Management of mental illness by the British Army

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Maagemet of metal illess by the British Army LEIGH A. NEAL, MATTHEW KIERNAN, DAVID HILL, FRANK McMANUS ad MARK A. TURNER BJP 2003, 182:337-341. Access the most recet versio at doi: 10.1192/bjp.02.

1 Maagemet of metal illess by the British Army LEIGH A. NEAL, MATTHEW KIERNAN, DAVID HILL, FRANK McMANUS ad MARK A. TURNER BJP 2003, 182: Access the most recet versio at doi: /bjp Reprits/ permissios You ca respod to this article at Dowloaded from To obtai reprits or permissio to reproduce material from this paper, please write to o December 20, 2011 Published by The Royal College of Psychiatrists To subscribe to The British Joural of Psychiatry go to:

2 BRITISH JOURNAL OF PSYCHIATRY (2003), 182, 337^341 Maagemet of metal illess by the British Army LEIGH A. NEAL, MATTHEW KIERNAN, DAVID HILL, FRANK McMANUS ad MARK A. TURNER cosultat military psychiatrist, accordig to istructios (Miistry of Defece, 2000) as follows: (a) recommeded for discharge from the army; Backgroud The Miistry of Defece has its ow hospital for soldiers requirig admissio for metal health problems. Aims To assessthe efficiecyofthe army psychiatric hospital atrestorig patiets to full active duty.to assess whether a ew military traiigadrehabilitatio rehabilitatio uit (MTRU) thatemphasises military-skills traiig, improves outcome. Method A 2-year, iceptio-cohort outcome study of hospital i-patiets. A 12-moth, case-matched, before ad after outcome study compared MTRU patiets with hospitali-patiets. i-patiets. Results 1(hospitali-patiets, ¼309): at 2-year follow-up 67 (22%) were fully fit for active duty. Military psychiatrists success rate at predictig recovery to activedutywas27%.2:theoddsofa soldier i the MTRU cohort (¼35) returig to active duty were14 times greater tha for the hospital cohort (¼35).The odds of remaiig i the army while ufitfor active duty were 20 times less for the MTRU tha for the hospital cohort. Coclusios The army hospitalis iefficiet at rehabilitatio to active duty. The MTRU sigificatly icreased the odds of returig to active duty ad reduced the odds of remaiig i the army while still ufit.these fidigs may be applicable to the emergecy services. Declaratio of iterest Noe.The views expressed i this paper are ot ecessarily those of the Miistry of Defece or Her Majesty s Govermet. The Miistry of Defece is uique amog the state sector services for ruig its ow secodary care metal health service, which is idepedet of the Natioal Health Service. This was bor of the ecessity to provide health care to troops o op- eratios overseas ad to provide fast-track treatmet i the UK to keep the armed forces fit ad ready for deploymet. The uiformed metal health care system i the military has cotiued largely as a le- gacy of the Secod World War (Shephard, 2000), with the additio of a commuity metal health service i the 1970s. I the UK, util 1995, army persoel were ad- mitted to the psychiatric ward at the Quee Elizabeth Military Hospital i Woolwich, ad sice 1995 they have bee admitted to the tri-service psychiatric uit at the Duchess of Ket s Psychiatric Hospital (DKPH) i Catterick Garriso. The British Army is at preset simul- taeously ivolved i peace support operatios i Norther Irelad, Cyprus, Bosia, Kosovo, Sierra Leoe ad Afghaista, leadig to a cotiuig ad pressig requiremet for traied, fit persoel. The preset full-time traied requiremet of the British Army is ad the traied stregth is (Defece Aalytical Services Agecy, 2001). All uiformed persoel are employed o the basis that they have a operatioal role overseas. It is there- fore essetial that the largest possible percetage of the fightig force is opera- tioally fit, which requires full metal fitess. About 3000 persoel preset to secodary care metal health services i the army per year ad about 260 army persoel are admitted to DKPH per year (Duchess of Ket s Psychiatric Hospital, 2001). This represets a psychiatric admissio rate of about 