JRSM >
Volume 101, Number 2 >
Pp. 78-84
Academic Centre for Defence Mental Health (ACDMH), King's College London, Weston Education Centre, London, SE5 9RJ, UK
Correspondence to: Dr Neil Greenberg. E-mail: sososanta{at}aol.com
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Design Using a sub-sample of the King's military cohort we surveyed personnel that deployed on peacekeeping operations between 1991 and 2000 (n=1198).
Setting Respondents' mean age was 36 years (min, 23 to max, 60) and 81% (n=964) were serving in the Armed Forces at the time of participation.
Main outcome measures PTSD prevalence was determined in British military peacekeepers using the PLC-M (cut-offs 44 and 50), the General Health Questionnaire (GHQ-12) and a composite brief measure of potential post traumatic symptomology, ‘PostTraumatic Stress Reaction’ (PTSR) for comparison.
Results PTSD prevalence varied from 3.6 to 5.5%. Officers and married personnel were less likely to be cases. Neither gender, age or deployment status influenced PTSD prevalence.
Conclusions PTSD was an uncommon disorder in this sample of British military peacekeepers, with prevalence rates being lower than those reported by other nations. Deploying without an established peer group was not associated with developing PTSD. We postulate that differences in culture and operational practices may account for the lower rates of PTSD.
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Over the past few decades, the British military has spent relatively little time waging conventional battles but has instead been engaged on numerous peacekeeping operations (PKOs). Military peacekeepers are often exposed to traumatic stressors, many being similar to those found during conventional war such as the threat of death or seeing dead bodies. PKOs are characterized by varying degrees of physical danger. The United Nations Peacekeeping Force in Cyprus, established in 1964, suffered 167 fatalities in the first 32 years of its existence whereas a United Nations Operation in Somalia suffered 147 fatalities in just two years.3 (Lower intensity missions are often referred to as ‘peacekeeping’ whilst higher risk operations are termed ‘peace enforcement’. However, this distinction is far from clear and in this paper PKO is used to cover both sorts of deployments.)
However some stressors frequently encountered during PKOs are specific to the peacekeeping role, often related to engaging with the local population in order to enforce or keep the peace. At times military personnel can witness atrocities or can be the targets of hostility from the very populations that they are trying to protect.4 The so-called ‘fog of war’ may apply even more to PKOs, reflecting conflicting pressures that may include mission creep, restrictive rules of engagement and unclear mission objectives.5
Military peacekeepers may therefore be subject to both physical risks and psychological stressors, both of which may impact upon individual's well-being, readiness and operational effectiveness.5 Such stressors may not only be associated with PTSD6,7 but also with other serious psychopathologies such as substance misuse, anxiety disorders and depression.8,9
This paper examines the prevalence of PTSD symptoms in personnel deployed on peacekeeping operations. The current study uses a sub sample of peacekeeping troops drawn from the King's military cohort (Unwin et al, 1999). Symptoms of PTSD were measured using an accepted diagnostic tool for PTSD in the military (the PCL-M), 10 the general health questionnaire, a measure of psychological distress (GHQ-12) 11 and an alternative measure of post-traumatic distress described in previous work.12,13
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Investigations
The postal peacekeeping questionnaire stated clearly that participation was
voluntary and the researchers were independent of the MoD. Twenty-one
different United Nations PKOs were enquired about including deployments to the
former Yugoslavia (including Bosnia and Kosovo), the Arabian Gulf and Cyprus
but not Northern Ireland (which is technically supporting the civil power
rather than peacekeeping) nor the 1991 Gulf War. Personnel were asked in what
manner they deployed (deployment status): with their main unit, with part of
their main unit, or as part of another unit (with or without colleagues). All
participants were asked to complete the General Health Questionnaire, 12-item
version (GHQ-12)11
when taking part in the follow-up of the main
study13 and the
Post Traumatic Stress Disorder Checklist, Military version
(PCL-M)10 was
included in the peacekeeping questionnaire. A cut-off of 3 or more was used to
decree ‘psychiatric caseness’ on the GHQ 1-12 and cut-offs of 45
and 50 were used on the
PCL-M.10,14
An additional measure of post-traumatic distress was sought to avoid giving undue prominence to overt psychiatric symptomology (required in stage one of the baseline study12 whilst investigating potential ‘Gulf War Syndromes’). This variable, ‘Post-Traumatic Stress Reaction’ (PTSR), was a brief measure that aimed to maximize the response rate. Table 1 demonstrates how PTSR caseness was ascertained. The seven individual items were included within the general physical symptom checklist (53 items) used within the main study.
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Ethical approval for the study was gained from the King's College Hospital Research Ethics Committee.
