Laura Goodwin

What explains post-traumatic stress disorder (PTSD) in UK service personnel: deployment or something else?

BACKGROUND In previous studies an association between deployment to Iraq or Afghanistan and an overall increased risk for post-traumatic stress disorder (PTSD) in UK armed forces has not been found. The lack of a deployment effect might be explained by including, in the comparison group, personnel deployed on other operations or who have experienced traumatic stressors unrelated to deployment. METHODS The sample comprised 8261 regular UK armed forces personnel who deployed to Iraq, Afghanistan or other operational areas or were not deployed. Participants completed the PTSD CheckList-Civilian Version (PCL-C) and provided information about deployment history, demographic and service factors, serious accidents and childhood experiences. RESULTS Deployment to Iraq or Afghanistan [odds ratio (OR) 1.2, 95% confidence interval (CI) 0.6-2.2] or elsewhere (OR 1.1, 95% CI 0.6-2.0) was unrelated to PTSD although holding a combat role was associated with PTSD if deployed to Iraq or Afghanistan (OR 2.7, 95% CI 1.9-3.9). Childhood adversity (OR 3.3, 95% CI 2.1-5.0), having left service (OR 2.7, 95% CI 1.9-4.0) and serious accident (OR 2.1, 95% CI 1.4-3.0) were associated with PTSD whereas higher rank was protective (OR 0.3, 95% CI 0.12-0.76). CONCLUSIONS For the majority of UK armed forces personnel, deployment whether to Iraq, Afghanistan or elsewhere confers no greater risk for PTSD than service in the armed forces per se but holding a combat role in those deployed to Iraq or Afghanistan is associated with PTSD. Vulnerability factors such as lower rank, childhood adversity and leaving service, and having had a serious accident, may be at least as important as holding a combat role in predicting PTSD in UK armed forces personnel.

Suicidal behaviours in South East London: Prevalence, risk factors and the role of socio-economic status

BACKGROUND Low socio-economic status (SES) is an established risk factor of suicidal behaviours, but it is unknown to what extent its association is direct, indirect or confounded, given its strong association to mental health. We aimed to (I) estimate the prevalence of suicidal behaviours; (II) describe relevant risk factors; and (III) investigate direct and indirect effects of SES on suicidal behaviours. METHODS We used cross-sectional community survey data of adults from randomly selected South East London households (SELCoH). Suicidal outcome measures replicated the 2007 Adult Psychiatric Morbidity Survey in England (APMS). Lifetime prevalence was described by socio-demographics, SES, mental health indicators, and life events. Structured symptom screens and a drug use questionnaire measured mental health. Structural equation models estimated direct and indirect effects of a latent SES variable on suicidal ideation and suicide attempts, adjusting for covariates. RESULTS 20.5% (95% CI: 18.4-22.7) reported suicidal ideation and 8.1% (95% CI: 6.8-9.7) reported suicide attempts (higher than APMS estimates: 13.7%, 4.8%, respectively). Unadjusted risk factors included poor mental health, low SES, and non-married/non-cohabitating relationship status. Black African ethnicity was protective, and women reported more suicide attempts. SES was directly associated to suicide attempts, but not suicidal ideation. SES had indirect effects on suicidal outcomes via mental health and life events. LIMITATIONS The cross-sectional design and application of measures for different time periods did not allow for causal inferences. CONCLUSIONS Suicidal behaviours were more prevalent than in the general UK population. Interventions targeting low SES individuals may prove effective in preventing suicide attempts.

Premorbid risk markers for chronic fatigue syndrome in the 1958 British birth cohort

BACKGROUND Little is known about the aetiology of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME); prospective studies suggest a role for premorbid mood disorder. AIMS To examine childhood and early adult adversity, ill health and physical activity as premorbid risk markers for CFS/ME by 42 years, taking psychopathology into account. METHOD Data were from the 1958 British birth cohort, a prospective study from birth to 42 years (n = 11 419). The outcomes were self-reported CFS/ME (n = 127) and operationally defined CFS-like illness (n = 241) at 42 years. RESULTS Adjusting for psychopathology, parental physical abuse (odds ratio (OR) = 2.10, 95% CI 1.16-3.81), childhood gastrointestinal symptoms (OR = 1.58, 95% CI 1.00-2.50) and parental reports of many colds (OR = 1.65, 95% CI 1.09-2.50) were independently associated with self-reported CFS/ME. Female gender and premorbid psychopathology were the only risk markers for CFS-like illness, independent of comorbid psychopathology. CONCLUSIONS This confirms the importance of premorbid psychopathology in the aetiological pathways of CFS/ME, and replicates retrospective findings that childhood adversity may play a role in a minority.