2.6 per 1000 army persoel per year. At the time of discharge from the i-patiet psychiatric uit each soldier is classified, by a (b) psychologically ufit for military opera- tioal deploymet, but likely to become fit durig the ext 18 moths; (c) psychologically fit for military opera- tioal deploymet. Soldiers i category (b) may have additioal temporary occupatioal restrictios attached to their cotiued employ- met, such as ufit live arms, ad they are ot permitted to go o operatioal tours. They therefore represet a group of army persoel who are cotiuig to be paid by the Miistry of Defece ad who are beig provided with out-patiet treat- met by the Miistry of Defece, but who are ufit for their primary operatioal role. The occupatioal outcome of soldiers requirig i-patiet care for metal illess is ot kow. I view of iteral cocers about the umber of medically ufit soldiers i the British Army, a ivest- igatio was desiged i two stages: the first to idetify the 2-year occupatioal outcome of soldiers admitted to a army psychiatric hospital, ad the secod to assess the effec- tiveess of a ew military rehabilitatio uit i terms of occupatioal outcome. METHOD Stage 1 This phase of the study was desiged to determie the occupatioal outcome of army persoel discharged from DKPH (but retaied i the army) at 6 moths, 12 moths, 18 moths ad 24 moths after discharge, as well as to assess the predictive ability of military psychiatrists to determie occupatioal outcome. Data collectio Baselie data o a iceptio cohort of cosecutive hospital admissios were collected prospectively over a 14-moth period at DKPH; 310 cosecutively admitted Army persoel were etered ito the study. At the time of follow-up aalysis, 2 years later, demographic data were miss- ig for oe perso, leavig a cohort of 309 (97.7%) persos followed up for 2 years after discharge. The follow-up iformatio was obtaied from the Army Persoel Cetre i Glasgow. 337

3 NEAL ET AL Data were recorded i terms of age, geder, diagosis ad occupatioal recom- medatios o discharge. Outcome for each soldier was recorded categorically i terms of fitess for operatioal deploymet i the 6 moths, 12 moths, 18 moths ad 24 moths after discharge. Stage 2 O the basis of the fidigs i the first stage of this study a experimetal assessmet ad treatmet uit was istituted for a 12-moth period at DKPH (the tri-service psychiatric hospital). The details of the operatio of this uit, amed the Military Traiig ad Rehabilitatio Uit (MTRU), are described i the Appedix. The MTRU was desiged to icrease the umber of soldiers restored to full operatioal fitess ad to reduce the cost to the Miistry of Defece of employig o-effective sol- diers. The aim of the study was to report data o the effectiveess of the MTRU by comparig the occupatioal outcome at 6 moths ad 12 moths after hospital discharge with the traditioal stad-aloe i-patiet psychiatric treatmet. Sample The study was to be a cotrolled before ad after desig ad this required a sample of pa- tiets maaged by the MTRU to be matched with a sample admitted to hospital before the MTRU was established. Commissioed officers ad warrat officers were ot admitted to the MTRU because of their usuit- ability to the basic traiig aspects of the rehabilitatio regime. A idex group of cosecutive MTRU patiets were selected accordig to the followig criteria: (a) admitted to DKPH after the MTRU was established; (b) referred directly from the i-patiet ward; (c) completed the full rehabilitatio ad assessmet process. A cotrol sample was selected by match- ig the three-digit ICD 10 diagoses (World Health Orgaizatio, 1992) of the MTRU sample, usig cosecutive patiets admitted to DKPH betwee 1 Jauary 1996 ad 1 Jauary All ICD 10 diagoses were made by cosultat psychiatrists. Statistics Data were statistically aalysed usig Pear- so s chi-squared test for categorical data ad the idepedet t-test for cotiuous data. The characteristics of the idex ad cotrol groups were compared. Outcome was assessed separately i the period 0 6 moths ad 6 12 moths followig dis- charge from hospital. Odds ratios with 95% cofidece itervals were calculated to determie the sigificace of the MTRU itervetio. RESULTS Stage 1 Sample characteristics Of the 309 army persoel i the study sample, 20 (6.5%) were wome ad the mea age was 26.4 years (rage years, s.d.