Department of Community Mental Health

The responsibility for medical care for serving personnel lies within the military, which, for mental health, is the Department of Community Mental Health or DCMH, in the region where the serviceman is based. Contact should be made with the nearest DCMH, which will ascertain exactly where and to whom the patient should be referred for further treatment.

There are key facts civilian clinicians should understand, particularly when a serviceman is ambivalent about seeking help within the military. Department of Community Mental Health personnel are colleagues, doctors and nurses who happen to wear uniform. They also include nonuniformed social workers and clinical psychologists (employed as Ministry of Defence civilians); they have the same capabilities as any CMHT. They adhere to the same professional standards and professional codes of conduct as the rest of us. Confidentiality is scrupulously observed and a DCMH will only liaise with an individual's unit chain of command when consent is explicitly given. Military medical records are held electronically with strictly controlled levels of access so there is no possibility of a patient's ‘mates’ seeing their medical record. Defence mental health personnel are non-judgemental and act in the interests of the patient. Many servicemen seeking help in the NHS are unhappy and embittered, wanting to leave the armed forces; not surprising, considering a private soldier on completion of basic training is tied into a 4-year contract. The ‘unhappy soldier’ wishing to leave is a common problem accounting for a large part of a DCMH's workload. The DCMH will not react negatively, but with sympathy and compassion. Military mental health professionals understand the administrative and medical routes out of service, and, with the patient's consent, will liaise and work with the chain of command to try to achieve the best outcome for the patient.

There are practical benefits for servicemen being treated by the DCMH. Apart from their better understanding of the military environment compared with NHS mental health professionals, the DCMH has considerably greater capacity than any NHS CMHT, shorter waiting times (less than 24 h in an emergency and less than 2 weeks for a routine appointment), and much more rapid access to clinical psychology and social work support. An individual can still remain ‘sick’ at home with their family and receive DCMH support. However, Departments of Community Mental Health have their limitations: out-of-hours care is generally unavailable and largely limited to telephone advice, and there are no alternatives to admission, such as CRHT.

Patients with predominantly social problems should be reminded that entirely independent organisations such as the Army Welfare Service are available to provide counselling and practical support, again outside the chain of command and defence medical services.

Admission to hospital

Transitions

Whether it is returning home from operations or leaving the armed forces, transitions are emotionally demanding for military personnel and their families (Reference Lincoln, Swift and Shorteno-FraserLincoln 2008). On return from operational service, personnel face a dramatic change in lifestyle, from the adrenaline-fuelled ‘high’ of combat to the realities of a more pedestrian domestic life and the ‘day’ job. Everyday life may seem monochrome and dull to many whose operational experience has been one of the most formative and rewarding periods of their life, prematurely triggering an existential mid-life crisis. A returning spouse expects life to continue as usual; all too often this is not the case: families have learnt to become more self-sufficient and independent. Respective expectations of families and returning service personnel may differ widely resulting in tension, discord and uncertainty (Reference Faber, Willerton and ClymerFaber 2008), and young children may show ambivalence towards a returning parent (e.g. Reference Sayers, Farrow and RossSayers 2009). Likewise, media and public hostility towards government and foreign policy may emotionally undermine service personnel who, as a result, may feel their effort and suffering have been nugatory and unappreciated, further contributing to family discord (Reference Pinder, Murphy and HatchPinder 2009).

This ‘transition gradient’ is all the more steep for members of the reserve forces and Territorial Army who part company with comrades and return to an environment in which few, if any, can understand or empathise with their experience. All of the above may be compounded by the effects of alcohol, frequently used to excess by returning service personnel (Reference Rona, Jones and FearRona 2010), with greatly reduced tolerance having been largely abstinent while deployed. An association between the steepness of the transition gradient and psychopathology is an as yet untested hypothesis, but one with considerable face validity that resonates with clinical experience and helps explain the increased rates of psychopathology seen among reserve forces compared with regular personnel (Reference Iversen and GreenbergIversen 2009).

The transition from serving to veteran status may be as administratively problematic as it is psychologically challenging. Around 20 000 service personnel leave the armed forces annually. Private soldier or general alike, an individual must adjust from being a ‘somebody’ (with rank and status) to a ‘nobody’, from a highly structured and regulated environment, to a world of laissezfaire ‘do as you please’, from a secure world where all needs are met, to one of insecurity, self-help and uncertainty. Adjustment issues on leaving the armed forces are arguably responsible for far more psychopathology than post-traumatic stress disorder (PTSD) and the ‘horrors’ of war.

Veterans – the lost tribe?

Service veterans are a diverse and heterogeneous group which broadly reflects the demographics of society (with, of course, proportionately fewer women), and may equally present to substance misuse and older people's services as to adult mental health services. Veterans typically deny popular stereotypes. Old and bold, or young and immature, they may present to any psychiatric subspecialty, as indeed may their families and children. Their needs are disparate, as are their attitudes towards the provision of dedicated services for veterans. Some veterans will insist that only those who have served themselves and worn a uniform can possibly understand their needs. Others, on the other hand, have no desire to have any further contact with anyone remotely associated with the armed forces or affiliated organisations and prefer to receive care in a civilian environment. Some veterans are extraordinarily ambivalent – complaining bitterly about perceived injustices and the way in which they have been treated by the armed forces while living in surroundings embellished with treasured mementoes and memorabilia of their military career. There are no hard and fast rules and an important question in any assessment is to ascertain whether the patient wishes to receive support and treatment in the more military setting of services dedicated to veterans.

