Average number of deployment-related mental disorders and development of comorbidities in a 5-year interval among military personnel

Ulrich Wesemann, Nils Hüttermann, Francesco Pahnke, Peter Zimmermann, Gerd Willmund, Kai Köhler, René Giesen, Karl-Heinz Renner

Summary

Background: Mental disorders are part of the occupational risk for military personnel. While the focus in recent decades has been on post-traumatic stress disorders, other disorders, and individual symptoms recently have also come to the fore. Studies from Afghanistan (International Security Assistance Force; ISAF) show a 1-year incidence of mental disorders of 7 %. The total number of military personnel diagnosed for the first time with a deployment-related mental disorder was an average of 340 per year. This data should be updated since the investigation period is already 5 years ago. In addition, the development of comorbid disorders is examined at 5-year intervals.

Methods: All servicewomen and men diagnosed with a deployment-related mental disorder are recorded in the deployment statistics maintained centrally in the Bundeswehr Center for Psychotraumatology. By using a HASH code, duplicate cases can be identified and excluded. The years 2018–2022 and 2013–2022 were used to calculate the initial diagnoses of deployment-related mental disorders. 2011, 2016 and 2021 were chosen and compared to calculate the comorbid conditions.

Results: In the 5-year period, a deployment-related mental disorder was reported for the first time in 301 soldiers; in the 10-year period 310. The number of comorbid diagnoses in the reference years differs significantly with χ² (2, N = 980) = 33.42; p < .001. The lowest number of comorbid mental disorders was recorded in 2011, and the highest in 2021.

Conclusions: The number of soldiers with deployment-related mental disorders has remained constant over the past 10 years. However, this should not be interpreted as an all-clear signal, as the number of unreported cases is still significantly higher. Above all, the emerging long latency between the onset of symptoms and the start of treatment, which is often associated with chronicity, and the significant increase in comorbid mental disorders make the course of therapy considerably more difficult. A focus should be placed on the unrecognized soldiers.

Key words: military personnel; mental health; comorbidity; incidence; stigma

Background

Deployment-related mental disorders represent a significant occupational hazard for military personnel and rescue services [27]. While the focus in recent decades has been on post-traumatic stress disorder (PTSD) [8][24], studies on depressive episodes and other anxiety disorders are now being conducted more and more frequently [21]. Individual symptoms such as sleep disturbances [3][5][6], aggression and hostility [9][19][28][34], distrust [29][31], body dysmorphic disorders, muscular dysmorphism, dissatisfaction with weight and shape, and use of medication also have an impact increased appearance [1]. Also changes in value orientations [2][40], moral injuries [38][39], changes in cytokines such as the TNF-α receptors [10, 25], tobacco consumption [22] or organic brain changes [13][14] are increasingly coming to the fore. Workplace conditions [7], such as the violence experienced there [18], military disciplinary procedures [4], the characteristics of the critical events [15][19][26][33], psychosocial factors [23] but also resources [16] and ethical challenges [20] increasing attention. Another important focus is suicidality in the armed forces [37]. In the Bundeswehr, suicide is still the most common specific cause of death among active servicewomen and men [36]. This more holistic view led to a more realistic picture of deployment-related mental symptoms, syndromes and disorders. This knowledge is particularly important for the troop medical care, as this is often the first point of contact for affected military personnel.

According to a recent study, the proportion of male combat troop soldiers who developed a mental disorder during or shortly after an ISAF operation is 7.3 %. The most common disorders were specific phobias, PTSD and depressive episodes. The most common comorbidities included PTSD and depressive episodes as well as PTSD and specific phobias, with almost 30 % of all sufferers developing comorbid disorders. Against this background, it is also interesting that 19.5 % of the soldiers intended for the deployment already suffered from a mental disorder before the ISAF deployment [35]. Although this is well below the average of 27.7 % for the general population living in Germany [11][17], it shows that a better detection rate would be helpful.

This could be achieved through further training measures in the field of troop medicine. Another important step could be the mental fitness framework developed by the Psychological Service to minimize the emergence of mental disorders. Destigmatization programs are also a helpful means of strengthening the personal responsibility of those affected. Here, too, the questionnaire of the State Trait Emerency responders Questionnaire for Partners (STEP) is currently being evaluated, which involves the partners in this process [32].

In a further analysis of the data set described above from the investigation of male combat soldiers, an influence of specific characteristics of the workplace conditions could also be determined here. For example, soldiers who experienced a life-threatening military-specific event during their deployment had a 6.7-fold greater risk of developing a depressive disorder [30]. This is important for routine reconnaissance of the troop medical section. Critical life events are a strong predictor of the development of mental health problems and can be assessed quickly. Of course, this does not replace a thorough assessment of mental fitness, but it does provide valuable initial information. In addition, these findings can help to further improve training and preparation measures [12] and further develop existing destigmatization programs.

