PTSD in an era of uncertainty and challenge

In the last decade, instability has become a characteristic of international politics, whilst conventional armed forces are increasingly engaged in asymmetric warfare in novel or testing environments; so too military psychiatry finds itself in an era of challenge. The recognition of post-traumatic stress disorder by the American Psychiatric Association in 1980 appeared to herald a new era of understanding with a promise of effective treatments for post-traumatic illnesses. Military psychiatrists embraced the concept of PTSD and adopted it as a key measure to assess the psychological health of serving personnel and veterans. Never have so many peer-reviewed papers been published on a specific psychiatric diagnosis experienced by members of the armed forces. However, any expectation that this research and clinical effort would resolve the issue of military mental health has not been fulfilled.

The latest cohort study of a representative UK military population found that 21.9% reported symptoms of common mental disorder, 6.2% reported probable PTSD, and 10.0% reported alcohol misuse (Stevelink et al., 2018). Probable PTSD was 4.8% in serving members of UK armed forces and 7.4% in veterans, but was 17% in ex-Regulars with a combat role, having been only 6% in 2010. Although these are self-report measures, and the response rate was 44.3%, the results suggest that there may be unaddressed, mental-health consequences for those who have been repeatedly exposed to trauma.

Whilst the primary determinant of psychological casualties is the rate of killed and wounded, higher rates of PTSD in the military may, in part, be associated with broader societal changes. A study of a population-representative birth cohort of 2232 children born in England and Wales between 1994 and 1995 found that one in 13 have experienced PTSD before reaching the age of 18, a prevalence of 7.8% (Lewis et al., 2019). The percentage for adolescents is, therefore, higher than that for UK armed forces. Important questions follow from this study: do the rates for young people reflect a true increase in psychiatric morbidity or a more accurate observation of what always existed? If this is a true increase, it prompts the further inquiry: what features of modern society have made adolescents more vulnerable than before or, conversely, what protective factors have been lost? If there are general effects impacting on the mental health of young people, then over time they will be reflected in military populations.

There is also evidence to suggest that PTSD may lose its dominant place in military psychiatry. Studies have demonstrated that it is not the most common or pressing issue. Depression, anxiety disorders, and abuse of alcohol are found more frequently in military populations and those exposed to conflict. Given that 60–72% of US veterans treated for PTSD with cognitive processing therapy (CPT) and prolonged exposure therapy continue to meet the criteria for PTSD after treatment (Steenkamp, Litz, Hoge, & Marmar, 2015), it has been suggested that such interventions fail to address some elements of post-traumatic illness, such as moral injury.

In sharp contrast to PTSD, few treatments for chronic multi-symptom illness (CMI) have been developed, and yet studies have shown that veterans with psychological ill-health often suffer from long-term pain and physical impairment. The potential benefits of finding effective treatments for medically unexplained somatic symptoms are significant, as these illnesses are not confined to the armed forces, but observed in other groups exposed to trauma, such as refugees and civilians in conflict zones. Drawing on the published reports of Arthur Hurst, who treated shell-shock cases in the First World War, clinicians in multi-disciplinary teams are exploring novel ways to treat functional neurological symptoms, such as persistent tremor, contractures, abnormal gait, and weakness in limbs. These techniques include a diagnosis based on physical signs (rather than psychological features), education in neurological processes, and the use of physiotherapy or cognitive behavioural therapy both to explain causation and to treat symptoms (Nielsen et al., 2015). This clinical approach is designed to avoid the binary split between organic and psychological explanations. A diagnosis is offered that recognizes the legitimacy of physical signs, whilst treatment combines education, psychotherapy, and behavioural initiatives. Occupational therapy has been included to encourage purposeful activity and to prepare for a return to the workplace.

This special edition on military psychiatry was purposefully given an international dimension and includes contributions from the Netherlands, Germany, Canada, Australia, Israel, and the UK. The authors are gratefully thanked for their papers and for delivering them within the publishing schedule.

Disclosure statement

No potential conflict of interest was reported by the author.