The presentation of depression in the British Army
Introduction
Depression is a diagnosis that acknowledges differences based on severity and frequency, and is classified as mild, moderate or severe (WHO, 2007). Depression is a dynamic disorder which can be used descriptively, based on signs/symptoms, as a reaction to an event, a reactive unhappiness and as a feeling, as a complaint of low mood. This study includes all of the above, and it is this complexity of fitting the continuous variation in depression severity into a categorical definition that poses problems to clinicians when diagnosing depression, and general practitioners (GPs) have only recognised depression in 47% of cases (Mitchell et al., 2009). This is further exacerbated by borderline cases, co-morbid symptoms and complex presentations (drug or alcohol use in tandem with low mood for example). In civilian assessment there is a high likelihood that the mental health (MH) team would utilize the Stepped Care Model to sign-post the type of intervention and treatment based on mild, moderate or severe depression. Mild may be in Step 1 (watchful waiting) or Step 2 (Self-help); whilst moderate depression may instigate a self-help programme or referral for psychotherapeutic and pharmacological management, (Step 3). Care for severe depression would be at Step 4 and include psychotherapeutic and pharmacological intervention and possibly in-patient care if required (Thomas and Drake, 2012).
Section snippets
Young Men's Mental Health
Depression is a common Military Mental Health (MMH) disorder in the British Army (Iversen et al., 2009) where the majority of personnel are fit, young, strong white men. These men are often recruited from socially deprived areas of the UK (Dandeker et al., 2008), living away from home and with a large expendable income. This is an important assessment criteria regarding history-taking as early childhood experiences coupled with impact experiences such as military conflict and dependence on
Theory
This independent research study was framed within a biopsychosocial model with data collected from experienced MMH clinical personnel and GPs. A Constructivist Grounded Theory provided the theoretical model (Charmaz, 2006). Grounded theory is a means of moving qualitative theory beyond descriptive studies into the realm of explanatory theoretical frameworks, thereby providing a conceptual awareness of the studied phenomena (Glaser and Strauss, 1967). The required information is grounded in the
Aim and Objectives
The aim was to construct a predictive model of the typical presentation of depression in the Army for utilisation at a clinical and educational tool. The objectives were to:
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Collect data that would inform the building of the above model.
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Validate the model as an accurate reflection of the presentation of depression in primary healthcare and the suitability for inclusion in military GP and nurse training and/or military clinical practice.
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Hypothesise as to the transferability of the model into
Method
Phase 1 collected information through 19 digitally recorded semi-structured interviews with MMH clinicians with 5 or more year's clinical experience. Seventy-nine percent (n = 15) of respondents were male and 21% (n = 4) female, with 84% (n = 16) being nurses and 16% (n = 3) consultant psychiatrists. The mean for MOD employment was 20 years, with 95% (n = 18) having operational experience, with a mean of 3.6 tours. The interviews lasted between 32 and 63 min; the mean age of respondents was 42 years. A
Results
Phase 1 results provided an overview of the presentation of depression and factors influencing help seeking. Thematic analysis defined 3 groups of army personnel presenting with depression, with these groups detailed in Fig. 2. The GP evaluations recognised the adaptability of the research into clinical and educational practice and are detailed in Table 1, Table 2, resulting in the development of the clinical aide memoire at Table 3. Presentation of the findings is intended to protect the
Symptoms and Coping
Stressful predisposing factors associated with serving in the Armed Forces result in large numbers of psychological, biological, social and occupational symptoms, leading to behavioural and personality changes, and depression. However, respondents indicated that soldiers predominately present with either an adjustment disorder or mild to moderate depression, and rarely a severe depressive illness as they are either prohibited from enlisting or inevitably discharged from service. All of the
Limitations
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The first author's role as a member of the interviewee groups “cohort”.
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A number of references are from the authors own peer reviewed publications, although these citations reflect original research in a poorly researched area.
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This study offers the presentation of depression from a clinician's perspective, not a soldier's, and does not examine the important aspect on the role the soldier's family.
Conclusion
Army employment and lifestyle can provide an extremely rewarding protective “family,” and provide significant opportunities, however, Army personnel often face unique multi-factorial stressors, that are often incremental/accumulative in nature, and a soldier's personality impacts on their ability to cope with military life, and their propensity for developing depression.