In a study published a few years ago, the average number of military personnel newly diagnosed with a deployment-related mental disorder was 340 per year [32]. The calculation period referred to the last 5 years; i.e. for the years 2014–2018. To update this data after the withdrawal from Afghanistan, these figures are to be recalculated for the last 5 years.

Objective

The aim of this study is to determine the average number of servicewomen and men who are diagnosed with a deployment-related mental disorder for the first time. For this purpose, the annual average for the last 5 and 10 years is to be calculated.

In addition to new diagnoses in military personnel with deployment-related mental disorders, it was noticeable in everyday clinical practice that military personnel were suffering from increasingly complex illnesses with other comorbid mental disorders. Another goal is therefore to investigate the changes in comorbid disorders over a longer period.

Methods

The deployment statistics kept centrally in the Bundeswehr Center for Psychotraumatology were used for the calculations. All servicewomen and men who seek treatment for deployment-related mental disorders are recorded there on behalf of the federal government. The figures are transmitted monthly by the Bundeswehr hospitals and medical centers of the Bundeswehr. The generation of a hash code does not allow any conclusions to be drawn about individuals, but persons who have been registered twice or more are recognized, regardless of the reporting body. This means that the newly reported persons can be clearly identified as a “new case”.

Due to the pseudonymized storage of the data, no declarations of consent can be obtained from the persons recorded. To ensure the standards of good scientific practice, an ethics vote was obtained from the Bundeswehr University in Munich (AZ: EK UniBW M 2023–2).

The years 2018–2022 were used to calculate newly recorded soldiers with a mental disorder. All persons who were diagnosed with a deployment-related mental disorder for the first time were summarized here, and the annual average was calculated from this.

To test whether the comorbidities of servicewomen and men with deployment-related mental disorders change over time, all cases with more than one diagnosis were extracted. Five-year intervals were chosen for this, starting in 2021. First, the most common mental disorders that occur simultaneously with others were ranked. Subsequently, selected mental disorders were examined using the χ² test for differences in the given intervals. Finally, the same test was used to check whether the intervals of all comorbidities differed from one another. Since these are individual comparisons, no alpha adjustment is required. The significance level is set at p < .05. The calculations were performed with SPSS.

Table 1: The 7 most common deployment-related comorbid mental disorders in servicewomen and men

Table 2: χ² test to compare the comorbidities “Mental and behavioral disorders due to psychoactive substance use” (without alcohol) in a 5-year interval

Table 3: χ² test to compare the comorbidities “mental and behavioral disorders due to use of alcohol” in a 5-year interval.

The groups differ in the comorbidity of the diagnoses “Mental and behavioral disorders due to psychoactive substance use” (without alcohol) with χ² (2, N = 980) = 14.37; p = .00076 significant. The lowest comorbidity was found in 2011.

Table 4: χ² test to compare the comorbidities “depressive disorders” in a 5-year interval.

Table 5: χ² test to compare the comorbid “anxiety disorders” at 5-year intervals.

Table 6: χ² test to compare the comorbidities “Disorders of adult personality and behavior” in a 5-year interval.

Table 7: χ² test to compare all comorbidities in a 5-year interval.

Results

In the 5-year period 2018–2022, 1,504 soldiers were newly reported with a deployment-related mental disorder. So almost 301 (300.8) per year, of which a total of 1,399 (93 %) are male; 104 female (6.9 %) and 1 diverse (0.1 %). The average number of deployments at initial diagnosis is 3.3 [standard deviation (SD) 3.5], the average number of years of service is 15.4 (SD 8.7) and the mean number of deployment days is 260.5 (SD 541.4).

For the investigation of the comorbid mental disorders, the seven most frequently occurring disorders were identified and ranked in the first step. The results are given in Table 1:

To evaluate comorbid disorders, “mental and behavioral disorders caused by psychotropic substances” (excluding alcohol), “alcohol-related disorders”, “depressive disorders”, “anxiety disorders”, “personality and behavioral disorders” and “comorbid disorders overall” were summarized and considered . The evaluation was carried out using the χ² test. The absolute numbers (without percentages) are given in the tables without brackets.