¼6.9). Table 1 shows the distrib- utio of their primary psychiatric diagoses accordig to ICD 10 (World Health Orgaizatio, 1992). Rehabilitatio to operatioal fitess The operatioal fitess of the subgroup of army persoel discharged from hospital ad retaied by the army was followed up over 24 moths at 6-moth itervals. From the iceptio cohort of 309 soldiers, 78 (25%) were operatioally fit i the period 0 6 moths after their discharge from hos- pital, 54 (17%) at 6 12 moths, 47 (15%) at moths ad 67 (22%) at moths. It ca therefore be predicted from the 2-year outcome data that about 56 (22%) of the 260 soldiers admitted to DKPH each year will evetually become fully fit for operatioal deploymet. The coservative estimate of the total cost of employig the army persoel i this study who were ufit for operatioal deploymet, i the 24-moth period followig psychiatric hospital discharge, was This equates proportio- ately to a cost of about 3 millio per year to cotiue to employ operatioally ufit army persoel followig their admissio to the army psychiatric hospital. Predictig recovery After 2 years 161 (52%) soldiers had bee recommeded for discharge o psychiatric grouds ad 70 (22.7%) had left for other reasos, such as the ed of their co- tracted period of service or admiistrative discharge. This group also icludes 3 soldiers who died while still servig. Military psychiatrists predicted that 196 of this cohort, who were ufit for operatioal deploymet at the time of hospital discharge, were worth retaiig i the army because they were likely to become fit withi 18 moths. The predictive success rate of the military psy- chiatrists, i terms of the umber of these 196 army persoel actually be- comig operatioally fit, was 4.6% at 6 12 moths, 15.8% at moths ad 27% at moths. Stage 2 Sample characteristics Betwee 1 February 2001 ad 1 March 2002 a total of 65 soldiers were admitted ad discharged from the MTRU. Twety- ie of these were excluded from the study o the basis of the selectio criteria described above: 15 of the 29 had bee admitted to DKPH before the MTRU was established ad 14 were referrals from commuity agecies outside DKPH. After these exclusios 36 remaied i the idex group. These were matched cosecutively ad as closely as possible for ICD 10 diagosis with the cohort of patiets admitted to DKPH betwee 1 Jauary 1996 ad 1 Jauary It was ot possible to fid a suitable match for a case of aorexia ervosa (ICD 10, F50.1) ad so this patiet was excluded, leavig 35 persos i the idex sample. Table 2 lists the distributio of ICD 10 diagoses i the two samples. There was o sigificat differece i the distrib- utio of diagoses betwee the two Table 1 Distributio of primary psychiatric disorders i terms of ICD ^10 for 309 army persoel admitted cosecutively to the Duchess of Ket s Psychiatric Hospital from1jauary1996 to 1Jauary1999 Psychiatric disorder % Neurotic, stress-related ad somatoform disorders Alcohol or drug misuse 26.4 Psychosocial ad evirometal problems 13.2 Depressive episode 12.5 Persoality disorder 9.9 Schizophreia, schizotypal ad delusioal disorders 3.3 Orgaic persoality chage 1.2 Bipolar affective disorder Oly oe soldier had a primary diagosis of post- traumatic stress disorder. 338

