The UK military has been extremely busy since 2000 with military personnel being deployed in large numbers to Afghanistan and Iraq. There are currently approximately 10,000 UK personnel deployed to Afghanistan alone, with many more deployed around the world providing peace-keeping and humanitarian support. As a result of the current high tempo of deployment in often demanding and hostile environments, there has perhaps not surprisingly been a steady flow of injured personnel who require a range of physical and psychological healthcare1.
Much of this healthcare treatment is provided by the military medical services at the frontline in forward operating bases and field hospitals such as Camps Bastion and Kandahar in Afghanistan. Those requiring further treatment are flown to the UK NHS Selly Oak Hospital in Birmingham. There are also 16 outpatient defence community mental health teams around the UK, Germany and Cyprus, staffed by a military multidisciplinary team including community mental health nurses with training in psychological therapies, which also deploy and provide mental health support and early psychological treatments2.
Why should veterans be targeted?
As those of us who work in the traumatic stress field know, military personnel are considered one of the highest risk occupational groups for exposure to traumatic and adverse events3. Such events, and the demands of being deployed away from family and social support, increase vulnerability to a range of mental health problems, in particular anxiety disorders, depression and substance dependency disorders4). Over the past 30 years, the development of evidence-based treatment approaches for mental health problems has greatly increased the range of options available to mental health clinicians5.
With 24-hour news coverage of the current conflicts, there has also been a change in awareness and support for the armed forces from the Government and wider public. In 2007, the Ministry of Defence (MoD) and devolved Governments funded six NHS community mental health pilots in Edinburgh, the North East, Staffordshire, London, Cornwall and Cardiff.
These pilots were tasked to set up community veteran services to see what the uptake would be from veterans, the range of mental health presentations, and which type of treatment was required and what worked. The pilots were staffed by a mental health therapist with a clinical training in a psychological therapy, with administrative support. The pilots have all completed their work and have been subjected to a review by Sheffield University6.
The All Wales Veterans’ Health and Wellbeing Service
Here in Wales, the Welsh Government requested that the pilot based in Cardiff undertake a ‘task and finish group’ to establish what a Welsh ex-service personnel outpatient service would require.
Professor Jonathan Bisson, consultant psychiatrist, and a team of experts from health, social services, military and the voluntary sector across Wales, developed a service specification document.
The group met on five occasions between July and September 2009, and the specification was informed by evidence obtained from the following sources:
- Existing literature regarding the needs of veterans and the provision of services for them
- Discussions with veterans, their carers and individuals involved in the psychosocial care of veterans
- Ongoing psychosocial research into the needs of veterans living in Wales
- The experiences of the six Community Veterans’ Mental Health Service Pilot Projects across the UK, with particular reference to the Pilot Project based in Wales
Setting up the service: aims and outcomes
The primary aim of the specification was to improve the mental health and wellbeing of veterans. The secondary aim was to achieve this through the development of sustainable, accessible and effective services that met the needs of veterans with mental health and wellbeing difficulties who lived in Wales. It was suggested that the service should be firmly based within existing NHS and Social Care Services and fully integrated with the other services and agencies that cater for the health and social needs of veterans.
The veteran service is just one part of the welfare pathway for veterans and has adopted a stepped care approach to ensure veterans’ needs are addressed by the most appropriate agency.
- Veterans who experience mental health and wellbeing difficulties are able to access and use services that cater for their needs.
- Veterans in this service are given a comprehensive assessment that accurately assesses their psychological and social needs.
- Veterans are signposted or referred to appropriate services for any physical needs that are detected.
- Veterans and others involved in their care are able to develop an appropriate management plan that takes their family and their surroundings into account.
- Veterans’ families are signposted to appropriate services if required.
- This service will develop local and national networks of services and agencies involved in the care of veterans to promote multi-agency working to improve outcomes for veterans and their families.
- The service will link with the military to facilitate early identification and intervention.
- The service will promote a recovery model so that veterans can maximise their physical, mental and social wellbeing.
- To provide brief psychosocial interventions.
- To provide expert advice and support to local services on the assessment and treatment of veterans who experience mental health difficulties to ensure local services, including addictions services, are able to meet the needs of veterans.
- To raise awareness of the needs of veterans and military culture to ensure improved treatment and support across services.
- To identify barriers to veterans accessing appropriate services and attempt to highlight and address these as appropriate.
- To collect data on patterns of referral, routine outcomes and referral on.
Eligibility and access
Eligibility was made very wide, to include any veteran living in Wales who had served at least one day with the British Military as either a regular member or as a reservist. An open referral system was adopted whereby veterans could self-refer, or be referred by their families or by other agencies or services; this is a single point of referral for each Local Health Board.
The service is based on a ‘hub and spoke service model’. The hub is based in Cardiff, provided by the Cardiff & Vale University LHB. The other five LHBs responsible for mental health service provision across Wales are the spokes. The LHBs have created local mental health and wellbeing services for veterans, covering the whole of Wales, that deliver the outcomes listed above.
The LHBs have employed an individual or individuals to undertake the role of a Band 7 community veterans therapist (CVT) who is a member of the most appropriate arm of the local mental health service (eg a community mental health team, psychological therapies service or traumatic stress service). The CVTs aim to spend a minimum of 50 per cent of their time delivering psychological treatments to veterans in order to address the gap in current tier three provision. They also skill up others within the mental health service to help provide/cover this service when that individual is away. The CVTs are appropriately skilled and trained mental health professionals from nursing, social work, and psychology backgrounds. The Cardiff & Vale University Local Health Board has employed a Band 8b CVT full time and a consultant psychiatrist, one session per week, to allow the development of the hub and spoke model. Each of the LHB services is supported by a 0.5 whole time equivalent Band 2 administrator, with an additional 0.5 whole time equivalent Band 2 administrator based at the hub to undertake all Wales administrative tasks.
