Guest editorial

Citation

Green, M. (2017), "Guest editorial", Journal of Public Mental Health, Vol. 16 No. 1, pp. 4-5. https://doi.org/10.1108/JPMH-09-2016-0041

Time for a radical rethink on how we approach veterans mental health services

Mementoes of Dave Salt’s former life were dotted all around his bedsit: photos from far-flung deployments, military-themed novels, and a figurine of a soldier standing guard on a shelf. But the starkest evidence of Dave’s service was not to be found in his souvenir collection: it was there in the shadows behind his eyes.

Dave’s gaze was too sunken and saddened for man in his early 40s. He made a determined effort to be friendly, but there was a flatness in his voice that robbed his words of feeling. He had managed to stay off the vodka, for a time, but he knew that just one drink would be his unravelling.

It was July 2014, and I had gone to visit Dave in Leamington Spa to hear about his lonely battle with post-traumatic stress disorder (PTSD) sustained during a career spanning Northern Ireland, Bosnia, Iraq and Afghanistan. He talked about the night terrors that made sleep impossible, and how the slightest trigger could plunge him into a deeply immersive, high-definition flashback. Pandemonium would erupt in his local Tesco as Dave – convinced he was under fire – started yelling military call signs. Police and ambulance crews knew him by name: in the past few years, he had been admitted to hospital more than 30 times:

“The first half bottle of vodka is medicine, because it calms you down. And it was better than any diazepam – whatever-pam,” Dave said. “And so it went on, until I was on about two and a half litres of vodka for breakfast. When you hit that low, it’s death. You’re a dead man walking.”

Just over two years to the day after he uttered those words, Dave was found dead at his flat. After serving almost 20 years in the army, he died alone – finally succumbing to alcoholism caused by his attempts to numb his symptoms of PTSD. He had been variously in the care of the Ministry of Defence, the NHS and the charity Combat Stress, but none had been able to save him. He was 45.

Across Britain, in quiet cul-de-sacs and terraces, on downtrodden estates and in picturesque villages, many more men and women like Dave are feeling invisible walls inexorably closing in. Yet, as I saw first-hand while researching Aftershock, with the right care, remarkable transformations are possible – even for trauma survivors who feel damaged to their very core. Many more lives could be saved, many families kept intact – but only if the military mental health community dares to re-imagine the failing status quo.

First, we need to acknowledge the limits of what can be said with any certainty about the prevalence of PTSD and other psychological disorders among service personnel. The King’s Centre for Military Health Research puts the prevalence of PTSD at about 4 per cent for the military as a whole, rising to 7 per cent among battle-tested infantry. These figures are widely quoted in media stories and official reports, but are almost never accompanied by a crucial caveat: the studies are based primarily on self-report questionnaires.

In Aftershock, Surgeon Captain John Sharpley, the MoD’s Chief Psychiatrist, estimates that some 90 per cent of service personnel suffering mental health problems do not seek treatment due to stigma. It is, therefore, questionable whether it is safe to assume that such personnel will respond entirely truthfully to mental health surveys, even when assured their responses are confidential. King’s has provided the most comprehensive data set on inner life of the British military – but like any scientific research, its findings cannot be seen as the last word. When it comes to the subjective, stigma-laden world of psychological distress, it is self-evident that what researchers are capable of measuring is not necessarily the same as what is there.

Second, the government needs to address the gaping holes in the current patchwork of veterans’ mental healthcare. Our ad hoc, hybrid system of NHS and charitable provision is simply not configured to provide the kind of specialised, integrated treatment that thousands of veterans will need to break the vicious cycle of self-medicating trauma symptoms with alcohol or drugs. Typically, those with the worst cases of PTSD end up bouncing back and forth between NHS psychiatric wards, ever-more despairing families and sometimes prison cells. To fix this, Britain needs a national network of specialized trauma units capable of providing the kind of intensive treatment that people with complex PTSD – whether military or civilian – need to get well.

Third, Britain needs to embrace pioneering new therapies based on the latest insights from neurobiology about the changes trauma can cause in the brain. Currently, many people with PTSD are offered trauma-focused Cognitive Behavioural Therapy – a mainstay treatment used by the MoD, NHS and Combat Stress. Despite the state-sanctioned orthodoxy that has grown up around CBT, there is limited evidence to show that it works for the worst forms of PTSD. Clinical trials tend to exclude subjects with complex constellations of symptoms or those using substances – a classic presentation among veterans. If we are going to treat trauma survivors effectively, we need to investigate new, body-oriented therapies capable of reversing the neurophysiological imprints of trauma. A promising contender is the Comprehensive Resource Model, being used in Scotland by a number of NHS psychiatrists and at rape crisis centres, and there are no doubt others.

Finally, the needs of veterans must spur Britain to embrace its rightful place at the forefront of a wider renaissance in psychedelic therapies. Teams at Cardiff University and Imperial College London have started important studies of the therapeutic application of MDMA and psilocybin in treating PTSD and treatment-resistant depression respectively. If ever there was a case for injecting much higher levels of funding into such research, it is the life-or-death needs of former combatants.

Our understanding of the psychological injuries caused in war has evolved considerably in the century since an epidemic of “shell-shock” tore through the British Army at the Battle of Somme. Nevertheless, far too many service personnel and their loved ones are still fighting desperate, dispiriting battles with a healthcare system that does not know how to help. It is time to marshal all the imagination, creativity and humility we can muster to offer those suffering as Dave Salt did a genuine shot at recovery. Only then will we begin to heal one of Britain’s deepest collective wounds.