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Mental Healthcare in the United Kingdom Armed Forces

Chapter 41

MENTAL HEALTHCARE IN THE UNITED 

KINGDOM ARMED FORCES

NEIL GREENBERG, MD*; JAMIE HACKER HUGHES, PsychD†; MARK EARNSHAW, BA(Hons), MSc‡; and

SIMON WESSELY, MD§

INTRODUCTION

HISTORY

CONTEMPORARY DEFENSE MENTAL HEALTH SERVICES

Operational Organization

Ministry of Defence Posttraumatic Stress Disorder Legal Case

Trauma Risk Management

CURRENT RESEARCH AND FUTURE DIRECTIONS

SUMMARY

*Commander, Medical Corps, United Kingdom Armed Forces; Defence Professor of Mental Health, King’s College, London, Weston Education Centre, Cutcombe Road, London SE5 9RJ; formerly, Senior Lecturer in Military Psychiatry, Academic Center for Defence Mental Health, King’s College, London

†

Head of Defence Clinical Psychology, Ministry of Defence, Joint Medical Command, Coltman House, Whittington Barracks, Lichfield, United Kingdom 

WS14 9PY; formerly, Senior Lecturer in Military Psychology, Academic Center for Defence Mental Health, London, United Kingdom 

‡

Lieutenant Colonel QARANC, Ministry of Defence, St Georges Court, Bloomsbury Way, London, WC1A 2SH, United Kingdom; formerly, Research 

Fellow, Academic Centre for Defence Mental Health, London, United Kingdom

§

Department Head, Department of Psychological Medicine, King’s Centre for Military Health Research, King’s College, Weston Education Centre, 

10 Cutcombe Road, London SE5 9RJ United Kingdom; formerly, Honorary Lecturer in Forensic Psychiatry, Institute of Psychiatry, London, United 

Kingdom
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Combat and Operational Behavioral Health

INTRODUCTION

Defense mental health services (DMHS) in the 

United Kingdom (UK) are primarily community based 

and provide both operational and homeland services 

to all 200,000 of the personnel in the UK armed forces. 

This chapter will examine the history of military mental health in the UK and bring readers up to date on 

important procedural and operational aspects of the 

DMHS today. 

HISTORY

In keeping with its tradition as the senior military 

service in the UK, the Royal Navy first established 

formal services to manage and treat service personnel 

who suffered from psychological problems. In August, 

1818, a lunatic asylum was opened at the Royal Naval 

Hospital Haslar1

; today a Royal Navy Department of 

Community Mental Health (DCMH) remains at Haslar 

Hospital. With the outbreak of World War I, British 

Army psychologists and neurologists deployed to 

France in 1914 in support of British troops. Operating 

from field hospitals, casualty clearing stations, and, 

later, “NYDN” (not yet diagnosed neurological) hospitals, these practitioners saw large numbers of personnel suffering from “shell shock,” “disordered action of 

the heart,” and related syndromes. Personnel deemed 

unfit for further combat, at least in the immediate 

future, were evacuated to rear areas or to the UK.2

 A 

large number of hospitals were established in Britain, 

including Craiglockhart3; Seale Hayne, a converted 

agricultural college; and Sir Edward Mapother’s No. 

2 General Hospital in Stockport.4 These institutions 

provided treatment for shell shock and other disorders, aiming, if possible, to return individuals to the 

front to continue fighting. Specialist training courses 

in military psychiatry were also established at the 

Maudsley Hospital in London and, by Gordon Mott, 

at Maghull Hospital in Liverpool. Specialist centers for 

the treatment of disordered action of the heart were 

also established at Mount Vernon in Hampstead and 

Sobraon House in Colchester. 

Although the British Psychological Society had 

been founded at University College London in the 

1890s, psychology was a largely experimental science 

in World War I; it was some years before psychotherapy and clinical psychology became disciplines 

in their own right. The first military psychological 

practitioners, such as Charles S Myers and William 

H Rivers, were mostly medical doctors. Myers later 

became consultant psychologist to the British Expeditionary Force, and Gordon Holmes was consultant 

neurologist. Myers established four forward NYDN 

centers modeled on the French system,5

 and, later, 

five forward “disordered action of the heart” centers 

in France, in addition to the hospitals in Britain. These 

facilities were established well before Thomas Salmon, 

the American psychiatrist, visited France in 1917 and 

influenced what has since become known as “forward 

psychiatry.”6

Following World War I, the UK built up a network of 

special civilian treatment centers and hospitals to treat 

the ongoing casualties generated by the war, peaking 

in 1921. (At that time nearly 15,000 inpatients and 

3,000 outpatients were still suffering with war-related 

psychological disorders.) Although the vast majority 

of those who worked throughout the war for the British military mental health services returned to civilian 

employment, some remained in the services, forming a 

core of psychological practitioners during the build up 

to World War II. For the additional practitioners necessary for the Royal Navy, Army, and new Royal Air 

