionnaire-based study on the health effects of serving in the UK Armed Forces (n=10,272), a subsample was selected for an in-depth telephone interview-based follow-up study. The subsample consisted of 1,105 participants, selected on the basis of their mental health status. An adjusted response rate of 76% was achieved (n=821).

Results

Various methods of contact were used in this study to ensure an adequate response rate was achieved.

Conclusions

Simple research strategies increase response rates and are likely to reduce bias. Use of multiple simultaneous tracing methods and customisation of the approach to the target population increases rapport between participants, ensuring that those who take part feel valued as members of the study. In the current climate of decreasing participation in studies, research teams need to engage with their study population and devise innovative strategies to keep participants involved in the research being undertaken.

Background

Monetary incentives are an effective way of increasing response rates to surveys, though they are generally less effective in physicians, and are more effective when the incentive is paid up-front rather than when made conditional on completion.

Methods

In this study we examine the effectiveness of pre- and post-completion incentives on the response rates of all the neurologists in the UK to a survey about conversion disorder, using a cluster randomised controlled design. A postal survey was sent to all practicing consultant neurologists, in two rounds, including either a book token, the promise of a book token, or nothing at all.

Results

Three hundred and fifty-one of 591 eligible neurologists completed the survey, for a response rate of 59%. While the post-completion incentive exerted no discernible influence on response rates, a pre-completion incentive did, with an odds-ratio of 2.1 (95% confidence interval 1.5 - 3.0).

Conclusions

We conclude that neurologists, in the UK at least, may be influenced to respond to a postal survey by a pre-payment incentive but are unaffected by a promised reward.

Background Little is known about the longer term occupational outcome in UK military personnel who require hospital-based treatment for mental health problems.

Aims To examine the documented occupational outcomes following hospital-based treatment for mental health problems within the British Army.

Methods Hospital admission records were linked to occupational outcome data from a database used for personnel administration.

Results A total of 384 records were identified that were then linked to occupational outcome after an episode of hospitalization. Seventy-four per cent of those admitted to hospital with mental health problems were discharged from the Army prematurely, and 73% of the discharges occurred in the first year following hospitalization. Discharge from the Army was associated with holding a junior rank, completing <5 years military service, having a combat role, being male and receiving community mental health team treatment prior to admission.

Conclusions Hospitalization for a mental health problem in a military context is associated with a low rate of retention in service. Outcome was not influenced greatly by duration of hospital stay; however, those who reported receiving individual rather than group-based therapy while in hospital appeared to do better.

Conversion disorder (‘hysteria’) was largely considered to be a neurological problem in the 19th century, but without a neuropathological explanation it was commonly assimilated with malingering. The theories of Janet and Freud transformed hysteria into a psychiatric condition, but as such models decline in popularity and a neurobiology of conversion has yet to be found, today's neurologists once again face a disorder without an accepted model. This article explores how today's neurologists understand conversion through in-depth interviews with 22 neurology consultants. The neurologists endorsed psychological models but did not understand their patients in such terms. Rather, they distinguished conversion from other unexplained conditions clinically by its severity and inconsistency. While many did not see this as clearly distinct from feigning, they did not feel that this was their problem to resolve. They saw themselves as ‘agnostic’ regarding non-neuropathological explanations. However, since neurologists are in some ways more expert in conversion than psychiatrists, their continuing support for the deception model is important, and begs an explanation. One reason for the model's persistence may be that it is employed as a diagnostic device, used to differentiate between those unexplained symptoms that could, in principle, have a medical explanation and those that could not.

Introduction

Chronic fatigue syndrome (CFS) affects between 0.006% and 3% of the population depending on the criteria of definition used, with women being at higher risk than men.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for chronic fatigue syndrome? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2007 (BMJ Clinical evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 45 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antidepressants, cognitive behavioural therapy (CBT), corticosteroids, dietary supplements, evening primrose oil, galantamine, graded exercise therapy, homeopathy, immunotherapy, intramuscular magnesium, oral nicotinamide adenine dinucleotide, and prolonged rest.

