Patient characteristics and clinical activities at a British military department of community mental health

AIMS AND METHOD

To describe patient characteristics and clinical activitiesat a British military department of community mental health(DCMH). Data were drawn from a clinical database over a 1-yearperiod (n=409).

RESULTS

Mean age was 29 years, 50% were single and 76% were from thejunior ranks. Women were over-represented compared with thewider military population. Mean length of service prior topresentation was 5 years. The main presenting problem was alcoholmisuse (33%) followed by depression (19%). Twenty-five per centwere referred for psychotherapy and 68% returned to full employmentafter treatment.

CLINICAL IMPLICATIONS

Patient characteristics of those treated at a DCMH differ fromthose in the wider military. An out-patient occupational mentalhealth service returns a substantial number of patients tooccupational fitness within the Armed Forces.

Background

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Background

In recent years, the UK Armed Forces have been involved in numerous operational deployments in both peace support (including humanitarian assistance) and war fighting roles. Service personnel are atrisk of psychological distress following deployment (e.g. Jones et al, 2006, Hotopf et al, 2006), with military health in relation to militarycampaigns in Iraq and Afghanistan currently being a sourceof considerable political and media interest, especially post-traumaticstress disorder (PTSD) (Wessely, 2005). Meanwhile, defencehealthcare in the UK has changed considerably over the past10 years; all dedicated military medical hospitals have closedand a new centre of excellence for defence medicine has openedin Birmingham. Also, the UK Ministry of Defence (MOD) has recentlyfaced a number of high-profile legal cases. For example, in2002 ex-service personnel brought an unsuccessful class actionagainst the UK MOD for failing to detect post-traumatic stressproblems at an early stage and provide effective treatment (McGeorge et al, 2006).

In terms of mental health, the military take a number of stepsto ensure the welfare of their personnel, for example, briefingson stress and trauma-related problems are provided before andafter deployment. These briefings are also designed to addressbarriers to care, such as the stigma of mental health problems,which is a significant issue for the military (Wessely, 2005).However, it is noteworthy that, within the UK Armed Forces,the psychological welfare of troops is considered to be primarilya function of the chain of command, who are, in most cases,advised by mental health professionals rather than directedby them. Regular military personnel who may suffer with mentalhealth problems are assessed first by a military general practitioner(GP) and, if required, referred to a military department ofcommunity mental health (DCMH); DCMH are the main providersof psychological care within the Defence Mental Health Service(Defence Medical Services Department, 2006). However, to datethere are few published data on the type of patients seen andthe treatments offered by such services. Military communitymental health services have been reported on in the past, butas far as the authors are aware not since 1982 (Anthony & Fowlie, 1982). This study describes the nature of work undertaken by one RoyalNavy DCMH in terms of the patient profile and clinical activitiesprovided.

Defence mental health and setting
Greenberg et al (2002) provide a comprehensive overview ofmilitary mental health services. Briefly, the Defence MedicalService is responsible for the health of 195 000 Armed Forcespersonnel and approximately 40 000 MOD civilians and familiesabroad. The Defence Medical Service runs 15 DCMHs in the UKand several abroad (Germany, Cyprus and Gibraltar). Naval MentalHealth Services consist of three DCMH, located in three baseport areas, which provide services to all military personnel(Royal Navy, Army, Royal Air Force) within their catchment area. Departments of community mental health carry out clinical,educational and advisory services to both primary care andthe chain of command. Their aim is to provide timely assessmentand treatment to maximise operational and occupational capabilityand, for personnel who cannot be rehabilitated, to ensure theyreceive a smooth transition to civilian life. They are multidisciplinaryin their approach to care delivery. The DCMH under study coversa population of approximately 25 000 and is staffed with militaryand civilian consultant psychiatrists, a civilian clinicalpsychologist, a nurse therapist, mental health nurses, a civiliansocial worker and administrative personnel. Out-patient clinicsare held within the DCMH and medical centres at nearby militaryestablishments. The DCMH runs a number of specialist activities,including a day support group, alcohol education and anxiety management courses. Previously, The Duchess of Kent’sPsychiatric Hospital in Catterick, North Yorkshire, providedin-patient services. Since the closure of the Duchess of Kent’sPsychiatric Hospital in April 2004, in-patient services havebeen provided by an independent service provider. The DCMHoperates an out-of-hours advisory service.