Force (RAF), formed between the wars from the Royal 

Flying Corps (originally part of the Army), neurologists and psychiatrists were recruited from four main 

sources (all in London): the Tavistock Clinic (Army), 

the Maudsley Hospital (Royal Navy), Saint George’s 

Hospital (Royal Navy), and Guy’s Hospital (RAF).7

For the first time psychologists were also recruited 

to work in personnel selection. Otherwise, the pattern of British Army military mental health service 

provision in World War II nearly mirrored that in 

the earlier war. In addition to a number of forward 

hospitals, treatment facilities also operated in the UK, 

including No. 41 Neuropathic Hospital in Bishop’s 

Lydeard (where the Tavistock Clinic psychoanalyst JA 

Hadfield, one of the first to use collective hypnosis and 

abreaction, was based) and the better-known centers 

at Northfield (where Wilfred Bion, John Rickman, and 

Michael Foulkes, the founders of group psychotherapy, 

worked). In addition, forward psychiatry began to 

be practiced, often by accident or through necessity, 

but increasingly by design, in North Africa, Italy, and 

northwest Europe. 

Support for the psychiatrists was far from unanimous, however; many saw them as fifth columnists (a 

clandestine group seeking to undermine the government), and Winston Churchill referred to psychiatrists 

as “gentlemen asking odd questions.”8

 Stigma was 

still attached to patients with mental illness. The RAF 

Neurological Hospital at Matlock was established as 

the final treatment center for the growing number of 

“lack of moral fiber” (LMF) cases, an administrative 

category rather than a diagnosis. This category was 
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Mental Healthcare in the United Kingdom Armed Forces

begun after 250 “breakdown” cases occurred after the 

Battle of Britain in 1940; by the end of the war the LMF 

category included nearly 3,000 cases of breakdown 

per year.9 It is believed that fear of being labelled as 

LMF was essential to keeping RAF pilots motivated to 

fly despite the high risk of being shot down (mission 

attrition rates of 50% were common, especially during the early days of the war).10 Sergeants labeled as 

LMF were reduced to the lowest rank and put to work 

shovelling coal, peeling potatoes, or even mining coal. 

LMF officers were asked to resign or transferred to 

desk jobs in administration. Many of those categorized 

as LMF had already completed a dozen or more 

operational raids, but the designation was deemed 

useful for encouraging continuous operational flying 

in the face of extreme risk.

By the end of 1943, the number of psychiatrists 

totalled 227 in the British Army, 43 in the RAF, and 35 

in the Royal Navy.11–13 The majority of the 35 military 

psychologists14 worked with selection panels and designed aptitude tests to ensure that officers were up to 

standard. These World War II selection tests included 

the “leaderless group,” a method by which a group of 

potential officer candidates are encouraged to come 

up with a plan to deal with a mock incident without a 

leader being assigned in order to see what transpires 

(ie, does a “natural” leader emerge?). It remains the 

basis for selecting the officers’ cadre today. Unlike in 

the United States during World War II, mental health 

professionals were rarely used in screening for vulnerability to future breakdown. This aptitude testing 

policy represented a major “democratization” of officer 

selection, in keeping with the social transformations 

the war brought about across society. At the end of the 

war, however, all the psychologists were demobilized, 

leaving only the psychiatrists in the service.

In the late 1960s, the UK began deploying large 

numbers of forces to contain the increasingly unstable 

situation in Northern Ireland. The particular demands 

of this counterinsurgency operation—effectively 

asymmetric warfare with an unknown and unseen 

enemy—began to take its toll on the mental health of 

troops. The Northern Ireland “troubles” continued 

until the late 1990s. Although no concrete evidence 

suggests that the conflict was more traumatogenic than 

other military operations, many of its veterans suffered 

from posttraumatic stress disorder (PTSD) and other 

psychological injuries.