Key Points

Chronic fatigue syndrome (CFS) is characterised by severe, disabling fatigue, and other symptoms including musculoskeletal pain, sleep disturbance, impaired concentration, and headaches. CFS affects between 0.006% and 3% of the population depending on the criteria used, with women being at higher risk than men.

Graded exercise therapy has been shown to effectively improve measures of fatigue and physical functioning. Educational interventions with encouragement of graded exercise (treatment sessions, telephone follow-ups, and an educational package explaining symptoms and encouraging home-based exercise) improve symptoms more effectively than written information alone.

CBT is also effective in treating chronic fatigue syndrome. CBT may also be beneficial when administered by therapists with no specific experience of chronic fatigue syndrome, but who are adequately supervised.In adolescents, CBT can reduce fatigue severity and improve school attendance compared with no treatment.

We don't know how effective antidepressants, corticosteroids, and intramuscular magnesium are in treating chronic fatigue syndrome. Antidepressants should be considered in people with affective disorders, and tricyclics in particular have potential therapeutic value because of their analgesic properties.

Interventions such as dietary supplements, evening primrose oil, oral nicotinamide adenine dinucleotide, homeopathy, and prolonged rest have not been studied in enough detail for us to draw conclusions on their efficacy.

A large study has found that galantamine is no better than placebo at improving symptoms of chronic fatigue syndrome.

Although there is some evidence that immunotherapy can improve symptoms compared with placebo, it is associated with considerable adverse effects, and should therefore probably not be offered as a treatment for chronic fatigue.

Background

During the early stages of the 2009 swine flu (influenza H1N1) outbreak, the large majority of patients who contacted the health services about the illness did not have it. In the UK, the NHS Direct telephone service was used by many of these patients. We used qualitative interviews to identify the main reasons why people approached NHS Direct with concerns about swine flu and to identify aspects of their contact which were reassuring, using a framework approach.

Methods

33 patients participated in semi-structured interviews. All patients had telephoned NHS Direct between 11 and 14 May with concerns about swine flu and had been assessed as being unlikely to have the illness.

Results

Reasons for seeking advice about swine flu included: the presence of unexpectedly severe flu-like symptoms; uncertainties about how one can catch swine flu; concern about giving it to others; pressure from friends or employers; and seeking 'peace of mind.' Most participants found speaking to NHS Direct reassuring or useful. Helpful aspects included: having swine flu ruled out; receiving an alternative explanation for symptoms; clarification on how swine flu is transmitted; and the perceived credibility of NHS Direct. No-one reported anything that had increased their anxiety and only one participant subsequently sought additional advice about swine flu from elsewhere.

Conclusions

Future major incidents involving other forms of chemical, biological or radiological hazards may also cause large numbers of unexposed people to seek health advice. Our data suggest that providing telephone triage and information is helpful in such instances, particularly where advice can be given via a trusted, pre-existing service.

Background

In October 2009 it was reported that 68 of 101 patients with chronic fatigue syndrome (CFS) in the US were infected with a novel gamma retrovirus, xenotropic murine leukaemia virus-related virus (XMRV), a virus previously linked to prostate cancer. This finding, if confirmed, would have a profound effect on the understanding and treatment of an incapacitating disease affecting millions worldwide. We have investigated CFS sufferers in the UK to determine if they are carriers of XMRV.

Methodology

Patients in our CFS cohort had undergone medical screening to exclude detectable organic illness and met the CDC criteria for CFS. DNA extracted from blood samples of 186 CFS patients were screened for XMRV provirus and for the closely related murine leukaemia virus by nested PCR using specific oligonucleotide primers. To control for the integrity of the DNA, the cellular beta-globin gene was amplified. Negative controls (water) and a positive control (XMRV infectious molecular clone DNA) were included. While the beta-globin gene was amplified in all 186 samples, neither XMRV nor MLV sequences were detected.

Conclusion

XMRV or MLV sequences were not amplified from DNA originating from CFS patients in the UK. Although we found no evidence that XMRV is associated with CFS in the UK, this may be a result of population differences between North America and Europe regarding the general prevalence of XMRV infection, and might also explain the fact that two US groups found XMRV in prostate cancer tissue, while two European studies did not.

