Veteran Mental Health: How can we give back?

Posted by Richard Maddicks

14th November 2022

Written by Cian Hancock.

UK Defence recently announced that it will be doubling its spending, meaning that the military is on track to grow over the next 8 years (Ministry of Defence, 2021a). With research showing that veteran mental health support especially for those navigating their way back to civilian life may not always be acceptable, it therefore feels necessary to explore the recent advances and limitations in support available.

The risk of suicide among army males has risen over the last 5 years, to reach the same level as the whole of the UK general population (Ministry of Defence, 2022). In the depths of emotional and psychological hardship, it’s difficult for an individual to see that ending one’s life is a permanent solution to problems which are in fact temporary. Due to the nature of military lifestyle, some servicepeople and veterans face, or have faced, unique challenges to their mental health (Mental Health Foundation, 2022). Defined as anyone who has served in the Armed Forces – regular or reserve – for at least one day, there are an estimated 2.4 million veterans in the UK (Grant & Simpson, 2022). This makes up 5% of the UK adult population. Working in stressful situations, obtaining physical injuries, and experiencing social exclusion or relationship problems are just some factors which could lead to depression, anxiety, adjustment disorder, post-traumatic stress disorder (PTSD), and / or alcohol misuse (Mental Health Foundation, 2022; Trueland, 2021). Veterans also have an eight-times greater risk of developing a gambling addiction than their civilian counterparts (Headquarters Regional Command, n.d.). Comorbidty is high, for instance data suggests that of those seeking help, about 82% meet criteria for PTSD, 74% have anger or other common mental health problems, and these are often presented along with alcohol problems (NHS England, 2021; Trueland, 2021).

Whilst the prevalence of mental health problems is generally speaking relatively low in the veteran community, this could be underestimated by barriers in seeking help (Ministry of Defence, 2021b). This means that the actual number of veterans suffering with mental health difficulties is likely to be a lot higher because they are not being assessed. For example, estimates suggest that 82% of UK Armed Forces veterans with mental health problems receive no treatment (Farrand et al., 2018).

Ex-servicepeople may be somewhat aware of the general support available to them but less comfortable with accessing it (Drabble et al., 2019). Stigma, fearing the impact of sharing personal burdens with family, and appearing weak, can contribute to veterans bottling up their feelings. Negative perceptions of mental health services and a belief that civilian health professionals won’t understand their military experiences can also act as a barrier to seeking help (Farrand et al., 2018). Not to mention that there’s no doubt returning to a relatively unchanged home environment, as a vastly changed individual, could inflict a sense of isolation. Feeling isolated can make it difficult to seek help, especially where the culture of the armed forces inherently promotes stoicism (Drabble et al., 2019). Veterans may feel that they can handle mental health difficulties alone, so trust needs to be the foundation on which paths to support are navigated and seeking help is encouraged.

Movement is being made, for example in March 2021 the NHS ‘Op COURAGE’ service was launched to provide specialist support for veterans, by professionals who understand the armed forces (RCGP Learning, n.d.). Three levels of support have been developed by clinicians alongside veterans, who were instrumental in developing the name of the service. Ranging from low-intensity psychological therapy to highly specialist inpatient support, the service should be able to provide appropriate support depending on individual needs. Those involved in the service also aim to raise awareness of the specific needs of ex-servicepeople and the importance of conducting veteran-sensitive assessments. As it is still early days, there is limited data to conclude whether the service is providing acceptable and accessible support for this population, however preliminary evidence that Op COURAGE received 4900 referral across 2020/21 does suggest that the service is being used (GOV UK, 2022). A survey was sent out in April 2022, ahead of the service contract revision for March 2023, to gather insight into the experiences of veterans mental and physical health services. This would include Op COURAGE, but the data is yet to be released.

In the government’s Veterans’ Strategy Action Plan for 2022-2024, it is stated that £18 million will be funded for veteran health services, with £5 million more for innovative health projects (GOV UK, 2022). Improvements to the Veterans Gateway website, where services are signposted, have also been promised by the government, but we must not forget about individuals who may struggle to access technology in the first place. For example, those with financial difficulties, disabilities, or some of the older veteran population may actually be disadvantaged by advancements in veteran healthcare. As such, hopefully this money will be utilised in the production of high-quality, service-user led research, to improve services particularly for underrepresented and minority groups within the veteran population. A key issue which has been addressed as an area of focus, is that of the historic hurt caused by pre-2000 practices on LGBT veterans. More information about this can be accessed in the action plan (GOV UK, 2022).

Furthermore, in September 2021 it was announced that numbers of ex-service personnel who take their own lives will be recorded officially by the government, to further understand where there is a need for dedicated services (Office for Veterans’ Affairs et al., 2021). The government can then ensure that these targeted services are signposted to veterans.