In 1982, Britain again went to war, this time thousands of miles away across the Atlantic,15 to recapture 

the Falkland Islands invaded by Argentina weeks 

before. Although the Royal Navy deployed psychiatrists to the conflict, the overall mental health burden 

was thought to be small. However, some current 

anecdotal evidence indicates that marines who sailed 

back to the UK after the war fared better in mental 

health outcomes than their airborne colleagues and 

other infantry units that were air-trooped home. These 

stories suggest that the marines settled back into their 

day-to-day lives after talking through their experiences during the sea voyage, as there was no formal 

mental health support made available for the troops 

during the voyage home. The airborne paratroopers, 

in contrast, displayed violent and aggressive behavior 

at home because they missed the necessary time to 

“decompress.”16 However, no research has been carried out to support or refute these claims.

At the end of the 20th century, UK forces were 

deployed on a number of fronts. Operation Banner, 

the name given to the Northern Ireland deployment, 

continued, with troops rotated at regular intervals for 

3-month “emergency” tours, 6-month tours, and 2-year 

“permanent” tours. In addition, British troops were 

deployed on United Nations and North Atlantic Treaty 

Organization peace and stabilization missions to 

Bosnia-Herzegovina, Kosovo, and Macedonia. Army 

field mental health teams (FMHTs) deployed in the 

majority of these operations, often led by psychiatrists 

in the initial “surge” phases, but increasingly relying 

on a pool of well-trained, highly skilled, and relatively 

autonomous mental health nurses drawn from the hospitals and community clinics to operational roles.17 At 

the same time, however, defense cuts and downsizing 

led to the closure of all but three military hospitals; 

these have since shut. Today, there is no dedicated 

military hospital in the UK, and military medical care is 

provided in military wings of civilian hospitals called 

“military district hospital units.”

In addition to these and other peacekeeping operations (eg, in Lebanon, Rwanda, and Sierra Leone),18 the 

UK was involved in two major, if short-lived, wars, 

followed by ongoing and increasingly intense operations in the hostile theaters of Iraq and Afghanistan. 

Saddam Hussein’s invasion of Kuwait in 1991 led 

to a rapid British military deployment—Operation 

Granby—as part of a multinational coalition led by 

the United States to reclaim the country from the Iraqi 

forces. British Army psychiatrists and mental health 

nurses deployed with the Army field hospitals as field 

psychiatric teams but, where possible, adopted a freestanding roving role providing mental health briefings, 

psychological debriefings, and mental health assessments as required throughout theater. A Royal Navy 

mental health team deployed with a hospital ship, 

offshore in the Mediterranean Sea, and RAF mental 

health teams supervised the aeromedical evacuation 

and repatriation of mental health casualties. This role 

continues outside times of major conflict, with RAF 

mental health nurses on standby to escort service personnel with mental health and other problems back to 
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the UK from anywhere in the world.

When British and American forces invaded Iraq 

in 2003 (the British component of the invasion and 

occupation is known as Operation Telic), FMHTs 

composed of psychiatrists and Army mental health 

nurses again deployed with the UK’s air assault and 

armored brigades, and were part of two military field 

hospitals. Again, the Royal Navy supplied a mental 

health capability on the primary casualty-receiving 

facility—Royal Fleet Auxiliary Argus—and the RAF 

continued to operate as before. All mental health aeromedical evacuations and repatriations went to Duchess 

of Kent’s Psychiatric Hospital (since closed) for assessment, treatment, and, if necessary, admission. Those 

requiring outpatient treatment, including mobilized 

reservists (who made up a large percentage of some 

Operation Telic units, especially medical units), were 

referred to the network of DCMH.

Contemporary Defense mental health services

The goal of DMHS is to provide military personnel with speedy access to skilled, effective, flexible 

treatment based on individual needs.19 The DMHS 

approach aims to foster recovery and rehabilitation, 

ensuring that personnel are rapidly returned to duty 

whenever possible, or supported and enabled to make 

a smooth, seamless, and effective transition back into 

civilian life. Treatment, care, and rehabilitation are 

provided in close proximity to the person’s work 

environment to maximize occupational recovery and 

in close partnership with primary and secondary care 

facilities. A clear understanding of the unique nature 

of military ethos, composition, and task underpins 

the effective delivery of mental healthcare to service 

populations. Delivery of this care is multidisciplinary, 

provided by a variety of skilled professionals, depending on individual needs.

