War has always been a potent stimulus to medical progress. Most people know of the numerous advances in surgery, anaesthetics and resuscitation that came about as a result of bitter experience in conflict, then went on save countless civilian lives. Changes in the way we replace lost blood developed by British medical teams in Afghanistan are already being introduced across the NHS to good effect. But did you know that the same applies to psychiatry?
In 1916, the British Army faced a manpower crisis. More and more soldiers were having mental breakdowns, many of which were called ‘shell shock’. But sending them to vast mental hospitals back in Britain wasn’t working and few got better, let alone returned to active duty. And so a different approach was taken, which became known as ‘forward psychiatry’. Soldiers would be treated as quickly as possible, as close to the front line as possible, and with the expectation that they would recover. These same principles now underlie interventions such as crisis care, home treatment, early intervention and the recovery movement — indeed all the principles of what we now take for granted as community care can be traced back to 1916. In our own time, the system of peer support known as Trauma Risk Management (Trim) began in the Armed Forces and is now used by numerous organisations in the UK and abroad.
Of course that did not end the problem. At the end of the war there were more than 80,000 veterans who would go on to receive pensions for shell shock, and many more were being treated for other related diagnoses. Good statistics are hard to come by, but there is no doubt that, even when discharged from hospital, many service personnel never recovered.
Things are different now. But perhaps not as much as we might think. Certainly the Blackadder view of history — that we knew nothing about the psychological impact of the first world war and shot everyone showing signs of a breakdown — makes for better TV drama or satire than it makes history. Nor should the reactions of a vast citizen army, latterly a conscript force, compelled to fight wars of dreadful attrition be confused with the experiences of a small, well-trained,volunteer professional military fighting ‘wars of choice’ — no matter how tough it gets these will not equate with the casualty rates sustained in the great offensives of the first world war, or the sustained nightly terrors of flying in Bomber Command during the second world war. In 1942, 60 per cent of crews were killed, wounded or captured after one tour, and 80 per cent after two.
But the reality of mental breakdown remains with us. And when that happens, things are better than they were 100 years ago. Treatments have improved. Talking treatments such as cognitive behavioural therapy (CBT), unknown in 1916, are of proven value. The drug treatments available in 1916 were by large useless or worse; nowadays antidepressants can and do help recovery. Some of the harsh disciplinary measures that were taken for granted in 1916 have thankfully vanished. And attitudes towards psychiatry and mental disorder have improved, although perhaps not as much as we might wish. The stigma of mental disorder remains — not just in the armed forces, but everywhere. Indeed, my experience of the forces compares favourably with many of the other organisations I have worked with over the years. Provided you have, as they say, ‘done your bit’, or alternatively ‘earned your breakdown’ I find them to be often more sympathetic than other organisations, including medicine, the police, parliament and many businesses.
We also have a better handle on the scale of the problem, largely thanks to studies we have been doing at King’s College London for the best part of two decades. As a result we know that the general mental health of our armed forces is surprisingly robust, even after a decade of war. For example, about 4 per cent of those who served in Iraq or Afghanistan come back with post traumatic stress disorder (PTSD). This is not the same as shell shock as seen in 1916 — back then soldiers would present with what looked like neurological problems, such as shaking, fits, strange walks and even loss of vision or speech. We don’t see that very much now. Instead, many of those who have developed psychiatric disorders present with depression, anxiety and the intrusive unwelcome memories that we call flashbacks, which were much less common in the case histories of 100 years ago. Psychiatric disorders can and do change over time.
Now 4 per cent may not seem very many, but there are reasons for this. Firstly, this is an overall figure for all personnel deployed across all three services. If we look only at those in direct combat roles — about 25 per cent of those who deploy — the rate goes up to around 7 per cent. And some are more vulnerable than others; for example, reservists seem to have higher rates of mental health problems. It is particularly worrying that these differences are not just visible when they come home, but are still visible when they are followed up five years later. We need to remember this when we plan to increase the proportion of reservists taking on combat roles in future — there may be hidden costs later.