Management and professional accountability
The service is directed by Professor Jonathan Bisson, who is based in Cardiff University Hospital, with support from the Band 8b CVT (the author). All CVTs are line managed and professionally managed locally with support from the Band 8b CVT and service director.
The nine Band 7 CVTs attended a week-long induction programme following their appointment in October 2011 at Dering Lines, Infantry Battle School, Brecon and receive face-to-face group supervision every six weeks, and telephone supervision from the Band 8b CVT on a monthly basis. The service director is accountable to the Welsh Government through the Cardiff & Vale University LHB.
The CVTs all have proven skills and experience in conducting a full biopsychosocial assessment, developing management plans, case management and the provision of brief psychosocial interventions and psychological treatments. An ongoing professional development programme will be delivered to enhance the CVTs’ ability to work effectively with veterans.
The LHBs are responsible for creating and maintaining local networks of key stakeholders which meet regularly. These include local veterans and carers, representatives from Health and Social Services, the Royal British Legion, Combat Stress, the Service Personnel and Veterans Agency and other organisations, eg Citizens Advice, Defence Community Mental Health Services, according to the local situation. These local networks help to develop a robust multi-agency approach to the care of veterans and support the CVT.
Each LHB veteran service will develop a care pathway that is agreed with the service director and will deliver the outcomes listed above. It is recognised that the care pathways will not be identical given the geographical and service differences across Wales. Veterans with more complex difficulties throughout Wales will be eligible to receive a second opinion assessment in Cardiff veteran service with Professor Bisson and Neil J Kitchiner to confirm a diagnosis and offer suggested interventions for the management plan following referral by the local CVT.
Engaging veterans in mental health treatment programmes remains particularly challenging due to a variety of factors, including stigma, perceived weakness at acknowledging emotional difficulties, and the military macho culture. Recent studies have shown that more than 60 per cent of US Iraq veterans screened positive for a mental health problem did not seek treatment7. Similar findings were reported in a UK study8, in which only 23 per cent of serving personnel with common mental health problems were receiving any form of medical professional help. Chaplains were much more likely to be supporting these individuals. Those who were receiving medical help were mainly in primary care (79 per cent) and being treated with medication, counselling or psychotherapy. Trials are ongoing in the US and UK with group programmes such as Battlemind, and Trauma Risk Management (TRiM) respectively, with some evidence that they may improve attitudes to mental-health-seeking behaviours9. In 2009, the IAPT programme published a veterans’ positive guide with helpful information for the NHS and in particular primary care, to aid commissioners when setting up veteran-informed services10.
What treatments work with veterans?
There is a range of evidence-based treatments for mental health problems that have been shown to be effective in civilian populations, but it is unclear whether or not they have similar efficacy in serving military and veteran populations, or how well these populations engage with them. Currently, the information is limited to addressing the specific interventions, settings, and lengths of treatment that are applicable in the veteran population. Therapies that have some evidence from randomised controlled trials (RCTs), completed mostly in the US and Australia, demonstrate that trauma-focused CBT and eye movement desensitisation reprocessing (EMDR) therapy does ameliorate PTSD symptoms11-14, insomnia15 and panic disorder co-morbid to PTSD16.
Based on our experience during the two-year pilot in Cardiff, the typical veteran is male, aged between 35 and 50 who has served in the army with multiple deployments, including several tours of Northern Ireland, Falkland Islands, and peacekeeping duties in Bosnia and Kosovo. Since leaving service, he has found it difficult to stay employed, has many and varied social problems, may have had contact with the criminal justice system, and has been classed as vulnerably housed or homeless.
These often complex presentations require a varied management plan with referrals and signposting to organisations and veteran charities that can assist with many of the social problems, including debts and benefit advice. They often require pharmacological therapy for anxiety and depressive disorders in tandem with outpatient psychological therapies.
From our experience, veterans will attend NHS facilities but prefer a veteran-specific service as they view their problems as being unique from the civilian population. Treatment gains are possible with the correct management plan, but often modest. Targeting their often multitude of social problems in the first instance appears to produce better attendance in outpatient psychological therapy and leads to improved positive outcomes.
The formation of a veteran steering group, with a wide membership from the main veteran charities, MoD service personnel and veterans’ agency, CAB, prison healthcare, homelessness teams, Combat Stress and local military medical services, will help the new veteran services develop positive practices.
In the last 10 years, there has been a proliferation of charities that have emerged claiming to be able to treat and ‘cure’ veterans’ mental health problems, particularly PTSD17,18. They are often staffed by well-meaning ex-service personnel, usually with some medical training from the medical centre. The treatment programmes are, though, often residential focused and use psychological treatments such as neurolinguistic programming (NLP) and emotional freedom techniques (EFT). New veteran services within the NHS need to be mindful of the different charities in their area and have an ability to give accurate information about the treatments they offer and their effectiveness and evidence-base whilst attempting to alleviate emotional distress in ex-service personnel.
Veteran mental health services need to collect routine outcome data and work together to share best practices. Continued research should also focus on which civilian biopsychosocial treatments are transferable to this deserving and often challenging occupational group and how they can be helped to reintegrate back into the wider community from which they came.
Neil J Kitchiner is principal clinician for the Veterans’ Health & Wellbeing Service, Cardiff & Vale University Health Board, Cardiff. Neil is also a Captain in 203 Army Field Hospital Cardiff (v), Wales
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