Walter Busuttil

PTSD, stigma and barriers to help-seeking within the UK Armed Forces

Among the general public, much is known about the longer-term consequences of not seeking support for mental health difficulties. However, within military populations, and in particular, the UK Armed Forces, less is known. Understanding the factors that present barriers for UK service personnel with mental health difficulties accessing support is important because this may provide a means for support personnel to seek help sooner. This paper explores the literature relating to the impact of untreated post-traumatic stress disorder (PTSD) among military personnel, attempts to draw conclusions about the barriers that may prevent personnel seeking help and the efficacy of previous interventions to address these. Stigma has been highlighted as the key barrier to help-seeking behaviours, in particular, internal stigma, which can be classified as negative beliefs about the self that an individual may hold as a result of experiencing symptoms of PTSD.

Mental health and functional impairment outcomes following a 6-week intensive treatment programme for UK military veterans with post-traumatic stress disorder (PTSD): a naturalistic study to explore dropout and health outcomes at follow-up

Objective Combat Stress, a UK national charity for veterans with mental health problems, has been funded by the National Health Service (NHS) to provide a national specialist service to deliver treatment for post-traumatic stress disorder (PTSD). This paper reports the efficacy of a PTSD treatment programme for UK veterans at 6 months follow-up. Design A within subject design. Setting UK veterans with a diagnosis of PTSD who accessed Combat Stress. Participants 246 veterans who received treatment between late 2012 and early 2014. Intervention An intensive 6-week residential treatment programme, consisting of a mixture of individual and group sessions. Participants were offered a minimum of 15 individual trauma-focused cognitive behavioural therapy sessions. In addition, participants were offered 55 group sessions focusing on psychoeducational material and emotional regulation. Main outcome measures Clinicians completed measures of PTSD and functional impairment and participants completed measures of PTSD, depression, anger and functional impairment. Results We observed significant reductions in PTSD scores following treatment on both clinician completed measures (PSS-I: −13.0, 95% CI −14.5 to −11.5) and self-reported measures (Revised Impact of Events Scale (IES-R): −16.5, 95% CI −19.0 to −14.0). Significant improvements in functional impairment were also observed (eg, Health of the Nation Outcome Scales (HONOS): −6.85, 95% CI −7.98 to −5.72). There were no differences in baseline outcomes between those who completed and those who did not complete the programme, or post-treatment outcomes between those we were able to follow-up at 6 months and those lost to follow-up. Conclusions In a naturalistic study we observed a significant reduction in PTSD scores and functional impairment following treatment. These improvements were maintained at 6 month follow-up. Our findings suggest it may be helpful to take a closer look at combining individual trauma-focused cognitive behaviour therapy and group sessions when treating veterans with PTSD. This is the first UK study of its kind, but requires further evaluation.

Iraq and Afghanistan veteran presentations to Combat Stress, since 2003

BACKGROUND Recently, proposals have been made to improve mental health care for U.K. military veterans. Combat stress (CS), a veterans charity, has provided mental health services for veterans since 1919. Since 2003, service users have included veterans from the Iraq and Afghanistan conflicts; however, their pattern of help-seeking has not been evaluated. AIMS To describe the characteristics of the veteran population of the recent Iraq or Afghanistan conflicts who sought help from CS between 2003 and May 2011. METHODS CS Iraq and Afghanistan veteran clinical and welfare records were evaluated. RESULTS Nine hundred and eighty-eight records were evaluated. The median time for veterans of recent conflicts to seek help from CS since discharge from military service was ~2 years, considerably shorter than the mean time of 14 years previously estimated by CS. Approximately, three-quarters of the veterans receiving a full clinical assessment (n = 114), received a diagnosis of post traumatic stress disorder (PTSD) (n = 87). Approximately half of the clinically assessed veterans self-referred to CS (51%); their most frequent diagnosis was PTSD. CONCLUSIONS Veterans who have served in Iraq and Afghanistan are presenting to Combat stress sooner, and at a younger age, than veterans of previous conflicts and operations.