Veterans may be ambivalent about their disorder. To some, a diagnosis of PTSD is a serious disability, isolating and alienating from society and loved ones; for others, PTSD is worn almost as a badge of courage and may bring with it status and recognition in the local community – successful ‘treatment’ may undermine this and assault an individual's core identity. Likewise, the threat of any potential loss of benefits is a powerful disincentive to recovery and it is hardly surprising that some veterans remain entrenched in the ‘sick role’.

Without doubt, a ‘one size fits all’ approach is unlikely to be effective. In general, younger veterans, particularly those having seen service since 2003 and deployed on operations in Iraq (Operation Telic) or Afghanistan (Operation Herrick) and who have an acute disorder of more recent onset, are likely to benefit from evidence-based treatments and psychiatric care, whereas older veterans, more entrenched in the sick role, are less likely to respond to treatment and more likely to respond to welfare and social support (Table 1). Most will benefit from accurate signposting given the confusing plethora of third-sector organisations offering help to ex-servicemen.

TABLE 1

Where to get help for servicemen and ex-servicemen

The problem of attribution

It is part of our nature to seek an external locus on which to blame our problems and the concept of effort after meaning has long been recognised (Reference BartlettBartlett 1916). It is hardly surprising therefore that ex-servicemen developing mental health problems may, entirely understandably, be quick to attribute these to their former military service (fuelled by potential financial incentives such as pensions or compensation). In some cases this may indeed be the case, be it PTSD, alcohol dependency or an affective disorder. However, it is important to bear in mind that for most, military service is formative, some of these individuals may have brought their vulnerability and problems into service with them, and others simply succumb to life's vicissitudes that befall all of us. There is little empirical evidence to suggest that military service per se is a significant cause of mental health problems.

The problem of identification

Many clinicians are oblivious to the fact that their patients have served in the armed forces (Box 3). Even when a service history is identified, it is seldom explored in depth. When taking a history it is important not only to ask whether an individual has served but to explore further and ascertain what the patient did in the armed forces, whether they served on operations and whether they feel their service has any bearing on their current problems. Data such as GP registration and care programme approach (CPA) documentation are only just beginning to be sensitised to record an individual's veteran status.

Organisations such as Combat Stress (www.combatstress.org.uk) argue that there is an iceberg of untreated morbidity among the veteran community, in particular a delay of more than 14 years between release from service and first contact with mental health services (Reference Fletcher, Lee and JonesFletcher 2007). It is difficult to know to what extent this is true. Epidemiological studies are difficult to conduct, not least because individuals can be very difficult to track once they have left the armed forces.

Service veterans frequently cross conventional boundaries of care. Their diverse needs may include relationship and family problems, accommodation, occupation, criminal justice and financial issues. Thoughtful and informed care planning is needed to achieve the best outcomes. Many organisations are dedicated to catering for veterans' needs, but their services often overlap, and it can be very difficult for the concerned professional to know which is the most appropriate resource for a particular individual. Veterans have an unhappy history of raised expectations; organisations (including the NHS) either offering services that they fail to deliver or ‘passing the parcel’ and sending the veteran on a wild goose chase from one organisation to another, wasting time, effort and achieving little or nothing.

Veterans' mental health has been a particular priority of the present UK government, who commissioned Dr Andrew Murrison MP to prepare a report suggesting ways of making improved access to services and treatment for veterans. The report, Fighting Fit (Reference MurrisonMurrison 2010), covers a number of elements of the care pathway (Box 4).

In response to these recommendations, the Department of Health has allocated £1.5 million to establish a national NHS Veterans' Mental Health Network with 30 dedicated veterans' mental health therapists covering all the English NHS regions. The therapists are (mostly) experienced mental health nurses, often with military experience. Their role is to educate fellow mental health professionals and liaise with the care coordinators over individual cases, offering advice, signposting to the plethora of service charities, co-working. They also have a small individual case-load of individuals with the most complex problems.

Further reading

An issue of the International Review of Psychiatry is devoted to military mental health: 2011, 23(2) ‘Military mental health – modern developments’.

MCQs

Select the single best option for each question stem

1. 1 The Veterans' and Reserves Mental Health Programme:

   1. a is available to any reservist

   2. b is only available to reservists who have deployed on operations since 2003

   3. c is synonymous with the Medical Assessment Programme

   4. d requires a GP referral

   5. e provides treatment and case management.

2. 2 The most common presentation to defence mental health services is:

   1. a PTSD

   2. b unhappy soldiers

   3. c conversion hysteria

   4. d alcohol misuse

   5. e malingering.

3. 3 Service veterans:

   1. a only want treatment with clinicians closely allied with the military

   2. b have high rates of PTSD

   3. c may, under certain circumstances, be entitled to treatment within the military

   4. d their mental health problems are usually attributable to military service

   5. e have unique mental health problems that only clinicians who have served themselves can properly understand.

4. 4 The Fighting Fit report:

   1. a recommends pension and compensation arrangements for veterans

   2. b advocates free access to the Big White Wall to servicemen and veterans

   3. c suggests Combat Stress provide exclusive mental healthcare for veterans

   4. d recommends veterans receive in-patient treatment in private hospitals

   5. e suggests more NHS clinicians should receive training in the treatment of PTSD.

5. 5 Transitions:

   1. a are mostly welcomed and a minor source of mental health problems

   2. b are an important cause of PTSD

   3. c probably cause more mental health problems than traumatic exposures in combat

   4. d are well managed by the military

   5. e usually involve the seamless handover of care to the NHS.

MCQ answers

1

b

2

b

3

c

4

b

5

c