Method

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Method

For audit purposes all clinicians complete a one-page summaryof their patient contact, which is entered into a clinicaldatabase. This includes socio-demographic data, service details,source of referral, treatments received, occupational functioningand presenting problem. Of note, not all patients are seenby a consultant psychiatrist so non-medical clinicians recordthe nature of the problem using a subset of ICD-10 (ICD-Light).Also, most patients meet with a mental health nurse who assumeskey worker responsibilities, therefore the clinical activitiesrecorded are in addition to meeting with a mental health nurse(where the mean number of contacts is seven). Data from ourclinical database were drawn on 409 patients (52% of the populationseen at the DCMH under study) over a 1-year period (1 November2005 to 31 October 2006). Due to time constraints data werenot collected on all patients. Data were entered into SPSS(version 12) and descriptive statistics were used to characterisethe sample and clinical activities.

Results

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Results

Socio-demographic and armed service characteristics are reportedin Table 1. Clinical activities are reported in Table 2. In brief, 82% were men, mean patient age was 29 years (range 17-54years) and most were from the junior ranks. The mean lengthof military service was 5 years. The main presenting problemswere alcohol misuse (33%), depression (19%) and anxiety (11%).Eighty percent of referrals were from primary care and 10%were urgent. After the initial assessment, 25% were referredfor psychotherapy and 4% were admitted to hospital. The meanlength of occupational downgrade (medically incapable of carryingout their primary military duty) was 12 weeks (range 4-67 weeks).At the end of the treatment 68% returned to full employment.

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Table 1. Patient and armed service characteristics

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Table 2. Clinical activity

Discussion

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Discussion

The main strength of this study is that it provides insightinto the care of a patient group that is currently attractingconsiderable interest and about which there is little publisheddata. Limitations are that data were collected on approximatelyhalf of all patients seen at our service and no psychometricdata were centrally available.

As expected the majority of referrals come from the unit medicalofficer (primary care). Given the high patient numbers thatare being referred to a limited number of busy clinicians,and the generally mild nature of problems (i.e. anxiety anddepression), it is perhaps questionable whether some patientsshould be referred to specialist services or whether they canbe maintained in primary care. In the UK National Health ServicePlan (Department of Health, 2000), primary care graduate mentalhealth workers (PCGMH workers) have been established with theaim of reducing the pressure from GP referrals by divertingpatients away from secondary mental health services. Primarycare graduate mental health workers receive training in evidence-basedbrief therapies, guided self-help and signposting. The militarymay benefit from considering whether a similar role could becarried out by providing further training for unit medicalassistants who currently administer paramedic-like servicesafter a year of training. However, it is possible that the high referral rate reflects the inherent risks of working in themilitary environment where access to weapons is commonplace,combined with the onus on unit medical officers to ensure thatthose they care for are sufficiently capable of carrying outtheir duty so as not to let their colleagues down in ways thatwould have potentially disastrous consequences. For example,even apparently minor degrees of distress might lead to a nuclearsubmariner not spotting a safety critical warning light oreffectively monitoring a mission essential navigational sonar.

Women were over-represented in our study (18%); women comprise approximately 10% of military personnel (Defence Analytical Services Agency, 2005).Existing data is limited and inconclusive as to whether womenin the military are at an increased risk of developing mentalhealth problems (e.g. Rona et al, 2006). That women are over-representedin the current sample is perhaps a reflection of gender differencesin help-seeking, rather than an increased prevalence of psychopathology,as men are more reluctant than women to seek help for bothmental and physical health problems (Moller-Leimkuhler, 2002).In addition, our findings showed only a minority (8%) of patientswere of officer rank whereas approximately 17% of the military workforce are officers (Defence Analytical Services Agency, 2006).Previous research has suggested that older personnel are moreresistant to mental healthcare perhaps because of the ‘stiffupper lip’ approach to coping (Greenberg et al, 2003).Therefore, a potentially important role for the DCMH is how to encourage reluctant but needy individuals to seek help.To this end, the Royal Navy actively engages in mental healthpromotion. As part of this activity the MOD is currently implementinga programme called Trauma Risk Management (TRiM); a peer-groupdelivered trauma-related psychoeducational and psychological‘first aid’ management strategy (Jones et al, 2003). Trauma Risk Management aims to target specific negative attributionswhich are commonplace in the military, for example, that seekinghelp is a sign of weakness. Such health promotion campaignsmay also have an impact on the substantial number of missedappointments (23%).