4 ARMY MENTAL HEALTH CARE samples (w 2 ¼6.09, d.f.¼15, P¼0.978). Table 3 compares the two samples i terms of age, geder, marital status, rak ad legth of hospital admissio. All the characteristics were matched except for marital status (P50.01).( Rehabilitatio to operatioal fitess Table 4 compares the outcomes usig odds ratios i terms of occupatioal re- commedatios 0 6 moths after hospital discharge. Table 5 compares the outcomes usig odds ratios i terms of the umber of soldiers leavig the army for other reasos ad the occupatioal recomme- datios for the remaider 6 12 moths after hospital discharge. DISCUSSION The rehabilitatio of army persoel admitted to the military psychiatric hospital (DKPH) is poor. Less tha a quarter of these patiets become fully operatioally fit durig the 24 moths followig their discharge from hospital. Military psychia- trists ability to predict which patiets will recover full operatioal fitess is poor, with a hit rate of oly 27% by 24 moths after hospital discharge. The army cotiues to employ soldiers who are ot operatioally fit for up to 2 years followig a hospital admissio. These soldiers are ot fulfillig their primary role ad ca be difficult to employ gaifully at their base uits over log periods. Outcome data from the MTRU iter- vetio study (Tables 4 ad 5) show that soldiers rehabilitated by the MTRU are 5 times more likely to be psychologically fit for operatios 0 6 moths after hospital discharge tha if they had bee treated traditioally. At 6 12 moths soldiers re- habilitated by the MTRU are 14 times more likely to be psychologically fit for operatios tha if they had bee treated traditio- ally. Therefore, as time progresses, there appears to be a icrease i the odds of soldiers i the MTRU group beig fully re- habilitated. Overall, these fidigs idicate the potetial for a sigificat icrease i the umber of soldiers becomig fit for operatioal duty i the 12 moths after hospital discharge followig rehabilitatio by the MTRU. Soldiers rehabilitated by the MTRU are 20 times less likely to be graded as operatioally ufit ad retaied tha those ma- aged i the traditioal settig, i the period Table 2 groups Table 3 Characteristics of the MilitaryTraiig ad Rehabilitatio Uit (MTRU) ad cotrol groups MTRU (¼35)( Cotrols (¼35) P (two-tailed) Age i years, mea (s.d.) 24.3 (5.5) 25.8 (5.5) Days spet i hospital, mea (s.d.) 93.5 (68.2) (134.0) Females ()( Married ()( * Private rak 2 () IcludestimeitheMTRUfortheidexgroup. i the the idex 2. Raks categorised ito privates ad o-commissioed officers. *P Table 4 Outcome i the period 0^6 moths after psychiatric hospital discharge: compariso betwee the MilitaryTraiig ad Rehabilitatio Uit (MTRU) ad cotrol groups Outcome Distributio of ICD^10 diagoses i the MilitaryTraiig ad Rehabilitatio Uit (MTRU) ad cotrol Psychiatric diagosis (ICD^10 code) MTRU (¼35) (%) Cotrols (¼35)( (%) Adjustmet disorder (F43.2) 12 (34) 12 (34) Moderate depressive episode (F32.1) 5(14) 6(17) Schizophreia, uspecified (F20.9) 3 (9) 3(9) Emotioally ustable persoality disorder (F60.3) 3 (9) 3(9) Severe depressive episode (ot psychotic) (F32.2) 2(6) 2(6) Alcohol depedece sydrome (F10.2) 2(6) 2(6) Mild depressive episode (F32.0) 2(6) 1(3) Geeralised axiety disorder (F41.1) 2(6) 1(3) Opioid depedece sydrome (F11.2) 1(3) 1(3) Other acute ad trasiet psychotic disorder (F23.8) 1(3) 1(3) Bipolar affective disorder, uspecified (F31.9) 1(3) 1(3) Symptoms but o psychiatric disorder (Z00.4) 1(3) 1(3) Mixed axiety ad depressive disorder (F41.2) 0 (0) 1(3) MTRU Cotrol Odds ratio (95% CI) Psychologically ufit for further service i the army (0.94^8.71) Not fit for military operatios (but likely to become fit) (0.02^0.24) 1 Psychologically fit for military operatios (1.70^15.39) 1 Total Sigificat odds ratio (95% CI does ot iclude1.0). Table 5 Outcome i the period 6^12 moths after hospital discharge: compariso betwee the Military Traiig ad Rehabilitatio Uit (MTRU) ad cotrol groups Outcome MTRU Cotrol Odds ratio (95% CI) Departed from the army for o-medical reasos (0.10^1.35) Psychologically ufit for further service i the army (0.54^3.89) Not fit for military operatios (but likely to become fit) (0.01^0.41) 2 Psychologically fit for military operatios (2.88^67.10) 2 Total Durig the previous 6-moth period. 2. Sigificat odds (95% CI does ot iclude1.0). 339