Describing the profile of a population of UK veterans seeking support for mental health difficulties

Abstract Background: Evidence suggests that veterans with mental health issues have poorer treatment outcomes than civilian counterparts. Understanding the difficulties faced by veterans could help focus treatments and improve outcomes. Aims: To survey a representative sample of treatment-seeking veterans to explore their mental health needs. Methods: A random sample of UK veterans who had engaged with a national mental health charity in the UK was drawn. Individuals completed questionnaires about their health, military experiences and pre-enlistment vulnerabilities. Results: Four hundred and three out of six hundred (67.2%) participants returned completed questionnaires. PTSD was the most commonly endorsed mental health difficulty (82%), followed by problems with anger (74%), common mental health difficulties (72%) and alcohol misuse (43%). Comorbidity was frequent; with 32% of those with PTSD meeting criteria for three other health outcomes versus only 5% with PTSD alone. Conclusions: Results indicate the complexity of presentations within treatment seeking veterans. These difficulties may partly explain the poorer treatment outcomes reported in veterans in comparison to the general public. As such, it would be prudent for interventions targeted at veterans with mental health difficulties to attempt to address the range of issues faced by this population rather than focus on a particular presenting problem.

Exploring optimum cut-off scores to screen for probable posttraumatic stress disorder within a sample of UK treatment-seeking veterans

ABSTRACT Background: Previous research exploring the psychometric properties of the scores of measures of posttraumatic stress disorder (PTSD) suggests there is variation in their functioning depending on the target population. To date, there has been little study of these properties within UK veteran populations. Objective: This study aimed to determine optimally efficient cut-off values for the Impact of Event Scale-Revised (IES-R) and the PTSD Checklist for DSM-5 (PCL-5) that can be used to assess for differential diagnosis of presumptive PTSD. Methods: Data from a sample of 242 UK veterans assessed for mental health difficulties were analysed. The criterion-related validity of the PCL-5 and IES-R were evaluated against the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Kappa statistics were used to assess the level of agreement between the DSM-IV and DSM-5 classification systems. Results: The optimal cut-off scores observed within this sample were 34 or above on the PCL-5 and 46 or above on the IES-R. The PCL-5 cut-off is similar to the previously reported values, but the IES-R cut-off identified in this study is higher than has previously been recommended. Overall, a moderate level of agreement was found between participants screened positive using the DSM-IV and DSM-5 classification systems of PTSD. Conclusions: Our findings suggest that the PCL-5 and IES-R can be used as brief measures within veteran populations presenting at secondary care to assess for PTSD. The use of a higher cut-off for the IES-R may be helpful for differentiating between veterans who present with PTSD and those who may have some sy`mptoms of PTSD but are sub-threshold for meeting a diagnosis. Further, the use of more accurate optimal cut-offs may aid clinicians to better monitor changes in PTSD symptoms during and after treatment.

Mental Health Difficulties and Help-Seeking Beliefs within a Sample of Female Partners of UK Veterans Diagnosed with Post-Traumatic Stress Disorder

In the UK there is a paucity of research about the needs of partners who are supporting ex-service personnel with mental health difficulties. In this study, we surveyed the mental health needs and barriers to help-seeking within a sample of partners of UK veterans who had been diagnosed with PTSD. Our sample included 100 participants. Forty-five percent met criteria for alcohol problems, 39% for depression, 37% for generalised anxiety disorder and 17% for symptoms of probable PTSD. Participants who met case criteria for depression, anxiety and problems with alcohol were more likely to report a greater number of help-seeking barriers. Participants who were experiencing mental health difficulties were more likely to endorse barriers connected to stigmatising beliefs than those associated with practical issues around accessing mental health services. The evidence presented suggests there may be a considerable burden of mental illness within this population. It would seem prudent to conduct further work to understand how best to address this clinical need.

Do Alcohol Misuse, Service Utilisation, and Demographic Characteristics Differ between UK Veterans and Members of the General Public Attending an NHS General Hospital?

