headley court trust report headley court trust proj ect · project report – january 2013 ... the...

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Headley Court

Trust Proj ect

Headley Court Trust Report

Project Report – January 2013 20132012November 2012

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THE HEADLEY COURT TRUST PROJECT

The identification of factors which conduce to and prevent rehabilitation and

adjustment in military personnel following combat-related injury: a pragmatic

evaluation of patients and their partners.

Emeritus Professor David A Alexander,

Professor Susan Klein,

Major Kevin Forbes

January 2013

Aberdeen Centre for Trauma Research,

The Robert Gordon University, ABERDEEN

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Table of Contents

Table of Contents ................................................................................................................ 3

List of Tables ....................................................................................................................... 4

List of Figures ...................................................................................................................... 5

Acknowledgements .............................................................................................................. 6

Introduction ......................................................................................................................... 7

Literature review ................................................................................................................. 8

Mental health and combat-related disorders ..................................................................... 8

Post-traumatic psychopathology ..................................................................................... 11

The ‘ripple effect’ of trauma ........................................................................................... 11

Study aims and research questions .................................................................................. 13

Study design ....................................................................................................................... 14

Population and samples .................................................................................................. 14

Selection criteria ............................................................................................................. 16

Recruitment..................................................................................................................... 17

Data collection ................................................................................................................ 19

Participant assessments ................................................................................................... 19

Clinical outcome data ..................................................................................................... 20

Self-report data ............................................................................................................... 20

Research governance ...................................................................................................... 24

Data analysis ................................................................................................................... 26

Results ................................................................................................................................ 27

Recruitment..................................................................................................................... 27

Response Rates ............................................................................................................... 29

Demographics ................................................................................................................. 30

Primary outcome variables – ‘independent samples’ ..................................................... 46

Primary outcome variables – ‘Paired samples’ ............................................................... 56

Health and lifestyle variables .......................................................................................... 62

Qualitative findings (Partner study) ................................................................................ 67

Conclusions ........................................................................................................................ 72

Recruitment..................................................................................................................... 72

Response rates ................................................................................................................ 73

Demographics ................................................................................................................. 74

Primary outcome variables ............................................................................................. 77

Health and lifestyle variables .......................................................................................... 80

Qualitative findings (Partner study) ................................................................................ 82

Recommendations ............................................................................................................. 83

References .......................................................................................................................... 84

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List of Tables

Table 1: 36-Month study period .............................................................................................. 15

Table 2: Study groups .............................................................................................................. 16

Table 3: Summary of selection criteria (all groups) ................................................................ 17

Table 4: Participant assessments ............................................................................................. 19

Table 5: Participant assessment schedule and summary of self-report measures.................... 24

Table 6: Response rates (all groups) ....................................................................................... 30

Table 7: Ethnicity of participants (01PG) and (01RG) ............................................................ 31

Table 8: Ethnicity of participants (02PG) and (02RG) ............................................................ 31

Table 9: Gender and incident type (01PG) and (01RG) .......................................................... 32

Table 10: Age at first admission to the DMRC (01PG) and (01RG) ...................................... 32

Table 11: Relationship status (01PG) and (01RG) (n=226) .................................................... 33

Table 12: Financially dependent children (01PG) and (01RG) ............................................... 35

Table 13: Highest level of educational achievement (01PG) and (01RG) .............................. 36

Table 14: Highest level of educational attainment (02PG) ..................................................... 37

Table 15: Employment status (02PG) and (02RG) ................................................................. 38

Table 16: Military service by type ........................................................................................... 39

Table 17: Branch of service ..................................................................................................... 40

Table 18: Current rank ............................................................................................................ 41

Table 19: Length of service ..................................................................................................... 42

Table 20: Type of incident (01PG) and (01RG) ...................................................................... 43

Table 21: Nature of incident (01PG) and (01RG) ................................................................... 45

Table 22: PCL-C – Baseline, six months and 12 months (01PG) ........................................... 47

Table 23: PCL-C - Baseline, six months and 12 months (02PG) ............................................ 48

Table 24: GHQ-12 - Baseline, six months and 12 months (01PG) ......................................... 52

Table 25: GHQ-12 - Baseline, six-months and 12-months (02PG)......................................... 54

Table 26 CDRIS-10 - Baseline, six-months and 12-months (01PG)....................................... 55

Table 27: Paired samples statistics (PCL-C) ........................................................................... 60

Table 28: Paired samples tests (PCL-C) .................................................................................. 60

Table 29: Paired samples statistics (CDRIS-10) ..................................................................... 61

Table 30: Paired samples tests (CDRIS-10) ............................................................................ 61

Table 31: Paired samples statistics (GHQ-12) ........................................................................ 61