The UK armed forces emphasize that stress management and day-to-day mental health hygiene are 

functions of the chain of command rather than medical or support services. The same principles apply for 

physical and psychological disorders; for instance, the 

management of hydration is directed by unit leaders in 

the same way as stress management. Both may need a 

subject matter expert to provide appropriate information and training; however, the subject matter expert 

does not assume responsibility for the process.19,20

When the chain of command is unable to continue 

to support personnel, three levels of mental healthcare provision exist: (1) primary care, (2) community 

mental healthcare, and (3) inpatient care. Provision of 

mental healthcare has moved from a hospital-based 

to a community-based service, mirroring changes in 

the UK’s civilian National Health Service. Care in the 

community, as the process is termed in the National 

Health Service, has been a key element of UK government health planning over the last 2 decades and is 

considered well-suited to both military and civilian 

mental healthcare delivery. A report by an independent 

team of experts led to the closure of the last military 

inpatient facility in early 2004. Currently all inpatient 

care is provided by an independent service provider 

(a private psychiatric hospital) on a pay-per-patient 

basis. Military protocols advocate using inpatient care 

for the minimum amount of time possible because 

community management is seen as the key to effective 

occupational rehabilitation. 

The “workhorse” of the system is the DCMH, 

which carries out all specialist mental health functions within the DMHS. There are 15 DCMHs in the 

UK, with additional units in Germany, Cyprus, and 

Gibraltar. The departments are tasked with treating 

service personnel, providing a range of mental health 

educational programs, liaising with the independent 

service provider, and facilitating medical discharges 

when appropriate. The current cadre of some 200 

military mental health professionals across the services 

are primarily uniformed members of the Royal Navy, 

Army, or Air Force. However, social work and psychology services are provided by civil servants. Most of the 

service members (75%) are nurses, with the remainder 

composed of psychiatrists, clinical psychologists, and 

social workers. Presently occupational psychologists 

and occupational therapists do not form part of the 

uniformed cadre. 

Policy and strategy for the DMHS comes from the 

surgeon general’s department through executive and 

professional advisory committees. In the UK, the military surgeon general, who may be a member of any 

service, is the head medical officer of all three services. 

The head of DMHS is the defense consultant advisor, 

and each service has a consultant advisor and a senior 

nursing officer. Although DMHS care is delivered 

on a triservice basis (ie, mental health professionals 

from each service routinely provide care to personnel 

of all three services), each service is responsible for 

career development and personnel management of 

its members.

Operational Organization

The deployable uniformed mental health assets 

are composed of registered mental health nurses (also 

called community psychiatric nurses), and consultant 

psychiatrists. The consultant psychiatrists traditionally 

have deployed only during the initial surge phase 
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Mental Healthcare in the United Kingdom Armed Forces

of operational deployments; at later stages, community psychiatric nurses form FMHTs with telephone 

supervision and a visiting service from a consultant 

psychiatrist. Experience has shown that the most effective FMHTs comprise one officer at captain-to-major 

level (or equivalent) and one senior noncommissioned 

officer. This structure helps remove barriers across 

the military rank structure and destigmatize military 

mental health.

Operational planning includes a casualty estimate, 

which, in conjunction with the size of the deploying 

force, dictates which mental health assets are deployed. 

In the majority of traditional war fighting scenarios, 

an FMHT consisting of a psychiatrist and two or three 

community psychiatric nurses is deployed at role 2 

(role 2 is usually collocated with the dressing station 

in the region of 1-hour travel by road from the fighting 

troops). Traditionally based at role 3 (3–4 hours traveling time by road from the front line) and collocated 

with the field hospital is a further complement of mental health personnel including a consultant psychiatrist 

and community psychiatric nurses. 

Predeployment

Before deployments, the DCMH and FMHT assess 

medically downgraded personnel or those undergoing 

mental health treatment to give a clear indication to 

commanders about whether these personnel might be 

fit to deploy, and if so, whether there are employability 

restrictions. Ideally, the deploying FMHT also assists 

with preoperational stress management presentations5

 and meets the commanders of units they will 

support in the operational theater to clarify arrangements (mental health personnel are often logistically 

prevented from deploying with units they supported 

in peacetime locations). The provision of formal briefings to all deploying personnel is mandated by policy. 