We found that younger personnel were over-represented in theDCMH sample although the age range was wide (17-54 years).It is possible that individuals at either end of this age spectrumare faced with adjustment issues, namely how to adapt to militaryculture for new recruits and in the case of leavers how toprepare for civilian life. Indeed, evidence exists which suggeststhat a small number of veterans will go on to have significantmental health issues after leaving the services (Iversen et al, 2005).The mean age in our sample was 29 years whilst the mean ageof all service personnel is 34 years (Defence Analytical Services Agency, 2005).In the main therefore, the DCMH needs to plan for young-adultfocused interventions (e.g. drug and alcohol, relationships). Significantly, only 40% of our sample were married or cohabitingwhilst in the military 79% are married or cohabiting. Militarylife can lead to family separation and strain as deploymentsare often for many months. It would seem therefore, that animportant function of the DCMH is to support service personneland their relationships with their families. The Armed Forceshave welfare and family services and DCMH personnel liaisewith them where required.

The main presenting problems in our study were alcohol misuse,depression and anxiety. Although caution is needed when interpretingour presenting problem data, as the database records the natureof problems treated rather than a diagnosis, our findings areconsistent with military epidemiological research. For example,Hoge et al (2004) assessed the mental health of the US armyand marines deployed to Iraq and Afghanistan, and found a highincidence of substance abuse (especially alcohol), major depression, PTSD and generalised anxiety disorder. Similar issues havebeen identified within the UK Armed Forces (e.g. Hotopf et al, 2006).There is considerable demand on the DCMH alcohol treatmentunit, which runs 1-day alcohol education courses and extendedweek-long treatment programmes. Although service personnel canbe ordered to attend the 1-day course their attendance at thelonger course is optional.

Referral rates for psychological treatment (i.e. cognitive-behavioural therapy and eye movement desensitisation and reprocessing)were high. Currently, the UK Armed Forces have one clinicalpsychologist per 30 000 troops. However, within the UK ArmedForces mental health nurses are trained to provide trauma-focusedpsychotherapeutic skills, with the psychologists concentratingon complex cases and supervision of other personnel providing psychotherapy.

Evaluating the rate of return to full fitness following treatmentis possible as every service person has a medical categorywhich indicates the occupational effects of any medical condition.The mean duration of reduced occupational fitness was about3 months with the majority of our sample returning to fullemployment after treatment, which suggests that either the mildpresenting conditions resolved spontaneously or the DCMH interventions were successful. Indeed, these outcomes are consistent withguidelines which suggest that brief psychological interventionsare effective for mild and moderate psychological problems,such as depression, over 10-12 weeks (National Institute for Health and Clinical Excellence, 2004).However, we suggest that further research is required to understandthe long-term mental health and occupational outcomes followingengagement with services. Personnel may not return to servicefor a number of reasons. For example, one of the peculiaritiesof service life is that, after the first 6 months of service, personnel cannot leave until they have served for approximatelya further 4 years. This causes difficulties for some personnelwho, understandably, feel trapped in the military. Some ofthese are referred to DCMH for assessment by a psychiatristwho might find the individual should leave the service as they are temperamentally unsuited to service life (often describedas ‘a square peg in a round hole’) or to be sufferingwith a mental disorder that is incompatible with a career inthe services, which would lead to medical discharge. Such individualsare likely to seek help early in their military career andit is perhaps because of this group that the mean length ofservice in our group was 4.6 years which compares with 12.4years across the Armed Forces.

In conclusion, DCMHs form the backbone of mental health servicesin the UK Armed Forces. They must balance the needs of militarycommanders (to conduct military operations as tasked) withthe therapeutic needs of the individual. Due to the currentdemand for mental healthcare within the military, there is considerablepressure placed on clinicians that is often exacerbated during military campaigns when healthcare professionals deploy tothe front line. Assessing healthcare delivery and uptake ofservices across the three branches of the military, and patients’and professionals’ experiences of the DCMH would be interestingareas for future research.

Acknowledgments

We are grateful to Dr J. Hacker Hughes (Head of UK Defence Clinical Psychology) and staff in the Defence Medical Services Departmentfor comments on an earlier draft of this article, and RobertLewis RN(MH) for his time and expertise with the department’sdatabase.

References

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