Nicola T Fear’s research while affiliated with The London College and other places

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Publications (490)


Illegal drug use amongst male UK military personnel who sustained physical combat injuries: The ADVANCE cohort study
  • Article

May 2025

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11 Reads

Addictive Behaviors

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Susie Schofield

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Alexander N. Bennett

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Nicola T. Fear

PRISMA flow diagram
Primary characteristics of studies included in the systematic review
Qualitative themes identified in the systematic review
A systematic review of military-to-civilian transition, The role of gender
  • Literature Review
  • Full-text available

February 2025

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7 Reads

Background The military-to-civilian transition can be a challenging period for many service members; however, recent research suggests that female ex-service personnel (veterans) confront additional complexities during reintegration into civilian life. This systematic review aimed to identify and synthesise findings across qualitative studies exploring the impact of gender on this transition process. Methods Peer-reviewed literature was drawn from a multi-database search, limited to qualitative studies. The studies included either female veterans or both male and female veterans aged 18 years or older who had previously served in the Armed Forces within the Five Eyes (FVEY) countries (Australia, Canada, New Zealand, the United Kingdom, and the United States). We used a Framework Analysis approach to guide the synthesis of the qualitative data. An assessment of study quality was conducted using the Joanna Briggs Institute (JBI) Qualitative Critical Appraisal Checklist for Qualitative Studies. The study protocol is registered with the Open Science Framework (registration: osf.io/5stuj). Results In total, 10,113 articles were screened after the removal of duplicates, 161 underwent full-text review, with 19 meeting the eligibility criteria. The review identified eleven themes split across individual’s experience whilst serving and after transitioning out of the military service. Both male and female veterans discussed a period of acculturation when they joined service and adapted to military norms, culture and identity. Female veterans faced additional challenges at this stage centred on the conflict between feminine norms and the military masculine ideal. Upon leaving service both male and female veterans experienced a loss of military identity and purpose, and dissonance with civilian norms illustrating a military-civilian divide. For female veterans, adjustments and adaptations learned in the military clashed with civilian feminine norms and stereotypically male veteran culture. Female veterans also struggled with the legacies of gender inequality, discrimination, and sexual assault which affected their development of a female veteran identity and affected the provision of services designed to meet their needs as a female. Despite these challenges, female veterans’ expressed pride in their service and accomplishments. Conclusions Any effort to improve the military-to-civilian transition should take account of the legacy of gender discrimination, especially within the military service, and the potential mismatch between historical civilian female norms and the more traditionally masculine norms of military life. Disclosures This project was supported by a grant from the Forces in Mind Trust (FiMT) 2202.

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Structural and functional social support in UK military veterans during the COVID-19 pandemic and associations with mental health and wellbeing: a cross-sectional study

January 2025

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11 Reads

BMC Public Health

Background The coronavirus disease (COVID-19) pandemic led to the implementation of social distancing laws in the UK. This had several negative consequences on health, wellbeing and social functioning within the general population. Military veterans may have had unique experiences of social isolation during this time. This study examined the level of, and relationship between, structural and functional social support, and its association with mental health and wellbeing in a sample of UK veterans during the COVID-19 pandemic. Methods Throughout the first summer of the pandemic (June-September 2020), an additional wave of cross-sectional data was collected from UK Armed Forces personnel who had left regular military service and were participating in a longitudinal cohort study. In total, 1562 participants (44.04% response rate) completed a series of online questionnaires measuring sociodemographic characteristics, COVID-19 experiences and psychosocial health and wellbeing. Multivariable logistic and ordinal regression analyses were conducted. Results For structural social support, 86.76% were in a relationship and 88.96% lived with others. For functional social support, one-quarter reported feelings of loneliness (27.42%) and low levels of perceived social support (28.14%). Structural support was associated with functional support. Being single, living alone and experiencing loneliness were associated with worse mental health and wellbeing, while living with other adults and reporting high levels of perceived social support were associated with better mental health and wellbeing. Conclusions This study has enhanced our understanding of social support among veterans and its implications for health and wellbeing. This knowledge is essential for advising the development of psychosocial interventions and policies to improve the psychological wellbeing of veterans in future pandemics and more broadly in their daily lives.