Statistical analyses
Analysis was limited to respondents reporting at least one peacekeeping
deployment during the study period. Chi squared tests were used for
categorical data and the independent samples T-test for continuous data. The
Pearson Correlation co-efficient was used where appropriate. Data were
analysed using SPSS version 11.0.
The final phase of the main study13 was over-sampled to include a disproportionate number of the most severely fatigue-affected individuals. To account for this the sample was weighted to correct for the fatigue variable when reporting caseness, following convention.
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In total, 1245 participants completed the questionnaire although a small number of participants did not endorse at least one PKO (n=47). The majority of the sample were male (n=1008, 84%); of mean age 36 years (min 23 to max 60) and 81% (n=964) were still serving in the Armed Forces. The sample consisted of 12% officers (n=143) and 75% (n=897) were married.
55% (n=661) of responders deployed with their main unit compared to 36% (n=425) who deployed with only part of their main unit and 21.3% (n=225) as part of another unit but with colleagues. Deploying with another unit but without any colleagues was reported by 16.4% (n=197).
Post traumatic stress symptomology
In total, 5.4% (n=64) were PTSD cases using the PCL-M cut-off of
44 and 3.6% (n=43) were cases using a cut-off of 50. For the GHQ,
29.1% (n=357) were cases.
The results revealed that on all measures (GHQ-12, PTSR, the PCL-M 45+ and
PCL-M 50+), those who were married or who were officers were significantly
less likely to be a case. However there was no effect of gender, age or the
number of deployments on caseness, except with the PTSR measure which showed
that those personnel who had been on more than two deployments were more
likely to be a case (
= 9.92, p<0.01). Those who had left the military
were also significantly more likely to be a case on every measure (e.g. PCL-M
50+: = 17.21, p<0.001).
Deployment status and associated rating scale scores
Analysis of deployment status and caseness using PTSR, PCL-M (cut-offs 45+
and 50+), and GHQ caseness did not show any significant differences for most
categories (Table 2). There was
no clear effect on traumatic stress symptomology in relation to personnel
deploying without their main unit or if they deployed without anyone else from
their main unit. Personnel who deployed alone with part of another unit were
statistically less likely to be a PCL 50+ case (n=3). No clear
pattern emerged from analysis of the GHQ caseness scores. Personnel that
deployed with their complete unit were less likely to be a case (27%) on the
GHQ and those deploying with part of their main unit more likely to be a case
(31%).
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Sensitivity analysis
Caseness defined by the PCL-M and the PTSR revealed a sensitivity of 58.3%
and a specificity of 94.7% whilst for a cut off of 50 on the PCL-M the
sensitivity was 61.7% and specificity 93%. The respective positive predictive
values for the above cut offs were 59.2% and 43.8%.
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TOPSUMMARYIntroductionMethodsResultsDiscussionConclusionREFERENCES |
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Limitations of this study
Our results were obtained using a postal questionnaire to estimate the true
prevalence of PTSD in UK military peacekeepers. Questionnaires are known to
overestimate the true rates of PTSD
28 and thus our
prevalence findings should be interpreted with caution. However the PCL-M is a
well used and well validated instrument which has been widely used to measure
PTSD caseness rates in a variety of military and non military populations.
7,10,25
The study was undertaken in 2001 and examined peacekeeping operations dating as far back as 1991. The results thus have to be interpreted with the possibility of recall bias in mind. Other authors have reported that in military cohorts such as this one, recall bias is likely to inflate rather than diminish rates of psychopathology.29 Additionally as the cohort was mostly composed of personnel from the Army, caution is required when extrapolating the results to the small numbers of Naval and Royal Air Force personnel who occasionally undertake peacekeeping duties.
In common with other retrospective cohort studies, we cannot determine issues of causality since there is no reliable way of clarifying whether the psychological distress levels found were a direct result of being deployed on peacekeeping operations or whether other causative factors could explain the results. The results found can, though, be taken as being valid indicators of association.
Our sample was stratified to include the most severely fatigued personnel. However, we must also consider there may be a ‘healthy-worker effect’ bias introduced, in that personnel that deploy on operations must be fit enough to do so; undergoing treatment for an identified formal mental health problem would preclude deployment. However within the UK military, personnel cannot be under treatment for any form of medical disorder for more than 18 months without being discharged or permanently employed in a non-deployable role. Therefore it is most probable that in our nine-year frame of study, we have included all relevant personnel, including those who may have been treated and returned to full fitness, and thus were deployable on PKOs.
Comparison with other studies
The prevalence of PTSD in the present study is lower than reported
elsewhere for military
personnel.6,7,15
PTSD rates for peacekeeping troops from western countries may vary from 2 to
15%.16 However,
there are few studies of UK peacekeepers for comparison. Baggaley et
al. studied 382 members of an infantry battalion three years after the
first British troops were deployed to the
Balkans.15 Of the
145 subjects who had been deployed to the Balkans at some point during their
career, 16% of personnel met caseness criteria compared to 9% of the
controls.