We assessed perceptions and likely reactions of 1,005 UK adults to a hypothetical terrorist attack involving pneumonic plague. Likely compliance with official recommendations ranged from good (98% would take antimicrobial drugs) to poor (76% would visit a treatment center). Perceptions about plague were associated with these intentions.

The UK government sees increasing individual preparedness as a priority, but the level of preparedness of people in the UK for a large-scale emergency is not known. The London bombings of July 7, 2005, affected many Londoners and may have altered their sense of vulnerability to a future terrorist attack. We used a longitudinal study design to assess individual preparedness within the same sample of Londoners at 2 points in time: immediately after the bombings (T1) and 7 to 8 months later (T2). A demographically representative sample of 1,010 Londoners participated in a phone interview at T1. Subsequently, at T2, 574 of the same people participated in a follow-up phone interview. At T1 51% of Londoners had made 4 or more relevant emergency plans; 48% had gathered 4 or more relevant supplies in case of emergency. There was evidence of increased preparedness at T2, by which time 90% had made 4 or more emergency plans. Ethnicity, low social status, and having felt a sense of threat during the bombings predicted increased preparedness between T1 and T2. Women in general, and women of low social status in particular, perceived themselves to be unprepared in the event of a future terrorist attack. In summary, Londoners show moderate levels of emergency preparedness, which increased following the London bombings. Although we cannot know whether this association is causal, the prospective nature of the study increases the likelihood that it is. However, preparedness is still patchy, and there are important demographic associations with levels of preparedness and perception of vulnerability. These findings have implications for future development of individual and community emergency preparedness policy.

Objective

Neurologists face a dilemma when communicating with their conversion disorder patients – whether to be frank, and risk losing the patient's trust, or to disclose less, in the hope of building a therapeutic relationship. This study reports how neurologists in the UK described dealing with this dilemma in their practice.

Methods

Practicing consultant neurologists from an NHS region were recruited by snowball sampling. Twenty-two of 35 consultants in the region were interviewed in depth, and the interviews qualitatively analysed.

Results

The neurologists were reluctant to disclose conversion disorder as a differential diagnosis until they were certain. They were guided by the receptivity of their patients as to how psychological to make their eventual explanations, but they did not discuss their suspicions about feigning. They described their communications as much easier now than they had seen in training.

Conclusion

Neurologists adapt their disclosure to their patients, which facilitates communication, but imposes some limits on truth-telling. In particular, it may sometimes result in a changed diagnosis.

Practice implications

An optimum strategy for communicating diagnoses will need to balance ethical considerations with demonstrated therapeutic benefit.

Background

The mental health of the Armed Forces is an important issue of both academic and public interest. The aims of this study are to: a) assess the prevalence and risk factors for common mental disorders and post traumatic stress disorder (PTSD) symptoms, during the main fighting period of the Iraq War (TELIC 1) and later deployments to Iraq or elsewhere and enlistment status (regular or reserve), and b) compare the prevalence of depression, PTSD symptoms and suicidal ideation in regular and reserve UK Army personnel who deployed to Iraq with their US counterparts.

Methods

Participants were drawn from a large UK military health study using a standard two phase survey technique stratified by deployment status and engagement type. Participants undertook a structured telephone interview including the Patient Health Questionnaire (PHQ) and a short measure of PTSD (Primary Care PTSD, PC-PTSD). The response rate was 76% (821 participants).

Results

The weighted prevalence of common mental disorders and PTSD symptoms was 27.2% and 4.8%, respectively. The most common diagnoses were alcohol abuse (18.0%) and neurotic disorders (13.5%). There was no health effect of deploying for regular personnel, but an increased risk of PTSD for reservists who deployed to Iraq and other recent deployments compared to reservists who did not deploy. The prevalence of depression, PTSD symptoms and subjective poor health were similar between regular US and UK Iraq combatants.

Conclusion

The most common mental disorders in the UK military are alcohol abuse and neurotic disorders. The prevalence of PTSD symptoms remains low in the UK military, but reservists are at greater risk of psychiatric injury than regular personnel.