A Brief Report on Sex-Specific Differences in Persistent Depression, Anxiety, and Loneliness Among Canadian Veterans During the COVID-19 Pandemic

December 2024

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7 Reads

Military Medicine

Introduction Older adults are at increased risk of severe illness and mortality from Coronavirus disease of 2019 (COVID-19) infection. However, public health strategies aimed at reducing spread of COVID-19 may have resulted in increased mental health symptoms, particularly among older adults. Currently, little is known about whether older Veterans were more likely to experience persistent mental health symptoms during the COVID-19 pandemic than non-Veterans. The objectives of the current study were to (1) compare differences in persistent symptoms of anxiety, depression, and loneliness among a sample of Canadian Armed Forces Veterans and non-Veterans ≥55 years of age and (2) to evaluate potential sex-specific differences in persistent mental health symptoms. Material and Methods The data for this study are drawn from a longitudinal survey of Canadian adults (55 years and older) during the COVID-19 pandemic. Ethical approval was received from the Women’s College Hospital Research Ethics Board. Participants completed a baseline survey of sociodemographic, mental health–related, and COVID-19–related variables in May 2020 and 8 follow-up surveys monthly between May 2020 and January 2021. Modified Poisson regression models with robust standard errors were used to estimate risk of persistent symptoms of anxiety, depression, and loneliness. Results Eight hundred twenty-nine participants (13.7% [n = 114] Veterans) were included in the analysis of persistent depressive symptoms, 859 participants (14.0% [n = 120] Veterans) were included in the analysis of persistent anxiety symptoms, and 862 (13.9% [n = 120] Veterans) were included in the analysis of persistent symptoms of loneliness. When comparing male Veterans and non-Veterans, there were small but statistically insignificant differences in persistent symptoms of anxiety (adjusted relative risk [aRR], 0.59; 95% confidence interval [CI], 0.24-1.46), depression (aRR, 1.54; 95% CI, 0.63-3.77), or loneliness (aRR, 0.79; 95% CI, 0.36-1.75); similar small but statistically insignificant differences were observed in persistent symptoms of anxiety (aRR, 1.26; 95% CI, 0.51-3.09), depression (aRR, 1.16; 95% CI, 0.49-2.73), and loneliness (aRR, 1.33; 95% CI, 0.61-2.90) when comparing female Veterans to female non-Veterans. Conclusions Qualitative, but statistically nonsignificant sex-specific differences in persistent symptoms of anxiety, depression, and loneliness during the early months of the COVID-19 pandemic were observed in this study comparing Veterans and non-Veterans. Additional sex-stratified analyses using larger samples or qualitative interviews may be useful in understanding the unique mental health experiences of older men, women, and gender diverse Veterans during the COVID-19 pandemic.


Directed Acyclic Graph explaining unmediated effects, mediated effects and interactions.
Unmediated direct effect of sustaining a physical combat injury on suicidal ideation using generalised linear models, controlling for age at assessment, combat role and socioeconomic status.
Bias-corrected confidence intervals bootstrapped with 1,000 replications.
Controlled direct effect of sustaining a physical non-amputation combat injury on suicidal ideation in mediation model when effect is fixed to in-service versus veteran groups, controlling for age at assessment, combat role and socioeconomic status.
Bias-corrected confidence intervals bootstrapped with 1,000 replications.
Sociodemographic and military characteristics, overall and by physical combat injury status.
Rates of suicidal ideation, stratified by combat injury and serving status.
Suicidal ideation in male UK military personnel who sustained a physical combat injury in Afghanistan and the mediating role of leaving service: The ADVANCE cohort study

