An exploration and critical analysis of the predisposing factors leading to depression within the British Army

Personal Author: Finnegan, Alan 
Year: 2011.
Dissertation: PhD Thesis -- Birmingham City University, 2011. 

Abstract

Background 

Depression is a common MH disorder within the British Army (Neal et al, 2003, Jones et al, 2008, Iversen et al, 2009), yet has never been the subject of an extensive empirical study.  

Aim

This original nursing research aimed to provide an exploration of the factors leading to British Army personnel presenting with Depression.  

Methods 

Information was collected from 3 sources.  Quantitative data was obtained from two anonymous and confidential cross sectional surveys designed by the author. In the first survey, experienced nurses trained in data collection obtained information from 1,030 consecutive Military MH (MMH) hospital admissions over a three year period; identifying the factors associated with Depression together with significant demographic, performance and clinical detail.  The second survey was completed by 317 serving soldiers following a formal community based MH program. This questionnaire contained a tick box list of the predisposing factors associated with Depression together with the option to provide additional information in free text areas. These comprehensive evaluations included an assessment of Army Medical Services (AMS) MH care provision, including patient satisfaction, significant events reporting and clinical performance indicators. The author coded the information, utilising SPSS for the management that included descriptive and inferential statistical analysis.

Qualitative information was obtained through semi-structured interviews with 19 Army MH clinicians, with a Constructivist Grounded Theory (Charmaz, 2006) provided the theoretical model.  Respondents provided detail on aspects of army life including military ethos, operational experience, help seeking behaviour and stigma. Interviews were digitally recorded and transcribed by the author, and continued until saturation was achieved (Charmaz, 2006).  The author’s MMH experience provided a familiarity with both the phenomena and the clinical and military nuances’ of language.

The respondents had 380 years of experience employed within MMH; thereby providing insight of how a soldier’s world functions in both peacetime and operational settings.   Interviews lasted between 32-63 minutes, following informed consent obtained following UK guidelines (Central Office for Research, 2005) and ethical approval provided by the MOD REC. 

Conclusions were based on triangulation of the findings from all three elements of the study.   

Results 

Depression resulted in 38% (N=476) hospital admissions. Statistically significant results indicated that women were more prone to Depression and men to alcohol related disorders. Depressed soldiers presented with multi-factorial problems displayed in a number of different ways, with the main causes being relationship problems, family issues and occupational stressors irrespective of rank, age and gender.  50% of young male soldiers requiring MH support displayed depressive symptomatology as a result of wanting to leave the Army, and they were positively associated with self harming ideology. In 95% of cases, a hospital bed was available within four hours, and 93% of patients were satisfied with their care.

Grounded theory analysis identified four major clusters; predisposing factors, maintaining factors, secondary coping mechanisms and help seeking behaviour. There were issues related to peacetime and operational settings; and the support provided by the AMS and Unit Command. These factors led to theoretical groupings under the headings of:  Occupational Stressors; The Macho Culture, Stigma & Bullying; The Unhappy Young Soldier; Relationships and Gender.

Discussion 

This seminal study provides the first in depth exploration of Depression within the British Army.  Results indicated that the AMS provided an exceptional standard of access to hospital beds, and patients were predominately satisfied with their care, indicating a high quality service provision.   This research  established that Depression was the major reason why soldiers’ required a MH hospital admission, with the majority presenting with multi-factorial problems with the main causes being relationship difficulties, family issues and occupational stressors.  This presentation of Depression was not uniform, or aligned to civilian definitions, and had a unique interpretation within the Army. 

Results draw attention to the plight of unhappy young soldiers’, where 50% of those requiring MH support reported that they wanted to leave the Army but were restricted by terms and conditions of service, often leading to self harming ideology.  Problems were attributed to a number of dysfunctional processes, in a group whose help seeking behaviour was often dependent on personal gain, and they were not inhibited by the stigma associated with MH disorders.  However, if retained in the Services then their symptoms became more pronounced.  At the opposite end of the continuum were older, senior personnel who were so concerned of stigma and the negative occupational implications of seeking AMS support that they accessed civilian MH services, with potential dangerous ramifications as they may be commenced on antidepressants and still deploy.

The young disaffected soldier was one of three distinct groups presenting with depressive symptomatology. The second group were soldiers aged 25 to 30 years old who faced numerous occupational, situational and environmental pressures.  The third group were older personnel with a classical depressive presentation. Consistently noted was that soldiers could cope with extreme pressures, often in hostile environments, but could not deal with a failing relationship.

The study demonstrated that female soldiers were significantly more likely to attend for a MH assessment and to be admitted to hospital for Depression. It appeared that female soldiers found it easier to seek support because they were more self-aware, emotionally expressive, and better at confiding in each other.  However, GPs were more likely to refer a tearful woman than a man who disguised his emotions, although this was often inappropriate.  The study also demonstrated that the impact of an operational deployment might result in symptomatology that could be misdiagnosed as PTSD, especially by civilian practitioners.

Conclusion

This independent nursing research contributes to nursing scholarship through high quality,  valid and reliable results, leading to better, more cost effective support.  The project produced a clear, unambiguous and easily understandable theoretical model detailing the predisposing factors leading to Depression in the Army and a clinical care pathway.  This multi functional paradigm can be utilised within Primary Healthcare, MH, and is being introduced into the training syllabi for MOD GPs; thereby influencing MOD policy to improve the operational capability of the British Armed Forces.  This research has featured in clinical press and mainstream media, and it is anticipated that the findings are transferable to other populations that deal predominately with young men’s MH, and other countries Armed Forces.

References

Central Office for Research: Ethics Committee. (2005).  About Us: www.corec.org.uk/applicants/about/about.hcm.

Charmaz, K. (2006). Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis.  London, Sage.

Iversen, A.C., Staden, L.V., Hacker-Hughes, J., Browne, T., Hull, L., Greenberg, N., Rona, R.J., Hotopf, M., Wessely, S. & Fear, N.T. (2009).  The Prevalence of Common Mental Health Disorders and PTSD in the UK Military: Using Data from a Clinical Interview-Based Study.  BMC Psychiatry, 9, 68 doi.

Jones, N., Greenberg, N., Fear, N.T., Earnshaw, M., McAllister, P., Reid, G. & Wessely, S. (2008).  The Operational Mental Health Consequences of Deployment to Iraq for UK Forces.  Journal of the Royal Army Medical Corps, 154(2), pp. 102-106.

Neal, L., Kiernan, M., Hill, D., McManus, F. & Turner, M.A. (2003). Management of Mental Illness by the British Army.  British Journal of Psychiatry, 182, pp. 337-341.

Read the full thesis

Finnegan, A (2011) , An exploration and critical analysis of the predisposing factors leading to depression within the British Army (PDF, MB), PhD thesis, Birmingham City University.

A hard bound copy of this thesis is available from the RCN Steinberg Collection.

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