Do medical services personnel who deployed to the Iraq war have worse mental health than other deployed personnel?
ABSTRACT There is evidence of increased health care utilization by medical personnel (medics) compared to other trades in the UK Armed Forces. The aim of this study was to compare the burden of mental ill health in deployed medics with all other trades during the Iraq war.
Participants' main duty during deployment was identified from responses to a questionnaire and verified from Service databases. Psychological health outcomes included psychological distress, post-traumatic stress disorder, multiple physical symptoms, fatigue and heavy drinking.
A total of 479 out of 5824 participants had a medical role. Medics were more likely to report psychological distress (OR 1.30, 95% CI 1.00-1.70), multiple physical symptoms (OR 1.65, 95% CI 1.20-2.27) and, if men, fatigue (1.38, 95% CI 1.05-1.81) than other personnel. Female medics were less likely to report fatigue (0.57 95% CI 0.35-0.92). Neither post-traumatic stress disorder nor heavy drinking symptoms were associated with a medical role. Traumatic medical experiences, lower group cohesion and preparedness, and post-deployment experiences explained the positive associations with psychological ill health. Medics made greater use of medical facilities than other trades.
There is a small excess of psychological ill health in medics, which can be explained by poorer group cohesion, traumatic medical and post-deployment experiences. The association of mental ill health with a medical role was not the consequence of a larger proportion of reservists in this group.
- SourceAvailable from: James Spira[show abstract] [hide abstract]
ABSTRACT: This study examines risk factors for post-traumatic stress disorder (PTSD), depression, and mental health care use among health care workers deployed to combat settings. Anonymous surveys were administered to previously deployed workers at a military hospital. PTSD and depression were assessed by using the PTSD Checklist and the Patient Health Questionnaire depression scale, respectively. Deployment exposures and perceived threats during deployment were also assessed. There were 102 respondents (36% response rate). Nine percent (n=9) met the criteria for PTSD and 5% (n=5) met the criteria for depression. Direct and perceived threats of personal harm were risk factors for PTSD; exposure to wounded or dead patients did not increase risk. Those who met the criteria for PTSD were more likely to seek mental health care after but not before their deployment. For health care workers returning from a warfare environment, threat of personal harm may be the most predictive factor in determining those with subsequent PTSD.Military medicine 06/2007; 172(5):451-5. · 0.77 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: This descriptive study investigated traumatic experiences and post-traumatic stress disorder symptoms among military professionals in Turkey. The sample included 225 military health professionals who were in charge in districts in which traumatic events occurred frequently in the past decade. The Impact of Event Scale, Beck Anxiety Inventory, and Symptom Checklist were used to obtain data in the study. More than one-half of the health professionals had experienced at least one traumatic event. Those who had a history of traumatic experience and loss of relatives or friends reported more symptoms than did those who had not experienced traumatic events. As expected, health professionals who had traumatic experiences were more likely to have higher Impact of Event Scale scores than were those who had not experienced physical or psychological trauma. The findings indicate that health professionals are as affected by traumatic events as are those in other settings or occupations. Future research should focus on the long-term effects of post-traumatic stress among health professionals.Military medicine 03/2005; 170(2):125-9. · 0.77 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Concerns have been raised about the mental and physical health of UK military personnel who deployed to the 2003 war in Iraq and subsequent tours of duty in the country. We compared health outcomes in a random sample of UK armed forces personnel who were deployed to the 2003 Iraq war with those in personnel who were not deployed. Participants completed a questionnaire covering the nature of the deployment and health outcomes, which included symptoms of post-traumatic stress disorder, common mental disorders, general wellbeing, alcohol consumption, physical symptoms, and fatigue. The participation rate was 62.3% (n=4722) in the deployed sample, and 56.3% (n=5550) in the non-deployed sample. Differences in health outcomes between groups were slight. There was a modest increase in the number of individuals with multiple physical symptoms (odds ratio 1.33; 95% CI 1.15-1.54). No other differences between groups were noted. The effect of deployment was different for reservists compared with regulars. In regulars, only presence of multiple physical symptoms was weakly associated with deployment (1.32; 1.14-1.53), whereas for reservists deployment was associated with common mental disorders (2.47, 1.35-4.52) and fatigue (1.78; 1.09-2.91). There was no evidence that later deployments, which were associated with escalating insurgency and UK casualties, were associated with poorer mental health outcomes. For regular personnel in the UK armed forces, deployment to the Iraq war has not, so far, been associated with significantly worse health outcomes, apart from a modest effect on multiple physical symptoms. There is evidence of a clinically and statistically significant effect on health in reservists.The Lancet 06/2006; 367(9524):1731-41. · 39.06 Impact Factor
Do medical services personnel who deployed
to the Iraq war have worse mental health
than other deployed personnel??
