Beverly P. Bergman

Acute Myocardial Infarction in Scottish Military Veterans: A Retrospective Cohort Study of 57,000 Veterans and 173,000 Matched Nonveterans

Few studies of veterans have examined cardiovascular disease as the primary outcome, other than in relation to specific conflicts or hazards. To assess the long-term risk and prognosis of acute myocardial infarction (AMI) in United Kingdom veterans from a broad range of military backgrounds and experience, we conducted a retrospective cohort study of 57,000 veterans resident in Scotland and 173,000 civilians matched on age, sex, and area of residence. Cox proportional hazards models were used to compare the risks of fatal/nonfatal AMI overall, by sex, and by year of birth, adjusting for the potentially confounding effect of socioeconomic status, and to compare rates of case-fatality following AMI at 30-day, 1-year, and 5-year follow-up. Over a mean follow-up period of 29 years between 1981 and 2012, a total of 2,106 (3.8%) veterans experienced an AMI as compared with 5,261 (3.1%) nonveterans (hazard ratio = 1.22, 95% confidence interval: 1.16, 1.29; P < 0.001). There was an increased risk of AMI among veterans born in 1945-1959 but not among those born from 1960 onward. Case-fatality was lower among veterans at 30-day, 1-year, and 5-year follow-up. We conclude that health behaviors such as smoking may have increased the risk of AMI in older veterans but that younger veterans have benefited from in-service health promotion initiatives.

Motor neurone disease and military service: evidence from the Scottish Veterans Health Study

Objectives In 2003, it was reported that motor neurone disease was linked to military service in the 1990–1991 Gulf War. A large study in the US confirmed an association with military service but found no association with specific conflicts or length of service. Non-veteran studies have suggested an association with physical activity, smoking and other risk factors. We used data from the Scottish Veterans Health Study to investigate the association between motor neurone disease and military service in UK veterans. Methods Retrospective cohort study of 57 000 veterans born 1945–1985, and 173 000 demographically matched civilians, using Cox proportional hazard models to compare the risk of motor neurone disease overall, and by sex, birth cohort, length of service and year of recruitment. We had no data on smoking prevalence. Results Veterans had an increased risk of motor neurone disease compared with non-veterans (adjusted HR 1.49, 95% CI 1.01 to 2.21, p=0.046). The increase was independent of birth cohort, length or period of service, or year of recruitment. Risk was associated with a history of trauma or road traffic accident in veterans and non-veterans. Conclusions We confirmed an increased risk of motor neurone disease in military veterans, although the absolute risk is extremely low. We found no evidence that the increased risk was associated with any specific conflict. We could not rule out that smoking (and perhaps other lifestyle factors) may be responsible for our findings. Trauma may play a role in the increased risk but further studies are needed.

Long-Term Mental Health Outcomes of Military Service: National Linkage Study of 57,000 Veterans and 173,000 Matched Nonveterans.

OBJECTIVE We used data from the Scottish Veterans Health Study to examine long-term mental health outcomes in a large cohort of veterans, with a focus on the impact of length of service. METHODS We conducted a retrospective, 30-year cohort study of 56,205 veterans born from 1945 through 1985, including 14,702 who left military service prematurely, and 172,741 people with no record of military service, using Cox proportional hazard models, to examine the association between veteran status and length of service and cumulative risk of mental health disorder. We stratified the veterans by common lengths of service, defining Early Service Leavers as those who had served for less than 2.5 years. RESULTS There were 2,794 (4.97%) first episodes of any mental health disorder in veterans, compared with 7,779 (4.50%) in nonveterans. The difference was statistically significant for all veterans (adjusted hazard ratio [HR] = 1.21; 95% CI, 1.16-1.27; P < .001). Subgroup analysis showed the highest risk to be in Early Service Leavers (adjusted HR = 1.51; 95% CI, 1.30-1.50; P < .001), including those who failed to complete initial training. The risk reduced with longer service; beyond 9 years of service, risk of mental health disorder was comparable to or lower than that in nonveterans. CONCLUSIONS The veterans at highest risk of mental health disorder were those who did not complete training or minimum engagement, while those with longest service were at reduced risk, suggesting that military service was not causative. The high risk among the earliest leavers may reflect pre-service vulnerabilities not detected at recruitment, which become apparent during early training and lead to early discharge.

Service Life and Beyond – Institution or Culture?