5 NEAL ET AL 6 12 moths after hospital discharge (Table 5). This idicates that the MTRU is better at assessig risk ad reducig the impositio of uecessary occupatioal re- strictios tha is the traditioal i-patiet settig. The results from the first stage of this study idicate that the MoD pays over 3 millio per year to retai operatioally ufit soldiers followig psychiatric hospital admissio. This figure is coservative because the additioal cost of employig raks above that of private was ot calculated. The secod stage of this study demostrates the potetial for a sigificat savig i these costs, with the MTRU. However, the relative cost of treatmet is a importat additioal cosideratio. There was o sigificat differece i the duratio of hospitalisatio betwee the two study groups (Table 3), although the mea period of hospitalisatio of the MTRU group was paradoxically 26 days less tha the mea for the cotrol group. Treatmet costs per day i the MTRU were less tha the costs of the traditioal wardbased treatmet because of a lower staff- to-patiet ratio. I this study, the MTRU optio was thus less expesive tha the traditioal form of i-patiet treatmet i terms of total treatmet costs. Limitatios The secod stage of this study may have bee limited by a umber of factors. First, the study was ot desiged as a radomised cotrolled trial because it was aticipated that soldiers would have reasoable grouds for objectig to their terms of ser- vice beig partly determied by chace. I these circumstaces, the cotrolled before ad after desig was the most practical ad methodologically soud evaluatio available. The stregth of quasi-experi- metal studies lies i their real world applicability (Cook & Campbell, 1979; Gilbody & Whitty, 2002). Secod, there may also have bee a selectio bias towards idividuals with a better progosis eterig the MTRU. Offi- cers ad warrat officers were ot admitted to the MTRU, but this was cotrolled for i the matched sample i the secod stage. Hospital i-patiets were selected to trasfer to the MTRU primarily o the basis of their capacity for idepedet livig, ad the first stage results idicate a iability of cliicias to detect patiets with a better progosis. All army patiets CLINICAL IMPLICATIONS & The rehabilitatio of British soldiers after admissio to a traditioal i-patiet psychiatric uit was poor, with oly 22% returig to full operatioal fitess i the 2 years after discharge from hospital. & The developmet of a specialised military rehabilitatio uit, as a adjuct to i- patiet care, sigificatly improved the12-moth outcome i terms of the odds of returig soldiers to full operatioal fitess. & The fidigs from this study may have implicatios for improvig the maagemet of metal illess i other frot-lie emergecy services. LIMITATIONS & For practical reasos the study was ot radomised but it used a ext-best cotrolled before ad after quasi-experimetal desig. & Substace use disorders were uderrepreseted i the cotrolled before ad after study compared with the ormal case-mix. & There was a sigificatly greater umber of married soldiers i the cotrol group tha i the idex rehabilitatio group. LEIGH A. NEAL, MD, St James s Uiversity Hospital, Leeds; MATTHEW KIERNAN, BSc, DAVID HILL, MSc, FRANK McMANUS, MRCPsych, MARK A. TURNER, MRCPsych, Duchess of Ket s Psychiatric Hospital, Catterick Garriso, NorthYorkshire,UK Correspodece: Dr Leigh A.Neal,Bristol Priory Hospital,Heath Heath House Lae, Stapleto, Bristol BS16 1EQ,UK.Tel: ; leigh@psychcosserv.fset.co.uk (First received 7 May 2002, fial revisio 24 September 2002, accepted 1November 2002) admitted to DKPH become fit for idepe- det livig prior to discharge from hospital because of the acute ature of their illess. Therefore, although patiets could ot be admitted to the MTRU util they had become fit for idepedet livig for practical reasos, this is ulikely to have itroduced a selectio bias i terms of the loger-term outcome. Third, the proportio of substace misuse cases i the MTRU (9%, Table 2) is less tha the proportio foud i all DKPH hospital admissios (26.4%, Table 1). This was because of a declared bias agaist admissio of people with this diagosis to the MTRU by the cliical team maagig substace misuse (however, this was co- trolled for i