Margaret Jones1, Nicola T. Fear2, Neil Greenberg2, Norman Jones2, Lisa Hull1,
Matthew Hotopf1, Simon Wessely1, Roberto J. Rona1
Aim: There is evidence of increased health care utilization by medical personnel (medics) compared to
other trades in the UK Armed Forces. The aim of this study was to compare the burden of mental ill
health in deployed medics with all other trades during the Iraq war. Methods: Participants’ main duty
during deployment was identified from responses to a questionnaire and verified from Service
databases. Psychological health outcomes included psychological distress, post-traumatic stress disorder,
multiple physical symptoms, fatigue and heavy drinking. Results: A total of 479 out of 5824 participants
had a medical role. Medics were more likely to report psychological distress (OR 1.30, 95% CI 1.00–1.70),
multiple physical symptoms (OR 1.65, 95% CI 1.20–2.27) and, if men, fatigue (1.38, 95% CI 1.05–1.81)
than other personnel. Female medics were less likely to report fatigue (0.57 95% CI 0.35–0.92). Neither
post-traumatic stress disorder nor heavy drinking symptoms were associated with a medical role.
Traumatic medical experiences, lower group cohesion and preparedness, and post-deployment experi-
ences explained the positive associations with psychological ill health. Medics made greater use of
medical facilities than other trades. Conclusions: There is a small excess of psychological ill health in
medics, which can be explained by poorer group cohesion, traumatic medical and post-deployment
experiences. The association of mental ill health with a medical role was not the consequence of a larger
proportion of reservists in this group.
Keywords: Iraq, medical personnel, mental health, military
stress because of their increased exposure to the death or
injury of others.1There have been some reports that military
medics have more mental ill health than their colleagues in
other trades. A small study of non-deployed UK military
healthcare professionals found an overall prevalence of psycho-
logical ill health of 35%.2The majority of reports on mental
health of military medical personnel are of small studies that
do not include a control group making it difficult to gauge
whether mental ill health is more common in medics than in
other military personnel.3–5
Medics are over represented amongst those referred to
mental health services and in those aero-medically evacuated
from Iraq. A total of 44% of all reservists, referred to field
mental health services in Iraq between February and June 2003,
were medics as were 7% of all psychiatric evacuees subse-
quently admitted to a military in-patient psychiatric facility
during the early phase of the Iraq war.6,7These findings are
consistent with studies which have reported that physical and
psychological ill health are high in UK civilian health care
workers but might simply reflect the relative ease of access to
medical services by military medics.8–10
Medics make up ?3% of the total strength of regular UK
Armed Forces, with ?6% of deployed personnel during
eployed military medics may be subjected to considerable
Operation TELIC 1 (the military codename for the initial
phase of the Iraq war between 18 January 2003 and 28 June
2003) having a medical role. A recent National Audit Office
(NAO) report identified medics as belonging to a ‘pinch point
trade’ in all three Services, with ‘insufficient trained personnel
to perform operational duties while enabling guideline levels
on amount of time away from home to be met’. The NAO
report estimated that 34% of A&E nurses and 21% general
surgeons were above guideline thresholds for duration of
deployments. Operational commitments are being met by the
use of large numbers of reservists.11In previous papers we
have shown both reservist status12and so called ‘overstretch’13
are associated with poorer health outcomes for deployed
The aim of this study was to compare the burden of
psychological ill health in deployed military medics with that
in all other trades who had served in the 2003 Iraq war. We
also assessed the possible reasons for associations between
medical trade and mental ill health in terms of medical and
combat traumatic experiences, unit cohesion and problems at
home on return from deployment, after adjusting for socio-
The data presented here were collected during the first stage
of a cohort study to compare the mental and physical health of
UK Armed Forces personnel, who deployed on Operation
TELIC 1 with individuals who did not deploy but who were in
service at the time (designated the Era group). Details of the
sampling method, participants, response rates and question-
naires are given in a previous publication.14A total of 4722
regular and reserve personnel in the TELIC 1 group and 5550
in the Era group completed a questionnaire about their
experiences during and after deployment, an adjusted response
rate of 61%. Of the Era group, 1145 people reported having
?In this article, UK military medical personnel including doctors,
nurses and medical support staff are referred to collectively as medics.
