Are there differences in the rates of post-traumatic stress disorder and harmful drinking in the UK Armed Forces and UK Police Service?

Patsy Irizar, Psychology, University of Liverpool, (2017 Cohort)

Patsy Irizar (University of Liverpool), Dr Sharon Stevelink (King’s College London) and colleagues have published a paper, comparing the rates of post-traumatic stress disorder (PTSD) and harmful drinking in males serving in the UK Armed Forces with those serving in the UK Police Service. A similar percentage of probable PTSD (approx. 4%) was found within the two occupations but identified a much higher percentage of military personnel meeting criteria for harmful drinking, compared to police employees (10% vs 3%).

Both military personnel and police employees are trained to work under high pressure and in potentially traumatic conditions. Frequent exposure to trauma increases the risk of mental health disorders, particularly PTSD [1, 2]. The relationship between PTSD and harmful drinking is well known [3], with alcohol often being used to cope with symptoms of mental distress [4].

Given the role of the military and police, these groups could show high levels of PTSD and harmful drinking. In addition, both groups may experience other organisational stressors (demand-control imbalances, lack of support, impact on family life) [5], which could impact mental distress and drinking behaviours. However, there could be differences between these two groups in the levels of PTSD and harmful drinking, which may relate to differences in trauma exposure (military personnel may undergo intense periods of stress during deployment, whereas police employees may experience more frequent stressors). No studies have directly compared the levels of PTSD and harmful drinking in these occupational groups.

How did we compare these groups?

This paper used data from two existing cohort studies, which included measures of mental health and alcohol consumption: The Health and Wellbeing of the UK Armed Forces cohort study (military personnel) and the Airwave Health Monitoring Study (police employees). Probable PTSD was measured using the 10-item Trauma Screening Questionnaire (TSQ) [6] in police employees and the 17-item PTSD Checklist, civilian version (PCL-C) [7], in military personnel. Weekly alcohol consumption was computed for both samples, and harmful drinking was determined using guidance specific to males from the National Institute for Health and Care Excellence (NICE) (>50 units) [8].

We included 7,399 male serving regular military personnel and 23,826 male serving police employees. The samples were first carefully selected to be comparable (male and serving employees only), and a statistical technique (a method known as entropy balancing) was used to make sure the two samples were comparable on a range of factors (including when the data was collected, age of participants, and education level of participants).  

What did we find?

There were several key findings. First, male military personnel and police employees showed similar levels of probable PTSD (approximately 4%), and this is similar to the level of PTSD observed in the general population. Second, military personnel showed higher levels of harmful alcohol use (drinking above 50 units per week) than police employees, with 10% of military personnel meeting criteria, compared to 3% of police employees. Third, comorbid (occur together) PTSD and harmful drinking was also more common in military personnel, but this was likely to be driven by the higher levels of alcohol consumption.

What do these findings mean?

These findings show similar levels of probable PTSD in military personnel and police employees, which are comparable to the levels in the general population [9]. This could reflect efficient trauma support and training, resilience in workers, or a sampling bias as people with poor mental health are more likely to stop working [10]. Military personnel who have left service show higher rates of PTSD compared to serving personnel [11], and those who had left service were not included here. Additionally, in the police sample, the PTSD questionnaire was only given to those who had experienced a traumatic event in the past 6 months, excluding those who may be experiencing PTSD from an earlier traumatic event, whereas all participants in the military sample were completed the PTSD questionnaire.

The findings on higher levels of harmful drinking in military personnel, in addition to comorbid PTSD and harmful drinking, highlights the importance of integrating alcohol and mental health support. High rates of harmful drinking have consistently been observed in UK military personnel, as alcohol has historically been used to increase unit cohesion through social bonding, and to de-stress after periods of deployment [12, 13].

This work had some limitations, mainly the use of different questionnaires to measure PTSD in military personnel and police employees, which may not be directly comparable. However, there were several strengths, including the use of two large samples with good response rates.

What are the implications?

The comparable rates of PTSD suggest that the current emphasis on making sure trauma support is available for high-risk occupational groups should continue, by actively monitoring those exposed to trauma and making additional help accessible, if needed [14]. The higher levels of harmful drinking in military personnel indicates a need for evidence-based alcohol interventions in occupational settings, possibly more so in the military than for other occupational groups.

