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KCMHR 20-year study finds enduring impact of combat in Iraq and Afghanistan on PTSD rates of UK Armed Forces

by Dr Marie-Louise Sharp, Prof Nicola Fear, Prof Sir Simon Wessely, Sofia Franchini, Dr Sharon Stevelink a month ago 5 min read

Today, we’re launching the final report of the fourth phase of our Health and Wellbeing Cohort Study (2022-2023). Findings revealed rises in probable Post Traumatic Stress Disorder (PTSD) and Common Mental Disorders (CMD) such as depression and anxiety among serving and ex-serving personnel of the UK Armed Forces since the last phase of the study in 2014-2016. CMD was the most prevalent in the cohort reported at 28%, followed by probable PTSD at 9% and alcohol misuse at 8%.

Background

The study has been running since 2003 with the aim of investigating the impact of deployment to Iraq (Operation TELIC) and Afghanistan (Operation HERRICK) on the health and wellbeing of serving and ex-serving personnel.

Data have been collected over three previous phases - Phase 1 (2004/06), Phase 2 (2007/09), and Phase 3 (2014/16), with the most recent phase taking place over 2022/23. In addition to examining key mental health outcomes such as CMD, probable PTSD and alcohol misuse, this phase also collected new data on additional topics relevant to UK serving and ex-serving personnel including complex PTSD (C-PTSD), loneliness and caring responsibilities.

For Phase 4 (2022/23), we followed up participants who took part in the previous phase in 2014/16. 4104 participants completed the survey. 69% of the sample had deployed to Iraq and/or Afghanistan and 72% had left service.

Relative frequencies of adverse mental health outcomes and alcohol misuse over Phases 1-4

**Note** – we used two measures to assess the presence of probable PTSD in our sample: the PCL-5, which is based on the most recent Diagnostic and Statistical Manual of Mental Health (DSM-5), and the earlier version, the PCL-C, which used the DSM-4 criteria. The PCL-5 showed a 9% rate of probable PTSD, while the PCL-C showed a probable PTSD rate of 10%. We used the PCL-C measure in this figure to be able to compare it with rates of probable PTSD in previous phases. It’s also important to note that we use the term “probable PTSD” as the PTSD measures are tools for screening purposes and are not a clinical diagnosis by a healthcare professional.

Probable PTSD, CMD and alcohol misuse trends

In our latest phase, we found that the majority of respondents (67%) did not report adverse mental health problems or alcohol misuse. However, our results also showed:

The overall rate of probable PTSD has risen from 6% in 2014/16 to 9% in 2022/23.
The prevalence of probable PTSD was higher in ex-serving Regular personnel, with a rate of 11% compared to 7% in Regular serving personnel.
Amongst ex-serving Regular personnel, those who deployed were more likely to report probable PTSD compared to ex-serving Regulars who hadn’t deployed to either of these conflicts.
Having deployed in a combat role to Iraq or Afghanistan was also associated with higher likelihood of reporting probable PTSD in both serving and ex-serving Regular personnel with PTSD rising to 13% and 18% respectively in these groups.

What might explain rises in probable PTSD?

1) The study finds an enduring impact of combat deployment in Iraq and Afghanistan on rates of probable PTSD for serving and ex-serving personnel 20 years on. However previous studies have also identified that PTSD rates can also be affected by childhood adversity and non-military trauma.

2) Rises in probable PTSD may be due to the higher risk of probable PTSD in ex-serving personnel compared to serving personnel, and ex-serving personnel make up more of the cohort in Phase 4 compared to Phase 3, with 72% having left service at Phase 4, compared to 43% in Phase 3.

3) Ex-serving personnel may have a higher risk of probable PTSD compared to serving personnel as individuals who aren’t well may leave military service and/or the process of transitioning out of the military and adjusting to civilian life can be challenging for some which could make PTSD symptoms worse.

4) However, there were still rises in probable PTSD found in serving personnel since the last Phase which may be due to military or non-military traumatic exposures experienced since 2014-2016.

We also observed an increase in the rates of CMD from 22% in 2014/16 to 28% in 2022/23. This may reflect general population trends that see rises in CMD pre- and post-COVID-19.

The general decline in alcohol misuse since the beginning of the study has levelled off and stayed relatively stable (from 10% in 2014/16 to 8% in 2022/23) but remains significantly higher compared to the general population.

Most of PTSD reported is complex PTSD

For the first time in this cohort, we examined C-PTSD. C-PTSD is a subset group within PTSD where individuals must meet the criteria for PTSD, and then meet additional criteria for C-PTSD. C-PTSD results from experiencing repeated trauma over a long period of time and can be more difficult to treat with individuals taking longer to seek help and often experiencing other mental health conditions at the same time. The rate of C-PTSD reported in the cohort overall was 5.7%.

Of those who reported PTSD, we found that 73% of PTSD in the sample met the criteria for C-PTSD, and the rate was higher amongst ex-serving compared to serving personnel. Amongst those who deployed in a combat role, the rate of C-PTSD was 7% in serving personnel and 14% in ex-serving personnel.

The impact of loneliness and caring responsibilities

In our report, we also looked at other factors that may impact ex-serving Regulars' mental health. We found that 14% of ex-serving Regular personnel had unpaid caring responsibilities. Those who reported unpaid caring responsibilities (compared to those with no unpaid caring responsibilities) were more likely to report CMD, probable PTSD, and C-PTSD.

One-third of ex-serving Regulars reported feelings of loneliness (34%). We found that loneliness (compared to not reporting loneliness) was associated with CMD, probable PTSD, C-PTSD, and alcohol misuse.

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Take away points - Our findings suggest that a substantial minority of personnel who served during the Iraq and Afghanistan era of conflicts experience mental health problems. Those who served in Iraq and Afghanistan should not be a forgotten generation and both research, policies, and support services should continue to focus on addressing the long-term impact of military service. Our report suggests key recommendations focused on continued funding for serving and ex-serving mental health services and support for prevention and treatment of alcohol misuse.

To read our full report, please see https://kcmhr.org/pdf/Phase_4_Health_and_Wellbeing_Cohort_Study_Report.pdf.

Note

Phase 1-3 of the Health and Wellbeing Cohort Study were previously funded by the Ministry of Defence. Phase 4 was funded by the Office for Veterans’ Affairs. KCMHR are a fully independent academic research group that carried out the research.

Office for Veterans’ Affairs Final Report: Health and Wellbeing Study of Serving and Ex-Serving UK Armed Forces Personnel: Phase 4. September 2024 (Marie-Louise Sharp, Sofia Franchini, Margaret Jones, Ray Leal, Simon Wessely, Sharon A.M. Stevelink, Nicola T. Fear)

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