1 King’s Centre for Military Health Research, Institute of Psychiatry,
King’s College London, London, UK
2 Academic Centre for Defence Mental Health, Institute of Psychiatry,
King’s College London, London, UK
Correspondence: Margaret Jones, King’s Centre for Military Health
Research, Weston Education Centre, Cutcombe Road, London, SE5
9RJ, tel: 020 7848 5594, fax: 020 7848 5408,
European Journal of Public Health, Vol. 18, No. 4, 422–427
? The Author 2008. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckn031 Advance Access published on 8 May 2008
by guest on June 3, 2013
served on subsequent TELIC deployments. The study received
approval from King’s College Hospital local research ethics
committee and the Ministry of Defence (Navy) personnel
research ethics committee.
For this article, we include those in the TELIC 1 sample plus
those in the Era group who served on later TELIC operations
(TELIC 2–6). From responses to the questionnaire we identi-
fied 526 participants whose main duty during TELIC opera-
tions was medical or welfare. We were able to verify from
personnel and deployment databases held by the Defence
Analytical Services Agency (DASA) that 479 had a medical
role. We excluded 43 individuals from this analysis because we
were unable to confirm their role and four people were
reassigned to the ‘other main duty’ group because their roles
were not medical. Personnel endorsing a medical role could be
doctors, nurses, medical assistants, medical technicians, aero-
medical evacuation staff, medical administration staff and
other professions allied to medicine. The comparison group
were 5345 respondents who endorsed any other main duty
during TELIC operations. These duties were: combat, logistics/
supply, aircrew, engineering, catering/chef, intelligence, mili-
tary police, flight operations, administrative, musician, warfare
branch and Air Force protection.
The following measures of current health were included in
the questionnaire: the 12 item General Health Questionnaire
(GHQ-12) as a measure of psychological distress; the civilian
version of the post-traumatic stress disorder (PTSD) checklist
(PCL-C); the Chalder fatigue scale; 53 somatic symptoms as
used in our previous study of Gulf War veterans; the World
Health Organization Alcohol Use Disorders Identification Test
(WHO AUDIT).15–18Cases for each measure were defined as
those with a score of: 4 or more for GHQ-12; 4 or more for the
fatigue scale; 50 or more for the PCL-C; 18 or more physical
symptoms; 16 or more on the AUDIT scale, corresponding
to ‘high levels of alcohol problems’ (‘heavy drinking’).18In
addition, participants were asked to provide military and social
demographic details and information about their preparedness
for, and experiences during and after their deployment.
Odds Ratios (OR) with 95% confidence limits (95% CI) were
calculated to assess the association between role in theatre and
health outcomes using logistic regression to control for con-
founders and to adjust for potentially traumatic experiences,
morale and unit cohesion, and problems on return from
deployment. We checked, a priori, for effect modification by
enlistment status (regular or reserve), because of possible
qualitative differences between regular and reserve medical
professionals. Model adequacy was tested using a specification
test and goodness of fit with the Hosmer–Lemeshow test.
A quadratic term was included for the continuous variable
(age) when model inadequacy was indicated. Where model
adequacy was not improved by including quadratic or cubic
terms for age plausible interactions were investigated. Analyses
were performed using STATA 9.2. Appropriate survey
commands (svy) were used to account for the over sampling
of reservists in the original sample.