These rates are lower than you would find in civilians exposed to trauma — such as those caught up in the 2005 London bombs, terrible rail crashes, or the victims of sexual assault. This is because military personnel are not chosen at random. They have volunteered for their roles and gone through selection procedures. They accept the risk of trauma that is explicit in the job. They are also well trained and prepared as best they can be. And perhaps most importantly, they benefit greatly from good leadership and strong group cohesion and morale. We did a study in Afghanistan that showed how units with strong cohesion and leadership suffered dramatically lower rates of mental health problems than those without these advantages, even with similar rates of trauma. None of this applies to the civilians commuting to work whose train crashes.
It would be remiss of me not to acknowledge that there is still public scepticism about the reality of psychological trauma. But before we start saying ‘disgraceful’, we should look at the facts. Exaggeration of war stories (at best) or fabrication (at worst) is nothing new. A paper in the most recent issue of Defence and Security Analysis suggested that between 5 to 10 per cent of narratives of contemporary military PTSD contain exaggeration or pure invention. But this must be set against the far greater opposite tendency to minimise or ignore psychological symptoms. Our research shows that about 40 per cent of personnel with psychological disorders do not present for any form of treatment, wishing to avoid the stigma that, sadly, still accompanies anything seen as ‘psychiatric’. Minimisation or denial is a far greater issue than exaggeration or lying.
So rates of psychiatric disorder are considerably lower than they were in 1916 and treatment is much better. But that does not mean that we have solved the problem. Between 1991 and 2014 about 750,000 served in the regular forces. A recent report from my unit and Help for Heroes estimated that about 66,000 will need some form of physical or mental health support, of which the largest need will involve mental health. This is not just PTSD — both alcohol misuse and depression are more common. Nor it is all due to active service. We know that half the cases of PTSD in veterans are not related to deployment, but to other experiences both in and out of service — accidents and assaults, for example.
We also know that PTSD, like most mental disorders, rarely has a single cause such as specific exposure to psychological trauma, but instead arises from the interaction of a person’s background, personality and previous history. Likewise, poor mental health is caused by and also causes a variety of other problems. So people may have trauma-induced symptoms and also suffer from relationship problems, excessive drinking, unstable housing or employment, and trouble with the law. It is difficult and perhaps not very helpful to know which causes which. Even if everyone was seen by a single, broad multi–disciplinary team that was able to help with mental health, debt, housing, family relationships, issues with aggression, problem children and substance misuse, management might not be straightforward.
Such ideal services are few and far between, if they exist at all. Health and social care are fragmented across the NHS. To add to the confusion, there are now more than 2,000 military charities — some of them established brands, others less so. Neither is the role of these charities clear compared to the responsibilities of the NHS. It must be a bewildering experience for a recently discharged serviceman or woman to make any sense of this.
Speaking as a trustee of Combat Stress, which has been looking after ex-service personnel with mental health problems since 1919, I know that our preferred outcome for a veteran who has left the service is to help them become fully and successfully integrated back into civilian life — proud of their military past, but now moving on to be good citizens, starting a new journey, in which any future health problems are dealt with by the NHS. But we also know that, even with the best help available, that doesn’t happen for everyone, and that some will continue to need support for many years.
But what really worries me for the future is not just the patchy availability and variable quality of mental health services. I worry about the misperceptions and misunderstandings that we, the public, have about those who have served. By 1944, about 80 per cent of the population had some engagement in the war effort. Most adults either served, or were closely connected to those who had. But this ‘military footprint’ has steadily diminished with each passing year, and now most of us know little about the realities of service life except what we read in the papers or see on screen. We should not then be surprised that a recent opinion poll showed that the public believe that 90 per cent of those who served in Iraq or Afghanistan return with physical or mental health problems, even though this is untrue — just as it is untrue that more Falklands veterans have taken their own lives than died in that conflict. Instead, we fall back on the easy clichés of seeing them as either heroes or victims. Both views are anathema to military culture, and both serving and ex-serving personnel are uncomfortable with either label. Most prefer to see themselves as professionals, doing a difficult job well.
Likewise, even when times are hard, they are more likely to see themselves as independent resilient people who have been trained to overcome life’s difficulties, but may require help to get back to how they were. As one ex-commanding officer of the Parachute Regiment put it: ‘We want your support, but not your pity.’
Professor Sir Simon Wessely is Honorary Civilian Consultant Advisor in Psychiatry to the British Army, and a trustee of Combat Stress.