November 2024

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13 Reads

Background/aims Suicidal Ideation (SI) is a risk factor for suicide, a leading cause of death amongst young men globally. In this study we assess whether sustaining a serious physical combat injury is associated with SI and whether leaving service mediates this association. Methods We analysed data from male UK Armed Forces personnel who sustained a combat injury in Afghanistan and a frequency-matched comparison group who did not sustain such an injury (the ADVANCE cohort). SI was measured from the Patient Health Questionnaire-9 item ‘thoughts that you would be better off dead or of hurting yourself in some way’. Results Approximately, 11.9% (n = 61) of the uninjured group, 15.3% (n = 83) of the overall injured group, 8.5% (n = 13) of an Amputation injury (AI) subgroup and 17.6% (n = 70) of a Non-Amputation Injury (NAI) subgroup reported SI in the past 2 weeks. The NAI subgroup reported greater likelihood of SI (Relative Risk Ratio (RR) = 1.44, 95% confidence interval (CI) [1.04, 2.00]) compared to the comparison group, whereas the overall injured group (RR = 1.23, 95% CI [0.90, 1.68]) and AI subgroup (RR = 0.65, 95% CI [0.36, 1.18]) did not. Leaving service fully mediated the association between sustaining a NAI and SI (natural direct effect RR = 1.08, 95% CI [0.69, 1.69]). Conclusions UK military personnel with NAI reported significantly higher rates of SI compared to demographically similar uninjured personnel, while those who sustained AIs reported no significant difference. Leaving service was associated with greater rates of SI for both injured and uninjured personnel and fully mediated the association between sustaining a NAI and SI.


Help seeking for self-reported alcohol problems among serving and ex-serving personnel: A cross-sectional study

November 2024

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8 Reads

Journal of Military Veteran and Family Health

LAY SUMMARY Prior research has found low levels of help seeking for alcohol problems among serving and ex-serving military populations. This study aimed to understand what factors were associated with help seeking for self-reported alcohol problems among serving and ex-serving UK military personnel. It was found that help seeking for alcohol problems among Veterans and serving personnel remains low. Although fewer than 10% of participants self-reported alcohol problems, more than 70% did not seek help for this issue. Formal medical services were the most accessed form of support when seeking help but were less likely to be used by those with current alcohol problems. Future research should prioritize understanding pathways to help seeking and target stigma regarding accessing clinical support among both serving and ex-serving personnel.


Figure 3 Percentage of people who were 'very' or 'extremely' worried between January 2020 and April 2022, by clinical at-risk status (at risk vs not at-risk). Error bars are 95% CIs. Case numbers before June 2020 and in April 2022 are an underestimate as widespread testing was not implemented at this time. Black vertical lines denote major Government interventions. Grey vertical lines denote the launch of advertising campaigns.
Figure 4 Percentage of people who were 'very' or 'extremely' worried between January 2020 and April 2022, by ethnicity (white British vs white other vs other minoritised ethnic group). Error bars are 95% CIs. Case numbers before June 2020 and in April 2022 are an underestimate as widespread testing was not implemented at this time. Black vertical lines denote major Government interventions. Grey vertical lines denote the launch of advertising campaigns. on October 22, 2024 by guest. Protected by copyright.
The changing nature of worry about COVID-19 among the English public: a secondary analysis of 73 national, cross-sectional surveys, January 2020 to April 2022

October 2024

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19 Reads

BMJ Open

Objectives To investigate worry about COVID-19 during the pandemic, and whether worry was associated with phase of the pandemic, COVID-19 death and incidence rates, Government interventions (including lockdown and advertising), age, being clinically at-risk, ethnicity, thinking that the Government had put the right measures in place, perceived risk of COVID-19 to self and the UK, and perceived severity of COVID-19. Design Secondary analysis of a series of cross-sectional surveys. Setting 73 online surveys conducted for the English Department of Health and Social Care between 28 January 2020 and 13 April 2022. Participants Participants were people aged 16 years and over living in the UK (approximately 2000 per wave). Primary outcome measures Our primary outcome was self-reported worry about COVID-19. Results Rates of being ‘extremely’ or ‘very’ worried changed over time. Worry increased as infection rates increased and fell during lockdowns, but the association became less obvious over time. Respondents aged 60 years and over were less likely to be worried after the launch of the vaccination campaign, while those who were clinically at-risk or from a minoritised ethnic community were more likely to be worried. Higher worry was associated with higher perceived risk, and higher perceived severity of COVID-19. There was no evidence for an association with agreeing that the Government was putting the right measures in place to prevent the spread of COVID-19. The launch of graphic Government advertising campaigns about COVID-19 had no noticeable effect on levels of public worry. Conclusions In future infectious disease outbreaks, spikes in worry may attenuate over time, although some sections of society may experience higher anxiety than others.