A total of 5867 responders who deployed on Operation TELIC
1–6 were included in the analysis. We found no interaction
between role and enlistment type (regular or reserve) for any
health outcome. Medics were older, of higher rank and
educational status than non-medical personnel. A higher
proportion of medics was female, in the army, belonged to
the reserve services, and had not experienced deployment
before the Iraq war (table 1).
The experiences of personnel during and after deployment
are shown in table 2. It was less common for medics to have
been deployed with their parent unit, to have felt well
informed about what was going on, for their seniors to have
been interested in what they thought or did, or to be able to go
to most people in their unit if they had a problem. Fewer
medics reported combat exposures but they more commonly
saw people wounded or killed, handled bodies and gave aid to
the wounded. Approximately two-thirds of personnel, irre-
spective of role, experienced diarrhoea and/or vomiting during
deployment but medics more often reported that they required
intravenous fluids, and said their symptoms prevented them
doing normal duties. Medics more often reported spending at
least one night under medical care. They were more commonly
evacuated by air from Iraq to the UK for medical reasons.
On return from deployment, more medics reported having
major problems, with fewer feeling well supported by the
military. More medics reported that other people did not
understand what they had been through.
Psychological distress and multiple physical symptoms, but
not PCL-C caseness or ‘heavy drinking’, were positively
associated with medical trade after adjustment for confounders
(model 1, table 3). Addition of a variable for ‘overstretch’
(up to 12 months/more than 12 months deployed in last three
years) to model 1 had no effect for any health outcome (results
not shown). The models for fatigue showed inadequacy, which
was not improved by adding quadratic or cubic terms for the
age variable. An interaction between trade and sex was thought
Table 1 Socio-demographic and military characteristics of
medics compared to all other duties in theatre, during TELIC
All other duties
Non commissioned officer
No previous deployment
Single or divorced
O level or equivalent
A level or equivalent
Degree or higher
255 (47) 1718 (30) <0.0001
300 (65) 4994 (94)
Percentages are weighted to account for sampling fractions.
a: Pearson’s Chi squared test with Rao and Scott second order
Mean age at completion of questionnaire: Medic=35.4 (SD
7.6), All other roles=32.1 (7.5)
Mental health of deployed medics
by guest on June 3, 2013
to be the most likely problem. We found a significant
interaction (P=0.002) between sex and trade for fatigue,
thus we report results for fatigue stratified by sex in table 3.
The separate models for males and females were adequate.
Medical trade was positively associated with fatigue symp-
toms for men but negatively associated for women (table 3).
All associations were of small effect size except fatigue in
women, which was moderate.
Adjustment for combat related traumatic experiences in
theatre (model 3) did not modify the level of associations
compared with adjustment for confounders only (table 3).
In contrast, traumatic medical experiences (aiding the
Table 2 Experiences during and after Operation TELIC (1–6)
Medics (%) All other duties (%)P
Comradeship, unit cohesion and preparedness
Felt comradship with others in unit
Could go to most people in unit with a personal problem
Seniors interested in what I thought and did
Felt well informed about what was going on
Deployed with parent unit
Work in theatre matched trade experiences and ability
Potentially adverse combat experiences in theatre
Time in forward area in close contact with enemy
Came under small arms fire
Came under mortar/scud/artillery fire
Experienced landmine strike
Experienced hostility from civilians
Discharged personal weapon in direct combat
Thought might be killed
Potentially adverse medical experiences in theatre
Saw personnel wounded or killed
Gave aid to wounded
Adverse medical events in theatre
Spent one or more nights under medical care during deployment
Had diarrhoea and/or vomiting during deployment
Needed intravenous fluids because of diarrhoea & vomiting
Symptoms of diarrhoea and/or vomiting prevent normal duties
Medically evacuated from theatre
Post deployment experience
Had major problems on return
Felt well supported by military
Had difficulty adjusting to being back home
Proud of contribution made in TELIC
People didn’t understand what been through
Didn’t want to talk to family about experiences
Frustrated at time taken to return home
Likely continue service
Percentages weighted to account for sampling fractions. Denominators vary because not all participants completed the relevant