Whilst Op COURAGE will hopefully make finding support practically easier, in that it acts as a central triage service, it’s important to bear in mind that this doesn’t necessarily remove all access barriers. This may only help after someone has made the decision to access support. Reaching out for help is difficult for anybody, let alone someone with unique experiences who may feel misunderstood or alone.

One step towards this has been the development of a ‘Veteran Friendly Accreditation Programme’ as part of the 2019 NHS long-term plan (RCGP Learning, n.d.). The Royal College of General Practitioners have recently worked with NHS England to consider how to encourage veterans to register with a GP practice and disclose their veteran status (RCGP Learning, n.d.). Previous research has suggested that because the mental state of this population can be difficult to determine, there are four things which can be focused on in assessments / first contacts with veterans to help: thought process, mood, anxiety, and substance use (Drabble et al., 2019). Asking the right questions to encourage open conversation and considering visual appearances are crucial for first contact. For example, something as simple as asking whether somebody has served and being aware of the potential impact of this on their mental health, could make that person feel better understood and accepted. By providing access to free online training, the accreditation allows staff at GP practices to identify and code their veteran patients, as well as offer advice on referrals or appropriate signposting. It must be noted that effective signposting is not just giving somebody a website; finding out how best one accesses information, whether one prefers letters or emails, whether one has access to the internet and if one has a stable home address is crucial. Coding veteran patients means that practices can obtain data which will inform future health provision, and can ensure that veterans are not disadvantaged in accessing health services, but in fact rightly prioritised.

Over 1300 (out of 6993) practices in England are already accredited, and 99% of them would recommend the programme. Some evidence suggests that there have been improvements in the number of veterans registering at GP surgeries, and enhanced doctor-patient relationships (Finnegan et al., 2022). A greater understanding of veterans’ needs, and hence a more acceptable provision of care, could be the mechanisms behind this improved relationship. Veteran engagement with secondary services has also increased, and some practices reported that veterans had registered with them directly as a result of hearing about their accreditation (Finnegan et al., 2022). Furthermore, because accreditation lasts for three years, adherence to the evidence-base for treatment recommendations and up-to-date signposting contacts is very likely. This programme has the potential to fill a gap in GP knowledge of support available for veterans, however, to the best of my knowledge, this programme has not involved members of the veteran community and there is no data on the quality of service-user experiences.

Improving services in the way of effective treatment can also improve accessibility, by gradually increasing trust in services. Involving experts by experience is crucial to developing comprehensive, effective psychology services, and its value is unquestionable. While work has been done in recent years in efforts to raise awareness of the approach one must make when supporting veterans, it perhaps isn’t enough.

It is disconcerting that there seems to be a significant lack of data to represent the negative experiences of ex-servicemen upon leaving the military. Yet the sheer volume of personal stories and reports in the form of books or social media communications suggest otherwise. For example, the most recently published rate of PTSD among serving personnel “remains low at 0.1%” yet NHS England director of health and justice, and armed forces, says 1 in 20 of the 2.4 million veterans in the UK, will have PTSD (Ministry of Defence, 2021b; Trueland, 2021). Where the former figure only encompasses those who have been assessed, and access to support is challenging in the first place, it seems that there may be a high number of veterans struggling with PTSD, amongst other mental health issues, who have no support. What this also suggests is an urgent need for more accessible care. The question still remains of how to ensure these services are taken up and accepted by these communities.

Leaving the military is a major life event, impacting not only their life but the lives of their loved ones. They are entitled to priority treatment in the NHS, but how can we encourage this client group to seek support when the ‘army mindset’ is so inherently drilled in from years of service? Without direct insight into their way of thinking, we cannot develop a means to do so. Surveys are not enough, and quantitative data can’t always give the whole picture. By reaching out to veterans who have been through mental health services themselves, the likelihood of obtaining insight into how access barriers can be overcome increases. We know what the barriers typically are, but the mechanisms of overcoming such barriers must be investigated. If veterans are aware of the support available, is there anything we can do to make taking that first step easier and sooner?

Is it reassurance in the 2-year military discharge communications which are sent out? Is it better dissemination of the warning signs of mental health difficulties? Is it an occasional text to ask if they’d like to have a check-in? To gather this information from current or past veteran service-users, we could ask directly if those things would help, or ask the following kinds of questions:

• What made you seek help? Was it something you read, someone you spoke to?
• Is there something you would have wanted your loved ones to know to make the process easier?
• Is there a time you felt isolated?
• What was that first contact like? What could have helped?
• If you were signposted to another service, how was that handled? How did you feel about that?

Research is the most important tool to improving access to mental health support, and whilst it can take time to complete, there is no better time than now. With potential to make a difference in whether somebody receives the support they deserve, or whether they deteriorate in isolation, it is with great hope that this new funding is used with veterans’ mental health at its core.

Because ultimately, one life lost to suicide is one life too many.

…

If you are currently serving and you’re worried about your mental health, speak to your chain of command or any medical officer. Combat Stress are also available with a 24-hour helpline run in partnership with the Ministry of Defence (MOD).