“Probable post-traumatic stress disorder and harmful alcohol use among male members of the British Police Forces and the British Armed Forces: a comparative study” by Patsy Irizar, Dr Sharon Stevelink, David Pernet, Dr Suzi Gage, Professor Neil Greenberg, Professor Simon Wessely, Dr Laura Goodwin, and Professor Nicola Fear, is available with open access here. This study was part of Patsy Irizar’s PhD studentship, funded by the Economic and Social Research Council (ESRC).

Read Patsy’s other Addiction Research blogs here.

References

[1] Skogstad, M., Skorstad, M., Lie, A., Conradi, H., Heir, T., & Weisæth, L. (2013). Work-related post-traumatic stress disorder. Occupational medicine, 63(3), 175-182.

[2] Nash, L. M., Daly, M. G., Kelly, P. J., Van Ekert, E. H., Walter, G., Walton, M., … & Tennant, C. C. (2010). Factors associated with psychiatric morbidity and hazardous alcohol use in Australian doctors. Medical journal of Australia, 193(3), 161-166.

[3] Debell, F., Fear, N. T., Head, M., Batt-Rawden, S., Greenberg, N., Wessely, S., & Goodwin, L. (2014). A systematic review of the comorbidity between PTSD and alcohol misuse. Social psychiatry and psychiatric epidemiology, 49(9), 1401-1425.

[4] Dixon, L. J., Leen-Feldner, E. W., Ham, L. S., Feldner, M. T., & Lewis, S. F. (2009). Alcohol use motives among traumatic event-exposed, treatment-seeking adolescents: Associations with posttraumatic stress. Addictive behaviors, 34(12), 1065-1068.

[5] Harvey, S. B., Modini, M., Joyce, S., Milligan-Saville, J. S., Tan, L., Mykletun, A., . . . Mitchell, P. B. (2017). Can work make you mentally ill? A systematic meta-review of work-related risk factors for common mental health problems. Occupational and Environmental Medicine, 74(4), 301-310.

[6] Brewin, C. R., Rose, S., Andrews, B., Green, J., Tata, P., McEVEDY, C., . . . Foa, E. B. (2002). Brief screening instrument for post-traumatic stress disorder. The British Journal of Psychiatry, 181(2), 158-162.

[7] Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour research and therapy, 34(8), 669-673.

[8] NICE. (2014). Alcohol-use disorders: preventing harmful drinking. Evidence update March 2014. Retrieved from National Institute for Health Care Excellence (NICE):

https://www.nice.org.uk/guidance/ph24/evidence/alcoholuse-disorders-preventing-harmful-drinking-evidence-update-pdf-67327165?fbclid=IwAR0LKAp-PgWt4wW3Qi83dT9KdNb7BvpF-yqZp_3BH7oPpizzOKjusrCJ_yI

[9] McManus, S., Bebbington, P., Jenkins, R., & Brugha, T. (2016). Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. A survey carried out for NHS Digital by NatCen Social Research and the Department of Health Sciences, University of Leicester.

[10] Li, C.-Y., & Sung, F.-C. (1999). A review of the healthy worker effect in occupational epidemiology. Occupational Medicine, 49(4), 225-229

[11] Stevelink, S. A., Jones, M., Hull, L., Pernet, D., MacCrimmon, S., Goodwin, L., … Fear, N. T., Wessely, S. (2018). Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study. The British Journal of Psychiatry, 213(6), 690-697.

[12] Ames, G. M., Cunradi, C. B., Moore, R. S., & Stern, P. (2007). Military culture and drinking behavior among US Navy careerists. Journal of Studies on Alcohol and Drugs, 68(3), 336-344.

[13] Jones, E., & Fear, N. T. (2011). Alcohol use and misuse within the military: a review. International review of psychiatry, 23(2), 166-172.

[14] Greenberg, N., Megnin-Viggars, O., & Leach, J. (2019). Occupational health professionals and 2018 NICE post-traumatic stress disorder guidelines. In: Oxford University Press UK.

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