the matched sample i the secod stage). Therefore, the study results caot be geeralised to iclude all patiets with a diagosis of substace misuse. Fially, members of the idex group were sigificatly less likely to be married tha the cotrol group (Table 3). Therefore, the MTRU group might be cosidered less stable i the absece of a cofidig relatioship. This does ot ex- plai the comparative icrease i the umber of those fully rehabilitated by the MTRU, which might be expected to ru couter to this effect. This selectio bias does ot appear to ifluece the iterpret- atio of the results. It was the impressio of the cliical staff that the success of the MTRU was attributable to a improved risk assess- met, based o the ability to observe the behaviour of the patiets i a simulated military eviromet, ad to the icreased self-cofidece i military skills acquired by the patiets. This allowed the cliical staff to retur more soldiers to duty 340

6 ARMY MENTAL HEALTH CARE without occupatioal restrictios, physi- cally fit ad cofidet i their military skills. These factors combied to reduce stigmatisatio at the soldiers uits, eablig rapid ad effective reitegratio. The approach to rehabilitatio described i this study may be trasferable to other sectors, such as the police, fire, ambulace ad other emergecy services, which may experiece similar difficulties i the effective rehabilitatio of employees with psychiatric problems to frot-lie duties. APPENDIX MilitaryTraiig ad Rehabilitatio Uit (MTRU) Locatio ad resources Located ext to the psychiatric i-patiet uit. Cotais 27 beds i sigle-room, barrack-style accommodatio. Admissio criteria Patiets are: selected for admissio to the MTRU from the i- patiet ward; screeed with a risk assessmet tool for the capacity to live idepedetly; admitted by agreemet with their supervisig cosultat. Phase 1traiig Traiig is maaged by a military cosultat psy- chiatrist ad multi-discipliary team: daycetre care, with occupatioal therapy; idividualpsychologicaltherapyis cotiued from the ward; patiets ca optto take part i Phase 2 exercises ad ca optto wear uiform; patiets are re-motivated to remai i the army. The cosultat recommeds oe of the followig: discharge fromthe armyadrehabilitatioto civi- lia life; returto the wardifthe patiet has deteriorated; graduatio to phase 2. Phase 2 traiig Traiig is maaged by military ursig staff with access to medical staff: 5-weekcourse of army exercises ad traiig; up to 4 h per week of idividual psychological therapy; uiform ad military traiig are compulsory; ormal military discipliary rules apply; patiets are traied to army stadards i fitess ad military skills; re-familiarisatio withthe army culture; ursig staff ca observe the soldiers behaviour i a peer-group situatio; soldiers ability tofitbackitotheiridividualuits ca be more accurately appraised; safe use of weaposis moitored; soldiers ca retur to their uit cofidet that they are militarily up to speed. The MTRU staff recommed oe of the followig: retetioithearmyadfullyfitforoperatios; i the ad fit for operatios; retetioithearmybutcurretlyufitfor operatios; discharge fromthe army. REFERENCES Cook,T.D. & Campbell,D.T. (1979) Quasi- experimetatio: Desig ad Aalysis Issues for Field Settigs.. Bosto, MA: Houghto Miffli. Defece Aalytical Services Agecy (2001) UK Armed Forces Full Time Stregths ad Traied Requiremets 1Apr 01. Lodo: Miistry of Defece. Duchess of Ket s Psychiatric Hospital (2001) Aual Statistical Returs.Catterick. Garriso: DKPH. Gilbody, S. & Whitty, P. (2002) Improvig the delivery ad orgaisatio of metal health services: beyod the covetioal radomised cotrolled trial. British Joural of Psychiatry, 180,13^18. Miistry of Defece (2000) PULHEEMS Admiistrative Pamphlet. Keysham: MoD. Shephard, B. (2000) A War of Nerves: Army Persoel i Psychiatry 1914^1994. Lodo: Joatha Cape. WorldHealthOrgaizatio(1992) Teth Revisio of the Iteratioal Classificatio of Diseases ad Related Health Problems (ICD^10).Geeva: WHO. 341

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