Such briefings are intended not only to provide factual 

information on stress reactions but also to detail the 

mental health provision (and how to access it) during 

the forthcoming operation. Specific briefings on subjects such as body handling or dealing with prisoners 

of war may be given, depending on the nature of the 

forthcoming deployment.

During Deployment

Teams aim to travel to all units in theater seeing 

patients as required (usually referred from medical 

services) and undertake a command liaison role within 

the unit lines. Operational travel restrictions sometimes prevent this mode of operations, and mental 

health professionals can then find themselves stuck 

in one location, unable to respond to other needs. In 

these instances patients may travel to the FMHT, but 

they will consequentially lose proximity support from 

their units. 

Assessment of potential patients in theater loosely 

follows the flowchart in Figure 41-1, which explains 

the referral pathway according to the seminal work 

undertaken by Goldberg and Huxley concerning the 

pathways to care followed by psychiatric patients in 

the community.21 Mental health nurses work with unit 

commanders and medical staffs to provide occupationally relevant advice aiming to maintain the fighting 

force whenever possible. However, unit commanders 

hold the ultimate responsibility in assigning operational duties. These decisions are based on a number 

of factors including the operational situation, the unit 

support available, and the location of medical and 

psychiatric assets.

Postdeployment

In line with postdeployment operational stress management policy,20 DMHS professionals assist with any 

decompression process. The level of decompression 

package is left to the brigade commander to decide 

in consultation with medical or psychiatric advisors. 

The surgeon general’s policy dictates that some form 

of homecoming brief will be delivered to returning 

troops, which should be tailored to suit the intensity 

of the operation once the unit has returned to the decompression area (a low-threat location in theater or 

another base such as Cyprus) or peacetime location.

Ministry of Defence Posttraumatic Stress Disorder 

Legal Case

In 2002, a number of former military personnel 

sued the Ministry of Defence (MOD) over claims of 

psychological injury related to their operational service.22 The claimants did not dispute their assignment 

of operational duties but claimed that the MOD was 

negligent in failing to provide appropriate predeployment screening and training as well as appropriate 

postoperational care that might have prevented, or 

at least detected and treated, their disorders prior to 

discharge from the services. Judgment in the PTSD 

group action was handed down by Lord Justice Owen 

on May 21, 2003. The judge found for the MOD on 

almost all of the generic issues, despite criticizing the 

ministry in several areas. The judge found against the 

MOD in 4 of the 16 lead cases, but these cases turned 

on their individual facts and did not represent institutional failure. 

During subsequent examination of the case, the 

judge made clear that the MOD has a duty to provide a 

safe system of work for its personnel where reasonable 
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Combat and Operational Behavioral Health

and practical. It does not, however, have a duty to do 

so in the course of combat, where the interests of personnel are subordinate to the military objective; this is 

known as “combat immunity.” The judge defined combat so that the immunity was not restricted to troops 

in the presence of the enemy but also all active operations against the enemy when personnel are exposed 

to the threat of attack, including attack and resistance, 

advance and retreat, pursuit and avoidance, and reconnaissance and engagement. Immunity extends to the 

planning of and preparation for operations in which 

there is the possibility of attack or resistance, including 

peacekeeping or policing operations in which personnel are exposed to the threat of attack.

The case was heated, and 16 subject matter experts 

from the UK, United States, Israel, and Australia gave 

evidence at the trial. Subjects discussed included 

screening before recruitment and before and after deployment, the potential use of critical incident psychoLevel 5

Level 4 (UK/BFG)

Level 3 (RTU)

Level 2

Level 1

Discharged at UK/BFG 

airhead for medical 

officer follow-up

Discharged at UK/BFG 

airhead for DCMH 

follow-up

Admitted to UK

inpatient unit

(ISP)

Returned to

UK/BFG via unit

welfare system

Returned to UK/BFG 

via aeromedical 

evacuation route 

RTU: maintained 

with FMHT

support

RTU: recommend unit

repatriation

Evacuation to

role 3 (field 

hospital

Full mental health assesment

undertaken by FMHT

Chain-ofcommand referral

Assessed by

military medic

Self-referral

Assessed by

medical officer

Chain-ofcommand referral

Personnel in theater

Self-referral

Figure 41-1. Operational mental health referral flowchart.