Table 3 The association between medical trade and psychological ill health adjusted for confounders and possible explanatory
All other roles
a: Model 1 adjusted for the following confounders: rank, age, (age2), sex, education, service, enlistment type, marital status,
b: Model 2 adjusted for model 1 variables and unit cohesion and preparedness: seniors interested, well informed, comradeship,
go most people with problems, deployed with parent, work matched trade and experience
c: Model 3 adjusted for model 1 variables and traumatic combat experiences: discharged weapon, small arms fire, forward area,
thought might be killed, mortar attack, landmine, civilian hostility
d: Model 4 adjusted for model 1 variables and traumatic medical experiences: aided wounded, handled bodies, see people
e: Model 5 adjusted for model 1 variables and post deployment experience: major problems, military not supportive, people
didn’t understand, difficulty adjusting, didn’t want to talk family/friends, frustrated by time to come home
European Journal of Public Health
by guest on June 3, 2013
wounded, seeing people wounded or killed, handling bodies)
(model 4) were a plausible explanation for the associa-
tions observed after adjustment for confounders only, as
indicated by the reduction in odds ratio to the null after
adjustment. Likewise, cohesion and preparedness (model 2),
and post-deployment experiences (model 5) were also able to
explain the associations. Of note, the association of fatigue
with medical trade in women was not modified by any
In the course of exploring possible interpretations of the
results we observed a significant interaction (P=0.003)
between aiding the wounded and trade for psychological
distress. Among medics, psychological distress was less likely
in those who aided the wounded (adjusted OR 0.62 95% CI
0.35–1.08), although this difference was of only borderline
statistical significance, whereas for other trades psychological
distress was more likely in those who aided the wounded
(adjusted OR 1.47 95% CI 1.20–1.81). Medics who did not aid
the wounded had an increased OR of reporting psychological
distress compared to other trades who did not aid the
wounded (table 4). Medics who did not aid the wounded
did not differ in social or military demographic characteristics
from other medics. Personnel from other trades who gave aid
to the wounded were younger, more often in the army and to
be in combat units but adjusting for combat role did not
account for the association between psychological distress and
aiding the wounded (results not shown).
Medics were more likely to report psychological distress,
multiple physical symptoms and, if men, fatigue than other
deployed Service personnel. PTSD was not associated with
medical trade and nor was ‘heavy drinking’. The association of
mental ill health with a medical role was not the consequence
of a larger proportion of reservists in this group. This finding
was contrary to the expectation since we recently reported that
deployed reservists had a higher prevalence of all health
outcomes measured than regular personnel.12Medical trau-
matic experiences, but not combat traumatic experiences,
explained the associations with psychological ill health.
Likewise, cohesion and preparedness and post-deployment
experiences can explain the associations. We were able to
demonstrate that medics made a greater use of medical
facilities than other trades.
Our study provides an evidence of a small increase in some
psychological symptoms in medics compared to other military
trades, which only partially explains the greater level of
utilization of medical resources evidenced in our study and
also in health data routinely collected by the military.
Our results suggest that medics tended to use medical facilities
over and above the differences in symptoms reported,
especially in relation to spending nights under medical care,
medical evacuation from theatre, and use of intravenous fluids
because of diarrhoea and vomiting. A large gastroenteritis
outbreak occurred in UK deployed forces between 28 March
2003 and 3 May 2003 which disproportionately affected
medics.19However, despite their increased need for intrave-
nous fluids, there was no difference in reported episodes of
gastroenteritis between medics and others in our study.
Female health workers, in most occupational groups, in the
National Health Service (NHS) have higher levels of fatigue
than their male counterparts.20This is contrary to the findings
in this study, possibly explained by differences in the duties
undertaken by male and female military medics not found in
the NHS. Significantly more male medics ‘spent time in a
forward area in close contact with the enemy’ where duties
would include frequent movement of heavy equipment as
units advanced, whereas female medics were more often
deployed to the static field hospital.