Table 32: Paired samples tests (GHQ-12) ............................................................................... 62

Table 33: AUDIT scores (01PG) ............................................................................................. 63

Table 34: Mean outcome measures for Abstainees compared with non-abstainees................ 63

Table 35: Mean outcome measures for abstainees and non-abstainees (non-parametric tests)64

Table 36: Regular social activities outside of work (01PG) .................................................... 64

Table 37: Were most of the people you socialised with involved with

the military? (Prior to injury) ........................................................................................ 65

Table 38: Social activity prior to injury - going to the gym with friends (Baseline)............... 65

Table 39: Marital/relationship satisfaction for panel (n=11) ................................................... 66

Table 40: SSI - Baseline, six months and 12 months for

strict panel (n=11) (01PG) ............................................................................................ 67

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List of Figures

Figure 1: Summary of clinical outcome data........................................................................... 20

Figure 3: Age at first admission to DMRC (01PG) and (01RG) ............................................. 33

Figure 4: Relationship status (01PG) and (01RG) (n=125) ..................................................... 34

Figure 5: Highest level of educational achievement (01PG) and (01RG) ............................... 35

Figure 6: Highest level of educational achievement (02PG) ................................................... 37

Figure 7: Military service by type ........................................................................................... 39

Figure 8: Branch of service ..................................................................................................... 40

Figure 9: Current rank (or rank at completion of service) ....................................................... 41

Figure 10: Length of service (01PG) and (01RG) - Regular and FTRS .................................. 42

Figure 11: Length of service (01PG) and (01RG) - Reservists ............................................... 43

Figure 12: Type of incident (01PG) and (01RG) .................................................................... 44

Figure 13: Nature of incident (01PG) and (01RG) .................................................................. 45

Figure 14: Injury category ....................................................................................................... 46

Figure 15: PCL-C - Baseline (01PG) ...................................................................................... 48

Figure 16: PCL-C - Six months (01PG) .................................................................................. 48

Figure 17: PCL-C - 12 months (01PG) ................................................................................... 48

Figure 18: PCL-C - Baseline (02PG) ...................................................................................... 49

Figure 19: PCL-C - Six months (02PG) .................................................................................. 49

Figure 20: PCL-C - 12 months (02PG) ................................................................................... 49

Figure 21: GHQ-12 - Baseline using Likert and GHQ scoring methods (01PG) .................... 50

Figure 22: GHQ-12 - Six-months using Likert and GHQ scoring methods (01PG) ............... 51

Figure 23: GHQ-12 - 12-months using Likert and GHQ scoring methods (01PG) ................ 52

Figure 24: GHQ-12 - Baseline using Likert and GHQ scoring methods (02PG) .................... 53

Figure 25: GHQ-12 - Six-months using Likert and GHQ scoring methods (02PG) ............... 53

Figure 26: GHQ-12 - 12-months using Likert and GHQ scoring methods (02PG) ................ 54

Figure 27: CDRIS-10 - Baseline, six-months and 12-months (01PG) .................................... 56

Figure 28: PCL-C and CDRIS-10 - Means for panel sample (n=12) ...................................... 57

Figure 29: PCL-C and CDRIS-10 - Medians for panel sample (n=12) ................................... 57

Figure 30: PCL-C and GHQ-12 Medians for panel sample (n=12) ........................................ 58

Figure 31: PCL-C and GHQ-12 Means for panel sample (n=12) ........................................... 59

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Acknowledgements

No study of this size could be successfully completed without the support, advice and

goodwill of a great many people. Although it is not possible to mention them all

personally, we are especially grateful to the following individuals whose personal

contribution greatly facilitated the progress of the study: Colonel John Etherington

(Director of Defence Rehabilitation); Flight Lieutenant Stuart Haggerty (Former

Officer Commanding, Mental Health Flight at the Centre for Mental and Cognitive

Health, DMRC), Mrs Anne Brannagan (Complex Trauma Team Manager) and Mr Kit

Malia (Project Manager, Mild Traumatic Brain Injury).

Thanks must also go to Colonel Jeremy Tuck (former Commanding Officer at the

DMRC), Major Helen Rickard, Mrs Lucia Piruch (Manager, Officers Mess) and to all

of the clinical staff for making us welcome at the DMRC and for assisting in the day

to day management of the study.

To the Board of the Headley Court Trust for their financial support we extend our

thanks. Special thanks are due to Commodore Tobin Elliott for his encouragement

and support throughout the study.

Finally, this project would have achieved little without the commitment and co-

operation of all of those who took time to reply to our questionnaires, patient and

partner alike. We made many demands on them, all of which were met with

enthusiasm and a strong desire to contribute to the care of those service personnel and

their families affected by combat-injury. We sincerely hope that our own efforts and

the outcomes of this study will go some way towards recompensing them.