BFG: British Forces Germany

DCMH: Department of Community Mental Health

FMHT: Field Mental Health Team

ISP: inpatient service provider

logical debriefings, preventative stress inoculation, and 

decompression or postdeployment briefings. None of 

these measures were found to be robustly effective in 

the prevention or treatment of psychological injury.22

An MOD internal report,23 providing guidance for 

the future management of operational mental health 

issues, called for initiating a robust research program, 

training the chain of command to identify the signs of 

stress and assist anyone likely to “break down,” and 

instituting a stress awareness strategy to destigmatize 

mental health problems and encourage those who 

need help to request it.6

Trauma Risk Management

In the late 1990s, the brigadier in charge of the 

Royal Marines Commandos, an elite group of military 

maritime personnel who often form the UK’s rapid 

reaction force, tasked a staff officer to investigate ways 

RTU: return to unit

UK: United Kingdom
663

Mental Healthcare in the United Kingdom Armed Forces

to improve his troops’ mental health in response to operational stress. An initial critical incident psychological debriefing program was rejected within the robust 

culture of the marines. Staff subsequently developed 

a more successful peer support/psychological risk 

assessment program called Trauma Risk Management 

(TRiM), which has since been adopted by a number of 

UK organizations, including some of the emergency 

services and the diplomatic service.

The program, now fully integrated into the Royal 

Marines and many parts of the Royal Navy and Army, 

aims to equip nonmedical personnel with the skills 

to detect service members who might be suffering 

from traumatic stress problems. TRiM practitioners 

are trained to provide relevant mentoring and support in the aftermath of potentially traumatic events 

and deployments and, when necessary, to encourage 

persistently distressed personnel to seek referral from 

professional sources of mental health support.24,25

The program has been embedded within the existing 

personnel management systems. For example, during initial training young marines are instructed in 

field craft, shooting skills, and using TRiM support. 

Potential TRiM practitioners are selected for their 

interpersonal skills, experience, and common sense. 

Once trained, they provide basic psychoeducational 

packages to their units. Furthermore, all promotion 

courses within the Royal Marines Command provide 

some detail on TRiM, ensuring that all marines, and 

especially those in leadership positions, are aware of 

TRiM and able to use the system. The training program 

has gained external certification and has also been 

considered by the US military26 (preliminary training 

courses for US personnel were held in Washington, 

DC, in 2003, and San Diego, California, in 2005). The 

TRiM system is also to form part of the new US Army 

Psychological First Aid package designed for use by 

Army medical staff. 

Among the TRiM program’s strategic aims is to 

be a vehicle for organizational culture change. The 

course aims to destigmatize mental health issues and 

provide a pool of informed peers or mentors who are 

likely to be more acceptable than mental health professionals as sources of support. Research on UK military 

peacekeepers showed that more than 90% of personnel 

talked to peers about their deployments, whereas only 

8% talked to medical or welfare staff.27

A cluster randomized controlled trial is underway 

in the Royal Navy to ensure that TRiM does not suffer 

the same fate as the critical incident psychological debriefing program. The trial will attempt to identify any 

potential for TRiM to do harm, as well as any positive 

or negative cultural changes that occur on warships 

that have received TRiM training. A possible positive 

result of the trial would be an increase in referrals with 

no increase in mental health problems.

Current Research and future Directions

The King’s Centre for Military Health Research 

(KCMHR) is the primary UK military mental health research institution. Although numerous other academic 

centers conduct relevant research into both serving and 

retired UK military service personnel, none has a solely 

military orientation. The center boasts close links with 

an internationally acclaimed war studies department at 

King’s College London and offers a master of science 

degree in war and psychiatry. 

KCMHR has just completed a 3-year study on the 

health of about 12,000 randomly sampled UK military 

personnel, examining the recurrence of “Gulf War syndrome” problems and the rates of psychiatric injury 

following Operation Telic. Results so far show no rise 

in multisymptom conditions.28,29 Furthermore, regular 

military personnel have not been especially affected 

by service in Iraq in terms of posttraumatic stress or 

general psychological or physical symptoms. Veterans 

of Iraq deployments drink more alcohol and display 

more risky behaviors than those who did not deploy, 

but the absolute risk increase has been small. This result does not appear to be true for reservists, who are 

displaying significant changes in both psychological 

and physical health. The absolute risk increase is still 

small (a doubling of PTSD symptoms from about 3% 

to 6%); however, the research has prompted MOD 

attempts to mitigate the problem (made more acute 

because veteran and reservist mental healthcare is not 

provided by the military). 