In the UK, armed services personnel are perceived to become institutionalised during service, with negative connotations, especially in the process of transition to veteran status. Beverly P Bergman, Howard J Burdett and Neil Greenberg argue that institutionalisation is an inappropriate model, and that becoming a member of the armed forces is better represented by a model of culture shock, with reverse culture shock being experienced upon leaving. The adoption of this model would be useful both in preparing UK service personnel for civilian life and in supporting them after transition, and may help to predict vulnerability.

Suicide in Scottish military veterans: a 30-year retrospective cohort study

Background Although reassuring data on suicide risk in UK veterans of the 1982 Falklands conflict and 1991 Gulf conflict have been published, there have been few studies on long-term overall suicide risk in UK veterans. Aims To examine the risk of suicide in a broad population-based cohort of veterans in Scotland, irrespect ive of length of service or exposure to conflict, in comparison with people having no record of military service. Methods A retrospective 30-year cohort study of 56205 veterans born 1945-85 and 172741 matched non-veterans, using Cox proportional hazard models to compare the risk of suicide and fatal self-harm overall, by sex, birth cohort, length of service and year of recruitment. Results There were 267 (0.48%) suicides in the veterans compared with 918 (0.53%) in non-veterans. The difference was not statistically significant overall [adjusted hazard ratio (HR) 0.99; 95% confidence interval (CI) 0.86-1.13]. The incidence was lower in younger veterans and higher in veterans aged over 40. Early service leavers were at non-significantly increased risk (adjusted HR 1.13; 95% CI 0.91-1.40) but only in the older age groups. Women veterans had a significantly higher risk of suicide than non-veteran women (adjusted HR 2.44; 95% CI 1.32-4.51, P < 0.01) and comparable risk to veteran men. Methods of suicide did not differ significantly between veterans and non-veterans, for either sex. Conclusions The Scottish Veterans Health Study adds to the emerging body of evidence that there is no overall difference in long-term risk of suicide between veterans and non-veterans in the UK. However, female veterans merit further study.

Long-term consequences of alcohol misuse in Scottish military veterans.

Objective Serving military personnel are more likely to drink heavily than civilians. The aim of our study was to examine whether veterans have an increased risk of alcoholic liver disease and alcohol-related death compared with non-veterans. Design Retrospective cohort study of 57 000 veterans resident in Scotland and 173 000 age, sex and area of residence-matched civilians, using Cox proportional hazard models to compare the risk of alcoholic liver disease and alcohol-related death overall, by sex, birth cohort, length of service and year of recruitment, adjusting for socioeconomic status. Results Over mean 29 years follow-up, 677 (1.20%) veterans developed alcoholic liver disease compared with 2175 (1.26%) non-veterans (adjusted HR=0.91, 95% CIs 0.84 to 0.99, p=0.035). Only the 1945–1949 veterans’ birth cohort was at higher risk, unadjusted HR=1.25, 95% CIs 1.07 to 1.47, p=0.004, although their difference in risk became non-significant after adjusting for socioeconomic status, p=0.052. The pattern was similar for alcohol-related death. Veterans were less likely than non-veterans to have comorbid hepatitis C. Older age at recruitment at a time of high operational activity in the early 1970s was associated with increased risk, but longer service was not. Conclusions Overall, veterans in Scotland had a significantly reduced risk of alcoholic liver disease or alcohol-related death compared with non-veterans, although the risk was higher in those born before 1950. Reasons for the changing pattern are likely to be complex and may reflect operational exposure, social attitudes to alcohol and the impact of recent military health promotion.

The influence of geology in the development of public health

Abstract Public health, the protection of the health of populations through community engagement, is a modern specialty originating in post-Industrial Revolution Britain, while environmental geochemistry is of even more recent origin. The influence of geology on health was first recognized in Classical times, although it was later supplanted by the miasma theory of disease. During the Renaissance, medical teaching began to concentrate more on diagnosis and treatment of the sick individual and less on preserving the health of populations. The concept of geology as a determinant of health re-emerged with the growth of scientific knowledge during the Enlightenment period of the eighteenth century. The nineteenth century saw the first identification of trace element deficiency disease and the publication of a textbook of public health which described geological influences on health. Over the next 100 years both public health and environmental geochemistry became established on a firm footing, although as separate disciplines. Recently the public health focus has been on lifestyle choices, but environmental geochemistry remains a potentially powerful partner in the fight to protect health, and there is much scope to enhance collaborative working. The legacy of the pioneers of both public health and geology must not be forgotten.