Figure 1 Neuropsychiatric symptoms after traumatic brain injury (TBI). (A) Extent of post-traumatic stress disorder (PTSD) symptoms, assessed using the PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (PCL4) total score, split by study group. (B) Anxiety symptoms on the Generalised Anxiety Disorder-7 (GAD7) questionnaire, split by study group. (C) Depressive symptoms on Patient Health Questionnaire-9 (PHQ9) instrument by study group. Raincloud plots shown, indicating distribution (left), box plot (middle) and raw data (right) per group, per variable. 'Uninjured'=uninjured controls shown in orange, 'extracranial trauma'=participants with extracranial injuries only, but no TBI shown in blue, 'TBI'=participants with mild-probable or moderate-to-severe TBI, shown in cyan.
Demographics and trauma exposure in the ADVANCE cohort
Poor long-term outcomes and abnormal neurodegeneration biomarkers after military traumatic brain injury: the ADVANCE study

October 2024

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59 Reads

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1 Citation

Journal of Neurology, Neurosurgery, and Psychiatry

Background Traumatic brain injury (TBI) is common in military campaigns and is a risk factor for dementia. A rme D Ser V ices Tr A uma and Rehabilitatio N Out C om E -TBI (ADVANCE-TBI) aims to ascertain neurological outcomes in UK military personnel with major battlefield trauma, leveraging advances in quantification of axonal breakdown markers like neurofilament light (NfL), and astroglial marker glial fibrillar acidic protein (GFAP) in blood. We aimed to describe the causes, prevalence and consequences of TBI, and its fluid biomarker associations. Methods TBI history was ascertained in 1145 servicemen and veterans, of whom 579 had been exposed to major trauma. Functional and mental health assessments were administered, and blood samples were collected approximately 8 years postinjury, with plasma biomarkers quantified (n=1125) for NfL, GFAP, total tau, phospho-tau 181 , amyloid-β 42 and 40. Outcomes were related to neurotrauma exposure. Results TBI was present in 16.9% (n=98) of exposed participants, with 46.9% classified as mild-probable and 53.1% classified as moderate to severe. Depression (β=1.65, 95% CI (1.33 to 2.03)), anxiety (β=1.65 (1.34 to 2.03)) and post-traumatic stress disorder (β=1.30 (1.19 to 1.41)) symptoms were more common after TBI, alongside poorer 6 minute walk distance (β=0.79 (0.74 to 0.84)) and quality of life (β=1.27 (1.19 to 1.36), all p<0.001). Plasma GFAP was 11% (95% CI 2 to 21) higher post-TBI (p=0.013), with greater concentrations in moderate-to-severe injuries (47% higher than mild-probable (95% CI 20% to 82%, p<0.001). Unemployment was more common among those with elevated GFAP levels post-TBI, showing a 1.14-fold increase (95% CI 1.03 to 1.27, p<0.001) for every doubling in GFAP concentration. Conclusions TBI affected nearly a fifth of trauma-exposed personnel, related to worse mental health, motor and functional outcomes, as well as elevated plasma GFAP levels 8 years post-injury. This was absent after extracranial trauma, and showed a dose-response relationship with the severity of the injury.