With predeployment data on a subset of those deployed in Operation Telic, KCMHR was able to model 

the effects of predeployment mental health screening 

(when it had been conducted). The results showed that 

predeployment screening would not have reduced 

postoperational psychiatric illness, but would have 

had a significant deleterious effect on the numbers of 

personnel deployed.30

Other work underway is investigating the impact 

of military service on family life, the usefulness of 

medical countermeasures to mental illness, and the 

effects of potential exposure to depleted uranium. 

KCMHR intends to follow the cohort for many years 

to gain relevant insights into the health of the UK service member in the 21st century. Preliminary results 

that have influenced strategic MOD policy include 

the finding that providing too much informed choice 

can adversely influence vaccine compliance31 and 

that predeployment mental health screening is likely 
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1. Jones E, Greenberg N. Royal Naval psychiatry: organisation, methods and outcomes 1900–1945. Mariner’s Mirror. 

2006;92:190–203.

2. Johnson W, Rows RG. Neurasthenia and the war neuroses. In: McPherson WG, Herrringham WP, Elliott TR, eds. History of the Great War, Diseases of the War. Vol 2. London, England: HMSO; 1923.

3. Salmon TW. The care and treatment of mental diseases and war neuroses (‘shell shock’) in the British Army. Ment Hyg. 

1917;1:509–547.

4. Jones E, Wessely S. Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War. Hove, UK: Psychology Press; 

2005.

5. Myers CS. Shell Shock in France, Based on a War Diary. Cambridge, England: Cambridge University Press; 1940.

6. Salmon TW. Care and treatment of mental diseases and war neurosis (“shell shock”) in the British army. In: Salmon 

TW, Fenton N, eds. Neuropsychiatry. Vol X. The Medical Department of the United States Army in the World War. 

Washington, DC: GPO; 1929: 497–547.

7. Shepard B. A War of Nerves: Soldiers and Psychiatrists 1914–1994. London, England: Jonathan Cape; 2000.

8. Churchill WS. War cabinet minutes (TNA PREM4/15/2. December 1942). In: Jones E, Wessely S. Shell Shock to PTSD: 

Military Psychiatry from 1900 to the Gulf War. Hove, UK: Psychology Press; 2005.

9. McCarthy J. Aircrew and “lack of moral fibre” in the Second World War. War Soc. 1995;18:87–101. 

10. Jones E. “LMF”: The use of psychiatric stigma in the Royal Air Force during the Second World War. J Milit Hist. 

2006;70:439–458.

11. O’Connor R. Work of Psychologists and Psychiatrists in the Services. TNA/WO32/11974, 5 December 1946. UK National Archives (Kew, Richmond, Surrey). 

12. Rees JR. The Shaping of Psychiatry by War. London, England: Chapman and Hall; 1945.

13. Sandiford HA. Army Psychiatry Advisory Committee Minutes (TNA, WO32/13462, 5 July 1945). In: Jones E, Wessely 

S. Shell Shock to PTSD: Military Psychiatry From 1900 to the Gulf War. Hove, UK: Psychology Press; 2005.

ineffective.30

The recently established Academic Centre for Defence Mental Health is a small cadre of MOD mental 

health staff attempting to stimulate DMHS research. 

The center also provides the defense consultant advisor in psychiatry, an advisor to the surgeon general, 

with regular reports on emergent research findings into 

potentially useful MOD policy actions. The MOD is 

increasingly realizing the need to use relevant research 

findings to inform future policy making.

SUMMARY

UK military psychiatry has a rich historical basis. 

Modern mental health provision is heavily community based, with operational provision being 

delivered by rendering appropriate support to the 

chain of command, which, in UK military doctrine, 

is primarily responsible for the psychological welfare of troops. The DMHS cadre of single-service 

uniformed and civilian staff provide triservice care, 

with a recently increased emphasis on research that is 

already providing a plethora of useful data informing 

and influencing MOD policy. Having weathered a 

protracted legal case and the shrinkage of the armed 

forces, the DMHS will continue to focus on supporting the sailors, soldiers, and airmen of the UK 

armed forces, as well as personnel and operational 

commanders in their missions, while ensuring the 

use of the ever-increasing body of research evidence 

to inform future practice.

References
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