Forces Psychological Symptoms in the British Armed Medical Downgrading

Downloaded from oem.bmjjournals.com on 7 April 2006 Medical downgrading, self-perception of health, and psychological symptoms in the British Armed Forces R J Rona, R Hooper, N Greenberg, M Jones and S Wessely Occup. Environ. Med. 2006;63;250-254 doi:10.1136/oem.2005.021311 Updated information and services can be found at: http://oem.bmjjournals.com/cgi/content/full/63/4/250 These include: References This article cites 22 articles, 5 of which can be accessed free at: http://oem.bmjjournals.com/cgi/content/full/63/4/250#BIBL 1 online articles that cite this article can be accessed at: http://oem.bmjjournals.com/cgi/content/full/63/4/250#otherarticles Rapid responses You can respond to this article at: http://oem.bmjjournals.com/cgi/eletter-submit/63/4/250 Email alerting Receive free email alerts when new articles cite this article - sign up in the box at the service top right corner of the article Topic collections Articles on similar topics can be found in the following collections Occupational Health (1176 articles) Other Psychiatry (828 articles) Notes To order reprints of this article go to: http://www.bmjjournals.com/cgi/reprintform To subscribe to Occupational and Environmental Medicine go to: http://www.bmjjournals.com/subscriptions/ Downloaded from oem.bmjjournals.com on 7 April 2006 250 ORIGINAL ARTICLE Medical downgrading, self-perception of health, and psychological symptoms in the British Armed Forces R J Rona, R Hooper, N Greenberg, M Jones, S Wessely ............................................................................................................................... Occup Environ Med 2006;63:250–254. doi: 10.1136/oem.2005.021311 Objective: To investigate the contribution of psychological symptoms to limited employability for medical reasons in the British Armed Forces. Methods: A sample of 4500 military personnel was randomly selected to receive either a full or an abridged questionnaire. The questionnaires asked whether the participant was medically downgraded See end of article for authors’ affiliations and if yes, the reason for it. The full questionnaire included the General Health Questionnaire-12 (GHQ- ....................... 12), the post-traumatic stress disorder (PTSD) checklist, 15 symptoms to assess somatisation, and selected items of the quality of life SF-36 questionnaire. The abridged questionnaire included the GHQ-4, a 14 item Correspondence to: Professor R J Rona, PTSD checklist, five symptoms, and the item on self-perception of health from the SF-36. Subjects above a Department of Public threshold score for GHQ, PTSD, and symptoms were considered to have psychological symptoms. Health Sciences, King’s Results: 12.4% of the participants were medically downgraded. The majority (70.4%) had social or work College London, Guy’s limitations. Medically downgraded personnel had higher odds ratios in comparison to non-downgraded Campus, 5th Floor, Capital House, 42 Weston Street, personnel for psychological distress 1.84 (95% CI 1.43 to 2.37), PTSD 3.06 (95% CI 1.82 to 5.15), and London SE1 3QD, UK; number of symptoms 2.37 (95% CI 2.37 1.62 to 3.47). GHQ, PTSD, and symptoms scores were mainly, [email protected] but not exclusively, related to chronic physical injury. Accepted Conclusions: Psychological symptoms are common among medically downgraded personnel. Although 30 November 2005 the mechanisms involved are unclear, tackling issues of psychological symptoms among these subjects ....................... could contribute to faster restitution to full employability in the Armed Forces. t least 8% of the personnel in the British Armed Forces and below standard-discharge. Its equivalent in the US— are medically downgraded at any given time with PULHES—is also viewed with some degree of scepticism. This higher rates reported for the Territorial Army (TA).1 A might contribute to the high level of errors in the entry A 1 medical reason is provided in nearly 17% of all discharges medical assessments. The frequency and detail of the process from the Armed Forces.2 The rates of medical downgrading may vary from being very stringent and frequent in highly vary according to the type of function and service. Medical specialised functions such as pilots, to less so for supporting downgrading and discharges are a serious drain of scarce functions. To date studies have looked at the wastage of resources, have considerable impact upon the military’s highly specialised personnel,5 the numbers of deployed operational capability and may have consequences in personnel whose employability does not match the level of organisational issues and issues of morale for the Armed fitness required for operational roles during deployment6 and Forces. false negatives of medical fitness at the recruitment