Are common mental disorders more prevalent in the UK serving military compared to the general working population

BACKGROUND Although the military is considered to be a stressful occupation, there are remarkably few studies that compare the prevalence of common mental disorder (CMD) between the military and the general population. This study examined the prevalence of probable CMD in a serving UK military sample compared to a general population sample of employed individuals. METHOD Data for the general population was from the 2003 and 2008 collections for the Health Survey for England (HSE) and for the serving military from phases 1 (2004-2006) and 2 (2007-2009) of the Kings Centre for Military Health Research (KCMHR) cohort study. Probable CMD was assessed by the General Health Questionnaire (GHQ-12). The datasets were appended to calculate the odds of CMD in the military compared to the general population. RESULTS The odds of probable CMD was approximately double in the military, when comparing phase 1 of the military study to the 2003 HSE [odds ratio (OR) 2.4, 95% confidence interval (CI) 2.1-2.7], and phase 2 to the 2008 HSE (OR 2.3, 95% CI 2.0-2.6) after adjustment for sex, age, social class, education and marital status. CONCLUSIONS Serving military personnel are more likely to endorse symptoms of CMD compared to those selected from a general population study as employed in other occupations, even after accounting for demographic characteristics. This difference may be partly explained by the context of the military study, with evidence from previous research for higher reports of symptoms from the GHQ in occupational compared to population studies, in addition to the role of predisposing characteristics.

Prevalence of Delayed-Onset Posttraumatic Stress Disorder in Military Personnel: Is There Evidence for This Disorder? Results of a Prospective UK Cohort Study

Abstract Delayed-onset posttraumatic stress disorder (PTSD) is defined as onset at least 6 months after a traumatic event. This study investigates the prevalence of delayed-onset PTSD in 1397 participants from a two-phase prospective cohort study of UK military personnel. Delayed-onset PTSD was categorized as participants who did not meet the criteria for probable PTSD (assessed using the PTSD Checklist Civilian version) at phase 1 but met the criteria by phase 2. Of the participants, 3.5% met the criteria for delayed-onset PTSD. Subthreshold PTSD, common mental disorder (CMD), poor/fair self-reported health, and multiple physical symptoms at phase 1 and the onset of alcohol misuse or CMD between phases 1 and 2 were associated with delayed-onset PTSD. Delayed-onset PTSD exists in this UK military sample. Military personnel who developed delayed-onset PTSD were more likely to have psychological ill-health at an earlier assessment, and clinicians should be aware of the potential comorbidity in these individuals, including alcohol misuse. Leaving the military or experiencing relationship breakdown was not associated.

Are reports of psychological stress higher in occupational studies? A systematic review across occupational and population based studies.

Objectives The general health questionnaire (GHQ) is commonly used to assess symptoms of common mental disorder (CMD). Prevalence estimates for CMD caseness from UK population studies are thought to be in the range of 14–17%, and the UK occupational studies of which we are aware indicate a higher prevalence. This review will synthesise the existing research using the GHQ from both population and occupational studies and will compare the weighted prevalence estimates between them. Methods We conducted a systematic review and meta-analysis to examine the prevalence of CMD, as assessed by the GHQ, in all UK occupational and population studies conducted from 1990 onwards. Results The search revealed 65 occupational papers which met the search criteria and 15 relevant papers for UK population studies. The weighted prevalence estimate for CMD across all occupational studies which used the same version and cut-off for the GHQ was 29.6% (95% confidence intervals (CIs) 27.3–31.9%) and for comparable population studies was significantly lower at 19.1% (95% CIs 17.3–20.8%). This difference was reduced after restricting the studies by response rate and sampling method (23.9% (95% CIs 20.5%–27.4%) vs. 19.2% (95 CIs 17.1%–21.3%)). Conclusions Counter intuitively, the prevalence of CMD is higher in occupational studies, compared to population studies (which include individuals not in employment), although this difference narrowed after accounting for measures of study quality, including response rate and sampling method. This finding is inconsistent with the healthy worker effect, which would presume lower levels of psychological symptoms in individuals in employment. One explanation is that the GHQ is sensitive to contextual factors, and it seems possible that symptoms of CMD are over reported when participants know that they have been recruited to a study on the basis that they belong to a specific occupational group, as in nearly all “stress” surveys.

Psychopathology and Physical Activity as Predictors of Chronic Fatigue Syndrome in the 1958 British Birth Cohort: A Replication Study of the 1946 and 1970 Birth Cohorts

Purpose In this study, we investigate whether prospective associations between psychopathology, physical activity, and chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) observed in the 1946 and 1970 birth cohorts were replicable in the 1958 British birth cohort. Methods Prospective study using the 1958 British birth cohort, which included 98.7% of births from 1 week in March 1958 in England, Wales, and Scotland. The outcome was self-reported CFS/ME by the age of 42 years, at which point 11,419 participants remained in the study. Psychopathology was assessed by the Rutter scales in childhood and the Malaise Inventory in adulthood. Physical activity was reported by the cohort member, mother and teacher in childhood and adulthood. Results The prevalence of CFS/ME was 1.0% (95% confidence interval [CI] = 0.9–1.3) and the median age of onset was 34 years. Premorbid psychopathology at 23 years (odds ratio [OR] = 1.85, 95% CI = 1.06–3.22) and 33 years (OR = 2.81, 95% CI = 1.28–6.18) significantly increased the odds of developing CFS/ME, supporting the 1946 cohort findings. Childhood psychopathology, sedentary behavior in childhood, and persistent exercise in adulthood were not associated with CFS/ME. Conclusions In cohort studies premorbid psychopathology in adulthood is a replicated risk marker for CFS/ME, whereas premorbid extremes of physical activity are not.