GOV UK have detailed NHS support for veterans who may be struggling with their mental health and their families:

• In England, veterans and their families can get specialist help from the NHS Op COURAGE service
• In Wales, you can reach out to Veteran Therapists in each Local Health Board through Veteran NHS Wales
• In Scotland, veterans can access veteran-led mental health and welfare support through Veterans First Point, part of NHS Scotland
• In Northern Ireland, the Northern Ireland Veterans’ Support Office links individual veterans, veterans’ groups, statutory and non-statutory bodies, and charities supporting veterans
• Anyone in the UK or overseas can also contact the Veterans’ Gateway helpline on 0808 802 1212, or visit the website for advice and signposting to further support, including for families and the bereaved

Additionally, there are lots of other specialist services for both current personnel and veterans:

• If you’re not sure what help you need, Veterans Gateway can be a good starting point. They can help you find the right support and signpost you to other organisations. As well as your mental wellbeing, they can help with housing, employment, physical health and financial worries.
• Combat Stress provides specialist treatment and support for veterans dealing with PTSD, depression, anxiety and other mental health problems. They offer a range of services including counselling, residential treatment, peer support and self-help resources.
• Help for Heroes’ Hidden Wounds service supports veterans and their families who are living with depression, stress, anxiety, anger or a drinking problem. They offer self-help as well as individual and group therapy.
• PTSD Resolution provides short courses of counselling for veterans who experienced trauma during their service.
• The Royal Air Force Benevolent Fund provides free access to mental health support and therapy through their wellbeing service.
• Togetherall is an online community where you can talk to other people with depression, anxiety and other mental health problems. It’s free to all serving personnel, veterans and their families.

References

Drabble, D., Allen, R., & Child C (2019) The Armed Forces Community Healthcare Navigation Project. Accessed on 25 October 2022 from https://s31949.pcdn.co/wp-content/uploads/armed-forces-community-healthcare-navigation-project-feasibility-study.pdf

Farrand, P., Jeffs, A., Bloomfield, T., Greenberg, N., Watkins, E., & Mullan, E. (2018). Mental health service acceptability for the armed forces veteran community. Occupational medicine (London), 68(6), p. 391-398. doi: 10.1093/occmed/kqy086

Finnegan, A., Salem, K., Ainsworth-Moore, L., Randles, R., West, L., Simpson, R., & Benedicta Grant, V (2022). The Veteran Friendly Practice accreditation programme: a mixed-methods evaluation. BJGP Open 6(3). doi: https://doi.org/10.3399/BJGPO.2022.0012

GOV UK. (2022, January 19). Veterans’ Strategy Action Plan 2022-2024. Accessed on 3 November 2022 from https://www.gov.uk/government/publications/veterans-strategy-action-plan-2022-to-2024/veterans-strategy-action-plan-2022-to-2024-html

Grant, V. B., & Simpson, R, G. (2022). Improving NHS primary care for military veterans. British Journal of General Practice, 72 (716), p. 134-135. doi: https://doi.org/10.3399/bjgp22X718781

Headquarters Regional Command (n.d.). Gambling – A Serious Risk to Military Personnel. Ministry of Defence. https://www.army.mod.uk/umbraco/Surface/Download/Get/11456

Mental Health Foundation (2022). Armed forces and mental health. Accessed on November 1^st 2022 from https://www.mentalhealth.org.uk/explore-mental-health/a-z-topics/armed-forces-and-mental-health

Ministry of Defence (2021a, November 25). British Army unveils most radical transformation in decades. GOV UK. https://www.gov.uk/government/news/british-army-unveils-most-radical-transformation-in-decades

Ministry of Defence. (2021b, June 17). UK Armed Forces Mental Health: Annual Summary & Trends Over Time, 2007/08 to 2020/21.https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/993208/20210617_MH_Annual_Report_2020-21.pdf

Ministry of Defence. (2022, March 31). Suicides in the UK regular armed forces: Annual summary and trends over time 1 January 1984 to 31 December 2021. Accessed on 23 October 2022 from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1063678/20220331_UK_AF_Suicides.pdf

Office for Veterans’ Affairs, Cabinet Office, Ministry of Defence, Office for National Statistics, Welsh Government, & MP Docherty, L. (2021, September 22). Veteran suicide figures to be recorded for the first time. Accessed on 23 October 2022 from https://www.gov.uk/government/news/veteran-suicide-figures-to-be-recorded-for-the-first-time

RCGP Learning (n.d.). Veteran friendly GP practice accreditation. Accessed on 25. October 2022 from https://elearning.rcgp.org.uk/mod/book/view.php?id=12533&chapterid=285

Trueland, J. (2021). Delivering support to military veterans with complex mental health needs. Mental Health Practice, 24(4), p. 10-12. doi: 10.7748/mhp.24.4.10.s4