Discussion

With 300 soldiers who receive the initial diagnosis of a deployment-related mental disorder every year, the absolut number has remained largely constant over the past decade. The number of unreported cases is estimated to be significantly higher. A decrease in the numbers after the withdrawal from Afghanistan since July 2021 has not yet been observed. This is attributed to the fact that the latency period between the onset of symptoms and the start of treatment is likely to be 3–4 years on average. A detailed evaluation of this is currently being carried out by the Center for Psychotraumatology at the Bundeswehr Hospital in Berlin in cooperation with the Bundeswehr University Munich.

Since the number of unreported cases is likely to be significantly higher, further efforts in the area of de-stigmatization make sense here. This could shorten the latency period between the onset of symptoms and the start of treatment, or lead to the start of adequate treatment at all. In order to increase the detection rates, training courses in the areas of troop medicine and troop psychology could be helpful. With the introduction of low-threshold measures such as morale prevention [39], the current development of individual and group resilience training by the psychological service and other offers in the field of mental fitness, the number of soldiers suffering from a mental disorder could be reduced. This is also largely independent of foreign assignments. In addition, the introduction of the new concept for “psychological crisis intervention” is expected to reduce the burden of illness. Involving relatives in health-promoting measures increases compliance and offers a broader framework.

With almost the same number of cases, an overall increase in deployment-related comorbid mental disorders from 2011 to 2021 by 70 % can be determined. This suggests that the treatments are becoming more and more complex, the prognosis is deteriorating and the duration of treatment is likely to increase significantly. This is likely to be particularly noticeable in soldiers with comorbid disorders caused by alcohol, depression and anxiety disorders. Based on the descriptive statistics (Table 1), there was a shift in the frequency of diagnosis of comorbid disorders. Adjustment disorders have decreased while agoraphobia has increased. This also speaks for a higher burden of disease and symptoms, which has a negative effect on the treatment setting (duration, prognosis, etc.).

The numbers of soldiers with comorbid PTSD have developed positively. There is a decrease here. However, this could also be related to the fact that no further diagnoses such as agoraphobia or depressive episodes are made with this disorder. There are clear overlaps in the symptoms here, so that this is included in the treatment anyway.

A trend towards more frequent diagnoses of “other reactions to severe stress” can also be observed in the last year. It can be assumed that the focus here is increasingly being placed on moral injury.

Limitations

The deployment statistics only include the reported soldiers, so that no statements can be made about those affected who have not been identified. However, it is precisely this proportion that is estimated to be considerably higher. Likewise, military personnel with deployment-related mental disorders are often not included in these statistics if they are treated in a non-military therapeutic setting.

When calculating the comorbidities, only the 3 reference years were included as comparison years. In a further study, it would be useful to cover the entire time span.

Conclusion

The increase in deployment-related comorbid mental disorders and the shift from “lighter” to “more serious” diagnoses speak in favor of more complex clinical pictures. This affects the duration of treatment and the prognosis. Improved diagnostics in the sense of early detection by the medical and psychological departments of the unit would be helpful in preventing chronification. This could be achieved through additional training. Perhaps the most important step in this direction could be the assessment of “mental fitness”. The screening of the “Psychological Crisis Intervention” is also rated as helpful, since this takes place over a period of 3 years and in this way servicewomen and men who later develop problems can be identified. The primary goal of both programs is to increase the resources and resilience of the servicewomen and men in such a way that mental disorders do not occur. Irrespective of future Bundeswehr missions abroad, a further increase in mental disorders among servicewomen and men is to be expected. However, the prevalence is expected to remain just below the average for the German population as a whole.

Key statements

• Deployment-related mental disorders are a significant occupational risk for soldiers and exceed the risk of physical injury or death.
• On average, 310 soldiers are diagnosed with a deployment-related mental disorder for the first time each year.
• Deployment-related comorbid mental disorders have increased significantly over the past 10 years, significantly complicating the treatment process.
• Training of troop physicians and troop psychologists could improve the detection rate and shorten the latency between disorder onset and treatment.
• Measures of “Psychological Fitness” and “Psychological Crisis Intervention” should prevent a disorder in a primary preventive way.

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Manuscript Data

Citation

Wesemann U, Hüttermann N, Pahnke F, Zimmermann P, Willmund G, Köhler K, Giesen R, Renner KH: Average number of deployment-related mental disorders and development of comorbidities in a 5-year interval among military personnel. WMM 2023; 67(9): e1.

DOI: https://doi.org/10.48701/opus4-196

For the Authors

Associate Professor Dr. Ulrich Wesemann

Bundeswehr Hospital Berlin

Bundeswehr Center for Psychotraumatology

Scharnhorststr. 13, D-10115 Berlin

E-Mail: uw@ptzbw.org