shows little evidence of an association between sarin exposure and overall cancer incidence. For example, in fully adjusted models, exposure to any sarin (HR=1.01, 95% CI 0.93 to 1.10), two or more tests (HR=1.09, 95% CI 0.85 to 1.38) or a 'high' dose (HR=1.01, 95% CI 0.87 to 1.18) was
Sarin exposure, mortality and cancer incidence in UK military veterans involved in human experiments at Porton Down: 52-year follow-up

September 2024

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12 Reads

Occupational and Environmental Medicine

Objectives We investigated whether UK military personnel exposed to sarin during the ‘Service Volunteer Programme’ at Porton Down had increased rates of mortality or cancer incidence over a 52-year follow-up. Methods A historical cohort study assembled from UK military records, comprising male veterans exposed to sarin during the ‘Service Volunteer Programme’ at Porton Down, UK (n=2975) and a comparison group of similar veterans who did not attend (n=2919). Mortality and cancer incidence data were obtained from national registries up to December 2019. Analysis was conducted using Cox regression adjusted for age, year of birth and service characteristics. Results Over a median follow-up of 52.2 years (range 2 days to 74.6 years), 1598 (53.7%) sarin-exposed veterans and 1583 (54.3%) non-exposed veterans died. Adjusted HRs for all-cause mortality were raised for any sarin exposure (HR=1.08, 95% CI 1.01 to 1.16), two or more exposures (HR=1.25, 95% CI 1.04 to 1.49) and higher doses (air >15 mg.min/m ³ ) (HR=1.15, 95% CI 1.02 to 1.30). For cause-specific mortality, sarin exposure was associated with deaths from ‘other’ circulatory diseases (excludes ischaemic and cerebrovascular diseases) (HR=1.41, 95% CI 1.06 to 1.87) and alcohol-attributable deaths (HR=2.66, 95% CI 1.40 to 5.07). There was no association between sarin exposure and overall cancer incidence (HR=1.01, 95% CI 0.93 to 1.10), but cancer incidence was higher for alcohol-related neoplasms (HR=1.24, 95% CI 1.01 to 1.51). Conclusions Sarin exposure was associated with increased rates of mortality over a 50-year follow-up. The strongest associations were observed for deaths attributable to alcohol and ‘other’ circulatory diseases.


Citations (40)


... Despite advancements in aviation technology, the persistence of occupational hazards such as nonhypoxic hypobaria and decompression stress continues to pose significant neurological risks to military aviators [50]. The association between WMHs and elevated biomarker levels suggests potential long-term cognitive and neurological impairments [51]. Addressing these risks requires ongoing research to elucidate the injury mechanisms and develop effective prevention and intervention strategies to safeguard the brain health and operational readiness of military personnel [21,52]. ...

Reference:

Neurological Biomarker Profiles in Royal Canadian Air Force (RCAF) Pilots and Aircrew
Poor long-term outcomes and abnormal neurodegeneration biomarkers after military traumatic brain injury: the ADVANCE study

Journal of Neurology, Neurosurgery, and Psychiatry

... 8 Drawing on systematic and narrative reviews 9-11 of PSP families research, the hub was grounded in three convergent lifestyle dimensions shaping PSP life -logistics, risks, and identities -that emerged from the work of an interdisciplinary research team who distilled the complexities of identifying the unique aspects of PSP life by using framework analysis. 12 Logistics are the structural requirements of PSP work that can spill over into home life. Risks refer to the ongoing exposure to heightened physical and psychological risks, which affect PSPfams through over-or under-sharing, behaviours, and unprocessed trauma responses. ...

Lifestyle Dimensions of Public Safety Personnel Families: There’s No Life Like It

Journal of Occupational Rehabilitation

... Social functioning is impaired among the general population with depressive and anxiety disorders even after remission (Saris, Aghajani, van der Werff, van der Wee, & Penninx, 2017). Recent meta-analyses among veterans reveal an inverse association between social support and PTSD, MDD and GAD, which is bi-directional and longitudinally predictive (Brewin, Andrews, & Valentine, 2000;Grover, Williamson, Burdett, Palmer, & Fear, 2024;Wang, Chung, Wang, Yu, & Kenardy, 2021). This unfortunate cycle is augmented among former service members after the loss of protective unit support following discharge (Kamphuis, Delahaij, Duel, Geuze, & Vermetten, 2021;Nielsen, Andersen, & Hogh, 2015;Pietrzak et al., 2010) who often experience difficulties re-integrating into the community, particularly for those who have been abruptly discharged from service (Barnett et al., 2021). ...