stage.2 The literature concerning medical downgrading is scant. We are unaware of any studies assessing the self- Most reports are of a descriptive nature. This is a neglected perception of health and psychological symptoms among area of research, maybe because the rules concerning medical those who are medically downgraded in the Armed Forces. downgrading are open to interpretation by military doctors Poor self-perception of health and a high prevalence of and therefore the process is likely to be subject to inherent psychological symptoms and somatisation can impact on the variability. Although there are military publications, which level of preparedness of the Armed Forces and impact on the purport to define a common standard to the process, there is length of time a person remains in a lower medical category no formal audit procedure to ensure that the standard is than that needed for full employability. Downgrading may 3 adhered to. This is not just because of inability to regulate itself impact on wellbeing if service personnel were to develop the Defence Medical Services personnel but also because the a sense of unsuitability and consequent low morale. PULHHEEMS procedure, used to assess medical fitness in the The purpose of this paper is to assess the self-perception of British Armed Forces, relies on clinicians making an health and psychological symptoms of medically downgraded assessment of occupational function based not just on a personnel and the association between the reasons given by medical diagnosis but also on the resulting degree of the servicemen for their medical downgraded status and their functional limitation. The assessment is also likely to be psychological symptoms. The analysis was based on a influenced by the patient’s view of his or her own problem. representative sample of military personnel who participated The system was developed in the Canadian Armed Forces in a study to assess the value of a screening programme for soon after the Second World War. PULHHEEMS is an psychological and physical health in the UK Armed Forces.7 acronym which denotes the medical function of aspects of health: Physical, Upper limbs, Lower limbs, Hearing (left and right ear), Eyesight (left and right eye), Mental capacity, and emotional Stability. The PULHHEEMS assessment is trans- 34 Abbreviations: AFPAA, Armed Forces Personnel Administration lated into employment standards. In brief the categories are Agency; GHQ, General Health Questionnaire; MO, Medical Officer; fit, fit (but permanently medically boarded and accepted PTSD, post-traumatic stress disorder; RAF, Royal Air Force; RN, Royal restriction), unfit and usually receiving treatment to improve, Navy; TA, Territorial Army www.occenvmed.com Downloaded from oem.bmjjournals.com on 7 April 2006 Medical downgrading and psychological symptoms 251 Table 1 Criteria for referral to medical centres syndrome. Miscellaneous: contact lenses to fly; pregnancy, according to length of the questionnaire overweight, need to wear glasses, Army cannot be bothered to send for doctors so cannot be upgraded, hearing problems. Dimension Full questionnaire Abridged questionnaire Some of the reasons did not fall neatly into one of the Symptoms >5 mild or combinations of At least 3 mild or moderate categories or may have fallen into more than one category, mild and moderate; >3 symptoms or at least 1 but these were a very small percentage (approximately 3%) of moderate; at least 1 severe severe symptom. the total. symptom The psychological scales included in our analysis were the GHQ GHQ-12 score 4/5 GHQ-4 score 1/2 11 PTSD 17 items score of 50 or more 14 items score . 40 post-traumatic stress disorder (PTSD) checklist (PCL), the General Health Questionnaire 12 (GHQ-12) as a measure of psychological distress,12 and 15 symptoms selected from a previously used questionnaire.13 We also assessed the quality of life in relation to medically downgraded status in part to METHODS check the quality of the information provided by the Two groups were randomly selected, by strength of each participants and in part to assess their feelings about their service (Royal Navy (RN), Army, and Royal Air Force (RAF)) own health. We included an item on self-assessed health 7 to receive either a full questionnaire or a short questionnaire. status, and questions on work limitation, vigorous activity, The questionnaires were individually addressed and sent to and social activity from the SF-36.14 We also included two the unit Commanding Officer. Stamped addressed envelopes questions on perception of health in comparison to others were supplied for the return of questionnaires. Three and expectations about future health. The abridged ques- mailings were carried out to increase response. tionnaire

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