Non-fatal self-harm in Scottish military veterans: a retrospective cohort study of 57,000 veterans and 173,000 matched non-veterans

PurposeAlthough suicide risk in veterans has been widely studied, there is little information on the risk of non-fatal self-harm in this population. We used data from the Scottish Veterans Health Study to conduct an epidemiological analysis of self-harm in veterans, in comparison with people who have never served.MethodsWe conducted a retrospective, 30-year cohort study of 56,205 veterans born 1945–1985, and 172,741 people with no record of military service, and used Cox proportional hazard models to examine the association between veteran status and cumulative risk of non-fatal self-harm, overall and stratified by birth cohort, sex and length of service. We also examined mental and physical comorbidities, and association of suicide with prior self-harm.ResultsThere were 1620 (2.90%) first episodes of self-harm in veterans, compared with 4212 (2.45%) in non-veterans. The difference was statistically significant overall (unadjusted HR 1.27, 95% CI 1.21–1.35, p < 0.001). The risk was highest in the oldest veterans, and in the early service leavers who failed to complete initial training (unadjusted HR 1.69, 95% CI 1.50–1.91, p < 0.001). The risk reduced with longer service and in the intermediate birth cohorts but has increased again in the youngest cohort.ConclusionsThe highest risk of non-fatal self-harm was in veterans with the shortest service, especially those who did not complete training or minimum engagement, and in the oldest birth cohorts, whilst those who had served the longest were at reduced risk. The risk has increased again in the youngest veterans, and further study of this subgroup is indicated.

Peripheral arterial disease in Scottish military veterans: a retrospective cohort study of 57 000 veterans and 173 000 matched non-veterans

BACKGROUND While traumatic limb loss in military personnel is widely known, the threat posed by peripheral arterial disease (PAD) in those who have served is less well recognized. The aim of our study was to examine the risk of PAD in a Scotland-wide cohort of veterans who served between 1960 and 2012. METHODS Retrospective 30-year cohort study of 56 205 veterans born 1945-85, and 172 741 non-veterans, matched for age, sex and area of residence, using Cox proportional hazard models to examine the association between veteran status, birth cohort, length of service and risk of PAD leading to hospitalization or death. RESULTS Overall, veterans were at increased risk of PAD compared with non-veterans, unadjusted hazard ratio (HR) = 1.46, 95% confidence intervals (CI): 1.33-1.60, P < 0.001. The highest risk was in veterans born between 1950 and 1954, HR = 1.76, 95% CI: 1.50-2.07, P < 0.001, and in those with the shortest service (early service leavers), HR = 1.84, 95% CI: 1.49-2.27, P < 0.001. CONCLUSIONS The findings provide evidence for a hidden burden of life- and limb-threatening PAD in older veterans and are consistent with the higher rates of military smoking which have been reported previously. The study emphasizes the need for vascular preventive measures in this group.

Road traffic accidents in Scottish military veterans

Road traffic accidents (RTA) are recognised to be an important cause of death and injury in serving military personnel but little is known about the risk in veterans. We used data from the Scottish Veterans Health Study to examine the risk of RTA in a large national cohort of veterans, in comparison with people who had never served. We conducted a retrospective cohort study of 57,000 veterans and 173,000 non-veterans, followed up for up to 30 years, using survival analysis to compare risk of RTA injury. Subgroup analysis was used to explore trends by birth cohort and length of service. Overall, veterans had a higher risk of RTA (Cox proportional hazard ratio (HR) 1.17, 95% confidence intervals (CI) 1.14-1.20). The risk was highest in the veterans with the shortest service (early service leavers), including those who did not complete initial military training (HR 1.31, 95% CI 1.23-1.40). The mean age at first RTA was 34 years, irrespective of age at leaving service, and the greatest increase in risk was in veterans born in the 1960s, but veterans born after 1970 showed no increase in risk. We have therefore demonstrated that the increased risk of RTA observed in serving military personnel persists in veterans through the fourth decade of life. The high risk in early service leavers is likely to be related to risk factors other than military service, including previous childhood adversity. Recent Ministry of Defence road safety programmes may now be reducing the long-term risk of RTA injury.