What accounts for differences in
Traumatic experiences during deployment
Previous reports have suggested that medical personnel
experience higher rates of PTSD. Emergency room personnel,
intensive care unit nurses and ambulance service personnel
have been reported as being at increased risk of PTSD as
a result of their job experiences, with a substantial proportion
of ambulance workers meeting GHQ case criteria for psy-
chiatric symptoms.21–23Carson and colleagues reported that in
Vietnam nurse veterans witnessing death and serious injury to
others contributed to PTSD.1However, a study of US health
care providers deployed in Iraq and Afghanistan found that
frequent exposure to injured or dead personnel did not
increase the risk of either PTSD or depression.5We did not
find a difference between medical and other trades for PTSD,
but we did find strong evidence that medical traumatic
experiences such as seeing personnel wounded or killed, giving
aid to wounded and handling bodies explained the excess in
multiple physical symptoms and fatigue in males. Aiding the
wounded was associated with psychological distress in both
medics and other trades. For medics, whose training and
experience prepare them for handling casualties, not fulfilling
that role may be associated with increased psychological
distress, whereas for personnel in other trades exposure to
casualty handling increases psychological distress, an effect not
accounted for by combat role.
Table 4 The association between medical trade and psychological distress reported separately for ‘aided the wounded’
All other roles
GHQ-12 aided wounded
GHQ-12 did not aid wounded
a: Adjusted for socio-demographics: rank, age (age2), sex, education, service, enlistment type, marital status, previously
b: Adjusted for socio-demographics+unit cohesion and preparedness: seniors interested, well informed, comradeship, go most
people with problems, deployed with parent, work matched trade and experience
c: Adjusted for socio-demographics+traumatic experiences (combat): discharged weapon, small arms fire, forward area,
thought might be killed, mortar attack, landmine, civilian hostility
d: Adjusted for socio-demographics+post deployment experience: major problems, military not supportive, people didn’t
understand, difficulty adjusting, didn’t want to talk family/friends, frustrated by time to come home
Mental health of deployed medics
by guest on June 3, 2013
Cohesion and leadership
Our study also indicated that factors such as cohesion,
leadership and preparedness could be possible contributors to
an excess of psychological symptoms. Medics expressed more
negative sentiments regarding cohesion and leadership. Medics,
particularly regulars, were less likely to report that they
deployed with their parent unit. We found evidence that lack
of unit cohesion and negative views about leadership are able to
explain the excess reporting of psychological distress, multiple
physical symptoms and fatigue in males. We are not aware of
other studies that have covered these factors in military medical
personnel, but unit cohesion has been found to be the most
important motivating factor for combat soldiers, to influence
strain experienced by soldiers on operation, to be the most
powerful predictor of psychiatric symptoms, and to attenuate
the impact of life experiences on PTSD.24–27Studies in civilian
health workers have shown that workload pressures are
associated with psychological ill health in doctors and nurses
and that psychological distress is caused by low involvement in
decision making and poor social support at work.8,28
Another factor that explained the differences in this study was
post-deployment experience. Medics reported more major
problems on return, and more claimed that people did not
understand what they have been through and did not feel well
supported by the military. The duties undertaken by doctors
and nurses, regulars and reserves, are similar whether deployed
or at home, although the conditions in which they work are
very different. Many will return from deployment to work in
NHS hospitals, or MoD hospital units within NHS hospitals,
where the military support network is less accessible.
Strengths and limitations
This is the largest study of the psychological health of military
medical personnel based on a representative sample of the
deployed British military population. It directly compares
psychological ill health between medics and other trades, unlike
other studies which rely for comparisons on other reports using
different methods.5Although the largest study of this nature,
the statistical power to analyse PTSD symptoms was low, but it
was sufficiently high for our other outcomes of psychological
health. Our analysis included all medical personnel but it is
possible that associations may differ between the various health
professions as shown for civilian health workers.29–31
Although the peacetime roles of military doctors and nurses
are comparable to those in the civilian health service and their
roles on deployment, particularly if deployed to the field
hospital are not dissimilar, the role of deployed military
medical assistants may differ markedly from their peacetime
role. Some military medical assistants are effectively well
trained paramedics with additional schooling in basic nursing
care, prescribing and medical administration, whereas others
have only rudimentary medical training and little experience
other than administrative medical centre work. On deploy-
ment they may work as part of a medical team, headed by a
doctor, but at times they will be called upon to practice
independently with only limited and sporadic access to
medical supervision. The effect of this on psychological ill
health could not be considered in our study, but the great
majority of medics felt that their work in theatre matched their
trade experience and ability.