Although female gender is considered a risk factor for PTSD in civilian populations,17 the present study did not show disparity in rates between male and female personnel, though there were limited female participants in the study. This accords with rates of PTSD reported previously for military cohorts7,18 and supports the view of enhanced resilience among women in the Armed Forces compared to their counterparts in the general population.18
The comparatively low prevalence of PTSD in the present study may reflect a true difference in PTSD rates in our sample, it may also be accounted for by other factors including the choice of PTSD rating scale used (other studies have used the Impact of Events Scale15 or the Composite International Diagnostic Interview (CIDI)19 to determine PTSD caseness) or by the cultural differences in reporting of symptoms of distress by UK troops. Non-military literature supports the notion that even in western countries there is variation in how symptoms of distress are reported20 and there is no reason to think such difference would not apply in military populations. Creamer et al., in a national survey of the Australian population,21 found PTSD rates to be one third of that found in a national survey of the US population.22 Both studies used the same instrument.
It is also possible that national variation in the types of operations that are conducted during PKOs, due to both national attitudes towards military risk taking and differing political pressures, may affect PTSD rates. A study of US troops deployed to Somalia showed that 8% met diagnostic criteria for PTSD.7 Undeniably, a US soldier operating in Somalia in 1994 would have been subject to very different stressors to those experienced by British soldiers in the Balkans in late 1999. National differences in training, both in terms of variety and intensity for peacekeepers may also explain the variation in prevalence rates, as effective training is known to protect against psychological injury.23
Deployment status
That deployment status (who subjects deployed with) was not found to be
linked to PTSD prevalence rates is at odds with Ismail et al. who
found increased levels of distress in combat troops who deployed without their
main unit.24
Ismail's study had specifically examined personnel deployed to the Gulf War of
1991, which only lasted for four days. While previous studies have shown that
most soldiers gain social support from their
peers,25 the
relatively short operational deployment in the Gulf War of 1991 may have been
an insufficient period for studied personnel to integrate with units that they
were attached to. Without sufficient time to form sufficiently strong
interpersonal bonds with their attached unit a socially supportive, and
therefore psychologically protective, environment may not have developed. In
contrast peacekeeping deployments usually last for six months, which is likely
to be sufficient for attached personnel to share sufficient experiences with
the main unit allowing ‘protective’ social integration to
occur.
It is also possible that the operational tempo (the number of hours spent on active patrolling or other potentially dangerous duties) may be less intense in PKOs than during war fighting operations. Indeed, Ismail's study failed to find the same increase in distress symptoms for non-combat troops as for combat troops, a finding which supports this idea. Further studies are needed to clarify effects of deployment status as during the recent Iraq War, allied armies made considerable use of reserve forces many of whom would have been deployed as attached rather than whole units.
Measures of PTS symptomology
This study has found that significant correlations between the different
measures of post traumatic distress used. This lends credence to our use of
the PTSR measure as a simple and relatively unobtrusive indicator of post
traumatic distress. Unsurprisingly there was also a significant correlation
between the general measure of distress used (the GHQ-12) and the various
indicators of post traumatic distress; similar correlations have been found in
other studies of UK service
personnel.26
However there were differences in the prevalence of PTSD found using the
different measures and the kappa scores were at best
moderate.27
Therefore, although it seems clear that the PTSR measure is yet another valid
measure of post traumatic distress, it may measure a different construct of
psychological distress from other well validated measures such as the
PCL-M.
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TOPSUMMARYIntroductionMethodsResultsDiscussionConclusionREFERENCES |
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| Footnotes |
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Competing interests NG is a full time active service medical officer who has been seconded to King's College Centre for Military Health Research as a liaison officer; although paid from Ministry of Defence funds he was not directed in any way by the Ministry in relation to this publication. SW is Honorary Civilian Consultant Advisor to the British Army. All other authors declare that they have no conflict of interest
Funding This study was funded by the UK Ministry of Defence (MoD). However the authors' work was independent of the funders and we only disclosed the paper to the Ministry of Defence at the point we submitted it for publication
Ethical approval Ethical approval for the study was gained from the King's College Hospital Research Ethics Committee
Contributorship All authors have made substantial contributions to the intellectual content of the research study, the preparation of the manuscript and have agreed to be part of the authorship
Acknowledgements We would like to thank the UK Ministry of Defence (MoD) for their cooperation, in particular the Defence Analytical Services Agency (DASA). We also thank all UK Armed Forces personnel who took part in this study
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