The aim of this paper was to provide insights into alcohol misuse within UK veterans to inform as to whether their presentations differ from the general public. This was done by exploring differences in the severity of alcohol misuse between UK veterans and the general public admitted to a general NHS hospital over an 18 month period using retrospective data. All patients admitted to the hospital were screened for alcohol misuse. Those deemed as experiencing problems were referred for specialist nurse-led support. A total of 2331 individuals were referred for this supported and administered with a standardised assessment that included measures of the severity of alcohol difficulties (AUDIT), dependency levels (LDQ), and assessed for the presence of withdrawal symptoms (CIWA-Ar). In addition, information was collected on service utilisation, referral category (medical or mental health), other substance misuse, and demographic characteristics. No differences were found between the severity of reported alcohol difficulties between veterans and non-veterans. Evidence was found to suggest that veterans were more likely to be referred for support with alcohol difficulties at an older age and to be admitted to hospital for longer periods of time. This could have considerable cost implications for the NHS. It was more common for veterans to present at hospital with physical health difficulties prior to being referred for support for alcohol.

Long-term responses to treatment in UK veterans with military-related PTSD: an observational study

Objectives Military-related trauma can be difficult to treat. Evaluating longer term responses to treatment and identifying which individuals may need additional support could inform clinical practice. We assessed 1-year outcomes in UK veterans treated for post-traumatic stress disorder (PTSD). Design Within-participant design. Setting The intervention was offered by Combat Stress, a mental health charity for veterans in the UK. Participants The sample included 401 veterans who completed a standardised 6-week residential treatment. Of these, 268 (67%) were successfully followed up a year after the end of treatment. Methods A range of health outcomes were collected pretreatment and repeated at standard intervals post-treatment. The primary outcome was severity of PTSD symptoms, and secondary outcomes included measures of other mental health difficulties (depression, anxiety and anger), problems with alcohol, and social and occupational functioning. Results Significant reductions in PTSD severity were observed a year after treatment (PSS-I: −11.9, 95% CI −13.1 to −10.7). Reductions in the secondary outcomes were also reported. Higher levels of post-treatment functional impairment (0.24, 95% CI 0.08 to 0.41) and alcohol problems (0.18, 95% CI 0.03 to 0.32) were associated with poorer PTSD treatment response at 12 months. Conclusions This uncontrolled study suggests the longer term benefits of a structured programme to treat UK veterans with PTSD. Our findings point to the importance of continued support targeted for particular individuals post-treatment to improve longer term outcomes.

Post-traumatic growth among the UK veterans following treatment for post-traumatic stress disorder

Introduction The aim of this paper was to examine levels of post-traumatic growth (PTG) in a sample of the UK veterans who had received treatment for post-traumatic stress disorder (PTSD). Methods The study followed-up 149 UK veterans after they had completed standardised treatment for PTSD provided by Combat Stress. Data had previously been collected on a range of mental health outcomes before treatment, and then repeated 6 months after the end of treatment. For the current study, participants completed the post-traumatic growth inventory (PTGI) measure. Analysis was conducted to explore levels of PTG and whether there were any relationships between pretreatment and post-treatment ratings of mental health and PTG. Results The mean score on the PTGI was 32.6. Evidence of a treatment effect on levels of PTG was observed. There appeared to be a relationship between improvements in symptoms of PTSD and depression and higher levels of PTG. Conclusions This study observed the presence of PTG following exposure to traumatic events within a sample of the UK veterans following their treatment for PTSD. PTG scores were moderately low in comparison to similar studies in the USA.

Describing the feasibility of using case management in a specialist forensic substance misuse intervention for UK veterans: a case study

ABSTRACT Veterans with mental health problems are a high-risk group for substance misuse difficulties and are over-represented in forensic settings. Yet, there are few substance misuse services available for this population. Evidence suggests that case management can provide effective interventions for veterans with substance misuse problems. However, there is little research to show its effectiveness in the UK. The present study reported on the implementation and preliminary outcomes of the Veterans Forensic Substance Misuses Service (VFSMS), piloted within a prison setting, to demonstrate the feasibility of the service. The VFSMS operated in four stages: Assessing needs, developing case management plans, providing bespoke support and developing discharge plans. Case studies were used to demonstrate this process, with measures of alcohol use and recovery showing outcomes for each case. Findings from three case studies suggested that case management was a feasible approach, with a range of interventions being used, including substance misuse and mental health services, plus housing and employment services. Outcome measures suggested that alcohol and substance misuse recovery improved following the VFSMS intervention. While the scope of the findings is limited, they suggested that case management is a feasible substance misuse intervention, with preliminary findings showing improvements in substance misuse outcomes.