Factors affecting help seeking for mental health problems after deployment to Iraq and Afghanistan.

OBJECTIVE This study assessed the prevalence of general medical problems, stress or emotional problems, and alcohol problems reported by members of the armed forces of the United Kingdom after deployment in Iraq or Afghanistan. The study also identified types of help seeking and factors associated with help seeking. METHODS A total of 4,725 military personnel who were deployed to Iraq, Afghanistan, or both were asked about health problems attributable to the deployment and whether they had sought help for them. Data were collected through postal surveys between 2007 and 2009. Service and sociodemographic covariates and measures of current mental health, alcohol misuse, and functional impairment were included in the analyses. RESULTS Of the 19% who reported stress or emotional problems, 42% sought help, most commonly medical help (29%). Of the 6% who reported alcohol problems, 31% sought help, most commonly medical help (17%). Medical help seeking for stress or emotional problems was associated with being female, holding a lower rank, having functional impairment, and meeting criteria for two or more mental health problems. Being divorced or separated was positively associated with nonmedical help seeking for stress or emotional problems. Help seeking for alcohol problems was associated with current mental disorders. CONCLUSIONS Medical help seeking for stress or emotional problems was uncommon and was related to meeting criteria for two or more mental health problems. Commissioned officers were reluctant to seek medical help for stress or emotional problems. Help seeking for alcohol problems increased if personnel were experiencing additional mental health problems.

The factor structure of the PHQ-9 in palliative care

OBJECTIVES The Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ-9) is a common screening tool designed to facilitate detection of depression according to DSM-IV criteria. However, the factor structure of the PHQ-9 within the palliative care population has not been evaluated. METHODS 300 participants completed the PHQ-9 within one week of referral to a palliative care service. Participants completed the PHQ-9 again four weeks later (n=213). Confirmatory factor analysis (CFA) and multiple-group CFA were undertaken to test the factor structure of the PHQ-9 and evaluate model invariance over time. RESULTS A two-factor model comprising somatic and cognitive-affective latent factors provided the best fit to the data. Multiple-group CFA suggested model invariance over time. Structural equation modelling revealed that follow-up (time 2) cognitive-affective and somatic symptoms were predicted by their baseline (time 1) factors. CONCLUSIONS The PHQ-9 measures two stable depression factors (cognitive-affective and somatic) within the palliative care population. Studies are now required to examine the trajectories of these symptoms over time in relation to clinical intervention and events.

Life Course Study of the Etiology of Self-Reported Irritable Bowel Syndrome in the 1958 British Birth Cohort

Objective Irritable bowel syndrome (IBS) is a common gastrointestinal disorder with unknown etiology. This is the first study to use a life course approach to examine premorbid risk markers for self-reported IBS in a UK birth cohort. Methods Cohort study using the 1958 British birth cohort, which included 98.7% of births in 1 week in England, Wales, and Scotland. The outcome was self-reported IBS by the age of 42 years, classified with onset after 24 years and onset after 34 years. Childhood psychopathology was assessed by the Rutter scales, and adulthood psychopathology was assessed by the Malaise Inventory. Results The prevalence of self-reported IBS in this cohort was 8.4% by 42 years (95% confidence interval [CI] = 8.2–8.6). In multivariate analyses, being female (odds ratio [OR] = 2.00, 95% CI = 1.67–2.36), reporting 1 week to 1 month of school absence for ill health at 16 years (OR = 1.27, 95% CI = 1.03–1.56) and psychopathology at 23 years (OR = 1.25, 95% CI = 1.01–1.54) and 33 years (OR = 2.20, 95% CI = 1.74–2.76) were associated with an increased odds for IBS. Prospectively measured childhood adversity showed no significant association. Conclusions This is the first study to show a long-term prospective link between premorbid psychopathology and later self-reported IBS, in agreement with previous findings on chronic fatigue syndrome. There is no evidence that prospective measures of childhood adversity are risk markers for IBS, and there is weak evidence that prospective measures of childhood illness at 16 years are risk markers for IBS, differing to results from the same cohort for psychopathology, chronic fatigue syndrome, and chronic widespread pain. This study also does not replicate the findings of retrospective studies examining the etiology of IBS.