Editorial

Citation

Caan, W. (2017), "Editorial", Journal of Public Mental Health, Vol. 16 No. 1, pp. 1-3. https://doi.org/10.1108/JPMH-12-2016-0059

This special issue on veterans’ mental health is fortunate to have a Guest Editorial by an authoritative writer, Matthew Green. The issue includes both European and American research, on the population defined by the department for work and pension as “ex-service personnel”, in terms of care for mental illness and also related problems like drug addiction, social isolation or poverty. For anyone involved in public health, I would highlight the work here of Megan Kelly and her Veterans Health Administration colleagues on smoking. In terms of “stolen years” of life, people with mental health conditions die on average 10-20 years earlier than the general population and smoking is the single largest factor accounting for this difference (http://ash.org.uk/information-and-resources/reports-submissions/reports/the-stolen-years/). Since the effects of the Vietnam War first raised professional awareness of post-traumatic stress disorder (PSTD), PTSD has been the focus of much research with ex-service personnel. Kelly et al. describe one deadly interaction between mental illness and smoking: half the US veterans with PTSD smoke at least 20 cigarettes a day, but few accept help for their entrenched tobacco use.

There is always public health concern about specific populations at risk of illness, such as refugees who have endured trauma or loss (Caan, 2015). In this editorial, I will focus on how our “special issue” came about. From my work on addictive behaviours, I knew vaguely that certain occupational groups were at increased risk of dependence on alcohol or heroin. For example, alcoholism used to be one of the most common health problems reported among doctors (Stanton and Caan, 2003). In my public health role, I began to encounter local veterans, their families and professional carers where their post-conflict drinking was a problem, often amplified by domestic violence and difficulties with employment or housing, and sometimes ending in suicide or imprisonment (Caan, 2012). A revelation came to me on 6 March 2012 at a national conference on Health and Wellbeing initiatives. The responsible minister in the department for work and pensions gave the keynote address. Back in 1918 and 1945, the post-war ministers for pensions realised the need for comprehensive and sustained support for veterans. Of the millions returning from the World Wars, many needed mental health care or employment support, and a period of social re-inclusion. In 2012, the numbers were much smaller but the minister seemed to believe that the existing civilian jobseeker services, including the new welfare to work programme, would fit the needs (and assets) of survivors returning from recent trauma in Afghanistan and Iraq. As it happened, I had recently done some research with Job Centre advisors and their local Customers struggling with a routine range of mental illness. I saw the Minister’s beliefs were, at best, implausible.

Why might veterans need services any different from people with routine employment histories?

In comparison to other professions studied, the Jubilee Centre for Character and Values has identified that armed forces (on both sides of the Atlantic) expect that “all ranks should display courage, discipline, respect, integrity and loyalty” and ultimately “soldiers may be required to give their lives for their country” (Walker, 2016). Some problems begin during service, for example, self-harm in young soldiers aged less than 24 years (News, 2016). Different personnel experience different levels and likelihoods of danger, but typically being a veteran doubles the risk of depression, and in one Australian study of people who had served in Vietnam, the odds ratio for depression increased to 13.1 (Bonde et al., 2016). Among veterans of working age, SSAFA (the Armed Forces charity) identifies a group growing in size “who are living in pretty desperate circumstances” (Gregory, 2016). The NEL Commissioning Support Unit (2016) found that working-age veterans were more likely to be suffering from depression than the UK population as a whole. Among the men that have been in combat, there are specific increases in PTSD and alcohol problems (Greenberg et al., 2016). The combination of PTSD with alcohol is especially linked to violence (Greenberg et al., 2016).

Sadly, in the UK even primary health care for ex-military patients is inadequate and referral routes to secondary care are not providing enough access (Leach, 2016). As for the department for work and pensions, even its assessment of civilians has now been associated with worsening public mental health (Barr et al., 2016). There are very few ex-service members of parliament, but the opposition MP Dan Jarvis recently spoke up for his fellow veterans about “serious gaps” in the Government’s understanding of health, employment, criminal justice and housing (Mudie, 2016).

A key lesson from soldiers in the USA is that they will only seek treatment for their mental health if they believe such treatment could work for them (Adler et al., 2015). In this issue, Edward Fraser quotes a former Sergeant’s service user perspective:

Having the full military background of knowing what someone might have experienced […] makes a huge difference.

An even more important lesson is that as well as problems, ex-service personnel can bring strengths to their community. As I write this Editorial, community action across the UK called Walking Home For Christmas aims to support homeless and other vulnerable veterans by helping them to reintegrate back into society and regain their independence, through employment. The charity behind this is based on “the inherent skills” of veterans (http://walkingwiththewounded.org.uk/who-we-are/). Bringing something to society is a hope of many people such as Steven Billy Mitchell (pen-name Andy McNab). He gained his education while serving as a soldier and just won the Ruth Rendell Award for promoting adult literacy through his books. Readers may be aware of the long and peaceful campaign by Native Americans this Winter, to prevent the Dakota Access Pipeline polluting the Sioux land and the Missouri River downstream. Just when it looked as though Big Oil’s money and their hirelings’ violence might prevail over the unarmed, indigenous people, hundreds of peaceful but determined Veterans converged on Standing Rock. In a display of courage, discipline, respect, integrity and loyalty, they were able to stop the pipeline (at least for now). As the leader of the Sioux reported (Archambault, 2016): “I want to give a special mention to the veterans who have come to Standing Rock”.

A Riddle

What has More than 600 silent Mouths, Over 1,200 blind Eyes, And still no Heart?

(Answer: Indifference in the UK Parliament)