This study is cross sectional and therefore it is not possible
to determine the direction of causation for the associations we
report. Although there is potential for recall bias, we believe it
unlikely that there would be a difference in recall, between
medics and other trades, of the exposures used in the analysis.
Implication and conclusions
Our study has shown that there are small associations between
medical trade and psychological ill health and that there is
greater utilization of health resources by medics that could be
explained by easier access or to a greater level of dissatisfaction.
Our study provides important pointers as to how to address the
excess of psychological ill health. We have demonstrated that,
in comparison to other trades, among medics there was a
feeling of poor group cohesion, a perception that they were
poorly informed and, to some extent that their superiors were
not interested in them. Combat units typically spend up to a
year preparing and training together for an operational
deployment whereas a medical group is assembled only weeks
before deployment and, in recent years, has only two weeks pre-
operational training as a unit, factors which are likely to impair
effective communication and make leadership more of a
challenge. Good team relationships, thorough preparation
and high morale have been shown to protect against serious
adverse reactions to potentially traumatic experiences.32
The situation on the ground in Iraq has undergone change
since data collection for this study ended and many medics
have been re-deployed to Iraq, some on a number of occasions.
A follow-up study is necessary to assess whether psychological
health is deteriorating in deployed medics.
We thank the following for their cooperation: the Defence
Personnel Administration Agency andthe Veterans Policy Unit.
The study was funded by the UK Ministry of Defence. Those
who funded the study had no input into the analysis, the results
presented, or the interpretation of those results.
Conflict of interest: S.W. is an Honorary Civilian Consultant
Advisor in Psychiatry to the British Army (unpaid). N.G. is a
full-time active service medical officer and N.J. is a full-time
reserve member of Defence Medical Services seconded to King’s
College; although paid by the Ministry of Defence they were not
directed in any way by the Ministry in relation to this paper.
All other authors declare they have no conflict of interest.
? Operational commitments are being met by repeated
deployment of medical personnel and by the use of
large numbers of reserve ‘medics’. Reservist status has
previously been shown to be associated with poorer
health outcomes for deployed personnel.
? The small excess of mental ill health found in deployed
medical personnel compared to other trades may be
explained by: poorer group cohesion and leadership;
exposure to wounded casualties; and post deployment
? The excess is not attributable to the larger proportion
of reservists in medical roles.
? Measures to increase group cohesion and effective
leadership may improve the mental health of deployed
? A need for improved access to military support
networks is indicated for medical personnel who
return from deployment to work in NHS hospitals.
European Journal of Public Health
by guest on June 3, 2013
1 Carson MA, Paulus LA, Lasko NB, et al. Psychophysiologic assessment of
posttraumatic stress disorder in Vietnam nurse veterans who witnessed
injury or death. J Consult Clin Psychol 2000;68:890–7.
2 Burden JIF, Jeffery SMT, Leach AJ. The psychological morbidity of military
healthcare workers. J R Nav Med Serv 2005;91:37–42.
3Akbayrak N, Oflaz F, Aslan O, et al. Post-traumatic stress disorder symptoms
among military health professionals in Turkey. Mil Med 2005;170:125–9.
4 Lubin G, Sids C, Vishne T, et al. Acute stress disorder and post-traumatic
stress disorder among medical personnel in Judea and Samaria areas in the
years 2000–2003. Mil Med 2007;172:376–8.
5Grieger TA, Kolkow TT, Spira JL, Morse JS. Post-traumatic stress disorder
and depression in health care providers returning from deployment to Iraq
and Afghanistan. Mil Med 2007;172:451–5.
6 Jones N, Greenberg N, Fear NT, et al. The operational mental health
consequencies of deployment to Iraq for UK Forces. J R Army Med Corps
7 Turner MA, Kiernan MD, McKechanie AG, et al. Acute military psychiatric
casualties from the war in Iraq. Br J Psychiatry 2005;186:476–9.