Emeritus Professor David A Alexander

Professor Susan Klein

Major Kevin J Forbes

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THE HEADLEY COURT TRUST PROJECT

The identification of factors which conduce to and prevent rehabilitation and

adjustment in military personnel following combat-related injury: a pragmatic

evaluation of patients and their partners.

Introduction

In 2009 the Defence Medical Rehabilitation Centre (DMRC) based at Headley Court

received considerable praise from the Healthcare Commission for its “excellent”

quality of care and treatment of UK service personnel in the first-ever independent

review of the Defence Medical Services (DMS) (Healthcare Commission, 2009). The

National Audit Office (NAO) further recognised the contribution of the DMRC in

2010, describing the service provided there as being ‘unique’ within the United

Kingdom (NAO, 2010). While these reports highlight the high standard of care

provided at Headley Court, they also highlight that, due to increased numbers of

operational casualties, additional demands placed upon the DMRC represent a

significant challenge for the rehabilitation services there and for the longer-term

management of those sustaining combat injury.

Between the 7th October 2001 and the 31st October 2012, 394 military and

civilian personnel were killed in action or died of wounds sustained on military

operations in Afghanistan (OP HERRICK)1. Over the same period, 587 individuals

were classified as being either ‘Very Seriously Injured or Wounded’ (VSI) (n=289) or

‘Seriously Injured or Wounded’ (SI) (n=298)2 and a closer examination of year on

year figures reveals a steady increase in casualty numbers from the beginning of OP

HERRICK until 2009 (DASA, 2012). The upward trend in operational casualties

sustained on OP HERRICK has had a corresponding effect on inpatient admission at

the DMRC. The NAO report Treating injury and illness arising on military operation

1 The total number of UK military and civilian fatalities in Afghanistan as reported by the Defence Analytical Services and Advice (DASA) agency totals 437 individuals. This total includes 43 ‘other’ deaths occurring as a result of accidental or violent

causes while deployed on operations and deaths due to disease related causes during the deployment. This total also includes

fratricide or so called ‘blue-on-blue’ or ‘green-on-blue’ incidents.

2 The Notification of Casualty or 'NOTICAS' system is used to categorise and report casualty status within the UK Armed

Forces. The classification 'Very Seriously Injured or Wounded' (VSI) is the definition used where the illness or injury is of such severity that life or reason is imminently endangered. The classification 'Seriously Injured or Wounded' (SI) is the definition

used where the patient's condition is of such severity that there is cause for immediate concern, but there is no imminent danger to life or reason.

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identifies that this upward trend represents a doubling of complex trauma inpatients at

the DMRC between 2006 and 2009 (NAO, 2010).

While 2009 saw annual casualty rates from OP HERRICK peak and subsequently

reduce to pre-2009 levels; the DMRC has continued to face the legacy of an increase

in inpatient admission. In order to address the demands of this increase in inpatient

numbers the DMRC has seen a rise of 23% in its staffing establishment, 83% in its

ward bed provision and an expansion of service both at Headley Court itself and

through the inception of DMRC-led rehabilitation throughout the United Kingdom

and Germany at the Regional Rehabilitation Units (RRU’s). While these measures, in

no small part, attempt to address capacity issues and ensure the continuation of a high

standard of inpatient care, significant challenges remain in respect of the longer term

management of those with combat injuries post rehabilitation and, often, post military

service. A recent report on the efforts of Combat Stress presents the argument that

many of the positive gains achieved by rehabilitation services; military and civilian

alike are frequently short term (Fletcher, 2007). There is therefore, a clear need to

find ways of sustaining any initial positive effect of rehabilitation and to identify

factors which either compromise, or facilitate the durability of such effects in the

longer term.

Literature review

A review of the literature has highlighted three initial areas of concern in respect of

the potential compromise, or facilitated durability, of the positive effects of

rehabilitation and the effective management of those with combat injuries in the

longer term. These areas of concern are: the long-term nature of mental health

problems and of combat-related disorders; the continued pre-occupation with Post-

Traumatic Stress Disorder (PTSD) as a single diagnosis following trauma; and the

nature of observed family and marital relationship problems following operational

deployment.