Level of perceived social support, and associated factors, in combat-exposed (ex-)military personnel: a systematic review and meta-analysis

Social Psychiatry and Psychiatric Epidemiology

... There are several mechanisms by which leaving service might affect suicidal ideation. Social support is a protective factor for self-harm and suicide behaviours in serving and ex-serving military personnel (Williamson et al., 2024). However, it is noted that involvement in the military community (Vogt et al., 2022) or social participation outside of employment (Hatch et al., 2013) ...

Risk and protective factors for self-harm and suicide behaviours among serving and ex-serving personnel of the UK Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force: A systematic review

... Nevertheless, research on slow-paced breathing techniques has largely concentrated on non-injured individuals (Kennedy and Parker, 2019;Maqsood et al., 2024), resulting in a serious gap in knowledge about understanding its clinical utility for injured populations (Minjoz et al., 2023). Notably, there has been no investigation into these practices among individuals injured in traffic crashes. ...

Exploratory analysis of spontaneous versus paced breathing on heart rate variability in veterans with combat-related traumatic injury
  • Citing Article
  • April 2024

PM&R

... SSO data show the fear of negative outcomes for PSPfams that the literature identified [8][9][10][11] connected with the logistics and risks and foregrounding of competing identities. Having to be caregivers and household managers, despite having their own full lives, was identified as leading to feeling overwhelmed and having even less time for connection. ...

Exploring the Occupational Lifestyle Experiences of the Families of Public Safety Personnel

Journal of Occupational Rehabilitation

... Ці чинники здатні призвести до передчасної смерті пацієнта. Проведене у Великій Британії когортне дослідження [7], у якому йшлося про зв'язок між бойовими травмами та 10-річним ризиком серцево-судинних ускладнень, підтвердило відносний ризик останніх у групах пацієнтів з ампутованими кінцівками. ...

Relationship between combat-related traumatic injury and its severity to predicted cardiovascular disease risk: ADVANCE cohort study

BMC Cardiovascular Disorders

... In general, ex-servicewomen do seek help for their mental health and are, in fact, more likely to seek formal support than ex-servicemen, yet they still face barriers to mental health help-seeking. Ex-servicewomen report similar levels of structural and attitudinal help-seeking barriers as men; in particular, self-stigma (12). ...

Gender differences in structural and attitudinal barriers to mental healthcare in UK Armed Forces personnel and veterans with self-reported mental health problems

Social Psychiatry and Psychiatric Epidemiology

... This is a prospective cohort study investigating the health and wellbeing of regulars and reservists of the UK Armed Forces who served during the Iraq and Afghanistan era across all three services (British Army, Royal Air Force and Royal Navy). To date, four phases of data collection have been undertaken over 20 years [20]. Participants received an email invitation to participate in Veterans-CHECK if they had completed phase 3 of the main cohort study, were ex-serving regular members of the Armed Forces and were living in the UK. ...

Health and well-being of serving and ex-serving UK Armed Forces personnel: protocol for the fourth phase of a longitudinal cohort study

BMJ Open

... Mental wellbeing was measured using the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS) [23], a 14-item measure with scores ranging from 14 to 70, covering experiences across the past two weeks. Scores were categorised as low , moderate (40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58)(59) or high (60-70) using cut-off points of plus or minus one standard deviation of the sample mean. Higher scores indicate better mental wellbeing. ...

Loneliness among UK Veterans: Associations with quality of life, alcohol misuse, and perceptions of partner drinking

Journal of Military Veteran and Family Health