The subjective views of experienced MMH clinicians, who treat these depressed personnel, supported through the findings of a
Colonel Alan Finnegan joined the NHS in 1978 and commissioned into the Royal Army Medical Corps in 1987. His clinical background is in Mental Health. He has deployed to Iraq, the Balkans, Northern Ireland, South Africa and Afghanistan. He has served as a Nurse Consultant in Military Mental Health and as the Defence Specialist Nursing Advisor in Mental Health. In 2007, he was appointed as the senior military nurse at the Royal Centre for Defence Medicine (Clinical) and is currently serving as
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Colonel Alan Finnegan joined the NHS in 1978 and commissioned into the Royal Army Medical Corps in 1987. His clinical background is in Mental Health. He has deployed to Iraq, the Balkans, Northern Ireland, South Africa and Afghanistan. He has served as a Nurse Consultant in Military Mental Health and as the Defence Specialist Nursing Advisor in Mental Health. In 2007, he was appointed as the senior military nurse at the Royal Centre for Defence Medicine (Clinical) and is currently serving as the Defence Professor of Nursing and Head of the Academic Department of Defence Nursing. He has been a reviewer for the Commission for Health Improvement, and is currently a member of the Royal College of Nursing (RCN) International Committee. He established the RCN Defence Forum, and then served as Chairman of the forum from 2004 until 2011. Well published in Defence Mental Health issues, he completed a PhD at Birmingham City University where he is the Visiting Professor of Army Nursing. Col Finnegan is also a Visiting Professor in Mental Health at the University of Chester.
Mrs Sara Finnegan joined the NHS in 1978 and is a Registered Nurse (Adult). During the past 34 years she has worked in the NHS, Defence Medical Services and the Private Sector. Her primary clinical experience is in Primary Healthcare nursing and she is currently a nursing Sister serving as an independent nurse practitioner in the Wirral Area of North West England. Sara also completes telephone triaging and autonomous nursing duties at Chester's primary walk in centre. Her clinical interests are in travel medicine, sexual health and asthma management. She has co authored several articles concerning army mental health issues.
Professor Mike Thomas is the Pro Vice Chancellor (Academic) and Executive Dean of the Faculty of Health and Social Care at the University of Chester and is an experienced clinician and educator, having worked within a variety of settings. As part of the Senior Management Team he works strategically with the other academic facility Deans and is responsible for the strategic and operational management of the Faculty of Health and Social Care. Mike served as a submariner and radio operator for several years within the Royal Navy before entering the nursing profession. Mike has worked as both a mental health clinician and an educationalist for twenty five years. He is a trustee of three charities. Mike has published and presented papers annually since 1986 and has written chapters in books ranging from patient assessment, sexual health, professional issues and cognitive behavioural psychotherapy. In 2012, he co-authored with Mandy Drake a clinical book on cognitive behaviour therapy structured around case studies.
Dr Martin Deahl is a Consultant Psychiatrist and the NHS national clinical lead for the United Kingdom Ministry of Defence inpatient mental health contract. This is helping to establish a national network of Mental Health Trusts providing inpatient care for Service-personnel. He is also a Colonel within the British Territorial Army (TA) with nearly 30 years service and civilian consultant advisor in psychiatry to the Royal Air Force. In his civilian role he leads a Crisis Resolution and Home Treatment team (CRHT) and nationally is the Royal College of Psychiatrists lead for pathway development and chairman of the College’s “Fair Deal” campaign. Martin commanded 256 Field Hospital (Volunteers) from 2003–2006 and was subsequently TA Colonel (South) from 2006–2009. He has deployed in Iraq on OP GRANBY, OP TELIC 1 and commanded the UK Medical group in Afghanistan on OP TELIC 4 when he was awarded the QCVS. Dr Deahl has researched and published widely on traumatic stress and military psychiatry. His current interest is identifying ways of improving the soldiers’ experience of transition from service to veteran status. He is passionately committed to achieving closer working and integration between NHS and Defence Psychiatry and sees this as a means to raise NHS standards, reduce stigma and provide a platform to provide mental health services for service veterans.
Colonel Robin Simpson was commissioned into the Army in 1984 having studied medicine at Aberdeen University. He has served as a military GP in UK, Germany, Cyprus, Hong Kong, Jamaica, Iraq and Afghanistan. Since 1995 he has been a MRCGP Examiner and is presently part of the Core Group responsible for the Clinical Skills Assessment. He also works as an Inner City GP in Central Birmingham. He is currently the Joint Defence Professor of General Practice and his department's research focus is on Primary Health Care in austere environments.
Professor Ashford is a podiatrist by profession having qualified from the Glasgow School of Podiatry in 1975. Much of his career has been higher education and has worked in four schools of podiatry two of which as head of school. He currently heads the Graduate School in the Faculty of Health at Birmingham City University where he is responsible for all of the faculty’s’ doctoral students. He has been an active researcher for over 30 years and has more than 100 peer reviewed papers, many international presentations and various successful research grants. His research interests include finite element analysis and computational modelling in dynamic biological systems; chronic pain management; complexity theory and its relationship to biological models. He is Visiting Professor at Staffordshire University and has held various visiting appointments overseas.
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Tel.: + 44 151 327 9702; fax: + 44 151 327 8670.
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Tel.: + 44 1244 511691; fax: + 44 01244 511340.
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Territorial Army Officer and Consultant Advisor to the RAF (Mental Health).
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Tel.: + 44 1952 632452.
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Regular Officers within the Army Medical Services.
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Tel.: + 44 121 415 8853; Fax: + 44 121 415 8869.
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