8 Michie S, Williams S. Reducing work related psychological ill health and
sickness absence: a systematic literature review. Occup Environ Med
9 Taylor C, Graham J, Potts HW, et al. Changes in mental health of UK
hospital consultants since the mid-1990s. Lancet 2005;366:742–4.
10 Burbeck R, Coomber S, Robinson SM, Todd C. Occupational stress in
consultants in accident and emergency medicine: a national survey of levels
of stress at work. Emerg Med J 2002;19:234–8.
11 National Audit Office. Recruitment and retention in the armed forces.
London: TSO, 3-11-2006.
12 Browne T, Hull L, Horn O, et al. Explanations for the increase in mental
health problems in UK reserve forces who have served in Iraq. Br J Psychiatry
13 Rona RJ, Fear NT, Hull LM, et al. Mental health consequences of overstretch
in the UK armed forces: first phase of a cohort study.[see comment]. Br Med
14 Hotopf M, Hull L, Fear NT, et al. The health of UK military personnel
who deployed to the 2003 Iraq war: a cohort study. Lancet 2006;367:1731–41.
15 Goldberg D, Williams P. A users guide to the general health questionnaire.
Windsor, UK: NFER-Nelson, 1988.
16 Blanchard EB, JonesAlexander J, Buckley TC, Forneris CA. Psychometric
properties of the PTSD checklist (PCL). Behav Res Ther 1996;34:669–73.
17 Chalder T, Berelowitz G, Pawlikowska T, et al. Development of a fatigue
scale. J Psychosom Res 1993;37:147–53.
18 Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The alcohol use
disorders test: guidelines for use in primary care, 2nd edn. Geneva: World
Health Organization, 2001.
19 Bailey MS, Boos CJ, Vautier G, et al. Gastroenteritis outbreak in British
troops, Iraq. Emerg Infect Dis 2005;11:1625–8.
20 Hardy GE, Shapiro DA, Borrill CS. Fatigue in the workforce of national
health service trusts: levels of symptomatology and links with minor
psychiatric disorder, demographic, occupational and work role factors.
J Psychosom Res 1997;43:83–92.
21 Laposa JM, Alden LE. Posttraumatic stress disorder in the emergency room:
exploration of a cognitive model. Behav Res Ther 2003;41:49–65.
22 Clohessy S, Ehlers A. PTSD symptoms, response to intrusive memories and
coping in ambulance service workers. Br J Clin Psychol 1999;38:251–65.
23 Mealer ML, Shelton A, Berg B, et al. Increased prevalence of post-traumatic
stress disorder symptoms in critical care nurses. Am J Respir Crit Care Med
24 Rielly RJ. Confronting the tiger: small unit cohesion in battle. Mil Rev
25 Farley K, Veitch J. Measuring morale, cohesion, and confidence in
leadership: what are the implications for leaders. The Canadian Journal of
Police & Security Services 2003;1:353–64.
26 Orsillo SM, Roemer L, Litz BT, et al. Psychiatric symptomatology associated
with contemporary peacekeeping: an examination of post-mission func-
tioning among peacekeepers in Somalia. J Trauma Stress 1998;11:611–25.
27 Brailey K, Vasterling JJ, Proctor SP, et al. PTSD symptoms, life events, and
unit cohesion in US soldiers: baseline findings from the neurocognition
deployment health study. J Trauma Stress 2007;20:495–503.
28 Tyler P, Cushway D. Stress in nurses – the effects of coping and social
support. Stress Med 1995;11:243–51.
29 Pattani S, Constantinovici N, Williams S. Who retires early from the NHS
because of ill health and what does it cost? A national cross sectional study.
Br Med J 2001;322:208–9.
30 Wall TD, Bolden RI, Borrill CS, et al. Minor psychiatric disorder in NHS
trust staff: occupational and gender differences. Br J Psychiatry
31 Calnan M, Wainwright D, Forsythe M, et al. Mental health and stress in the
workplace: the case of general practice in the UK. Soc Sci Med
32 Alexander DA, Wells A. Reactions of police officers to body-handling after a
major disaster – a before-and-after comparison. Br J Psychiatry
Received 6 February 2008, accepted 31 March 2008
Mental health of deployed medics
by guest on June 3, 2013