Mental health and combat-related disorders

Post-traumatic reactions have been observed throughout recorded human history but it

is only with the introduction of PTSD into the Diagnostic and Statistical Manual of

Mental Disorders-III (DSM-III) (American Psychiatric Association, 1980), that a

more widespread acceptance that major catastrophes and military combat could result

in identifiable psychopathology and problems of psychosocial adjustment (Alexander,

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1996). In terms of contemporary conflicts, Hotopf et al (2006) estimate a 4%

incidence of PTSD among UK troops returning from Iraq (without combat-injury);

Hoge et al (2004) however described a figure of just under 13% for returning troops,

and Engelhard et al (2007) report rates varying from 4%-21% among Dutch troops

returning from Iraq. Higher rates of PTSD were associated with higher levels of

direct combat exposure and minor wounds or injury, and rates of PTSD among

soldiers returning from war increased over time post-deployment as the majority of

soldiers with PTSD or depression at seven months had not met the criteria for either

condition one month following injury. These findings highlight the clinical

challenges of providing early psychiatric care for combat exposed personnel and the

difficulties associated with the management of these conditions in the longer term.

Whilst the evidence suggests that exposure to combat may be a potent source

of such sequelae, it is also recognized that no single traumatic event is guaranteed to

cause psychopathological reactions in all those exposed to it (Alexander, 1996). Why

considerable individual differences exist remains a challenge to clinical investigators

(Klein et al, 2002). Meta-analyses have identified several risk factors for PTSD in

both the military (Iversen et al, 2008) and the general population (Brewin et al, 2000;

Ozer et al, 2003) in terms of pre-trauma, peri-trauma, and post-trauma factors. Over

the past twenty years there has been a particular interest in the psychological

consequences of physical injury caused by a traumatic event among survivors of a

variety of traumatic events including road traffic incidents, terrorism, criminal assault,

and burn injuries (O’Donnell et al, 2003). While a few studies have shown that risk

for PTSD is associated with severity of injury, other studies have failed to replicate

these results in civilian populations.

Even although the research literature on traumatic injury is not yet sufficiently

advanced to differentiate whether some types of injury are more likely to elicit

emotional traumatic responses than others (O’Donnell et al, 2008), epidemiological

data suggest that certain traumatic events such as those involving interpersonal

violence, result in higher rates of PTSD (Klein & Alexander, 2006). Further studies

are required to investigate in depth whether there are potentially key mechanisms

inherent in certain physical injuries that increase the risk of poor psychological

outcomes. In one of the few studies which have attempted to identify predictors of

PTSD following combat-related injury, Koren et al (2005) directly compared, in a

matched case-control design, injured and non injured Israeli soldiers who experienced

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the same combat events to estimate the unique contribution of physical injury over

and above that of the trauma itself to the subsequent development of PTSD.

Consistent with the outcome of some earlier studies (e.g., Kulka et al, 1990; Michaels

et al, 1999), their findings unequivocally indicated that bodily injury is a risk factor –

rather than a protective one – for PTSD. Approximately fifteen months post-injury,

16.7% of injured soldiers had PTSD compared to 2.5% of non-injured soldiers with

similar combat experiences. Moreover, the data also suggested that the odds of

developing PTSD following traumatic injury are approximately eight times higher

than following injury-free trauma. Interpretation of the validity of these figures

requires careful analysis of such factors as the intensity of combat; whether the data

were from reservists or full time troops; whether the data derived from self-report or

from structured clinical interviews; whether the psychopathology was genuinely

combat-related, and how long after deployment the surveys were conducted.

Moreover, objective measures of physical injury are often not related to PTSD

outcome. High levels of physical problems, chronic pain, and seeking of medical care

are often seen in patients diagnosed with PTSD. However, the relationship of pain and

other physical problems shortly after injury to PTSD outcome has not been well

studied. Thus, it is not clear what factors contribute to low initial rates of PTSD. For

example, it may be due to high levels of social and medical support, pain or sleep

medications routinely administered during the immediate post-injury period and a

focus on recovery. In addition, the literature does not support a predictable trend of

recovery from PTSD over time.

Given that a delayed onset of symptoms has been reported in several studies

(e.g., Hoge et al, 2004), further research is required to understand the longitudinal

course of post-traumatic reactions and to assess the factors which may affect the

reporting of symptoms at follow-up such as persisting physical problems, anticipation

of returning home and starting work, concern over health care, and pending disability.

This is particularly pertinent in light of the increasing numbers of injured combat

troops returning from Afghanistan with blast related poly-trauma (Sayer et al, 2008)

and associated traumatic brain injury [TBI] (French & Parkinson, 2008). Although the

acute clinical management of poly-trauma has been well described, the post-acute

clinical management of such cases in rehabilitation and primary care settings has not

been adequately addressed in the literature.

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Post-traumatic psychopathology

It is now well established that PTSD is not the only psychiatric condition that may

develop in the aftermath of trauma (Klein & Alexander, 2006). Traditionally,

however, PTSD has tended to adopt centre stage thereby dominating the focus of

military research (Wessely, 2005). Comorbidity and PTSD however is the norm

rather than the exception (O’Donnell et al, 2004). In large community samples, for

example, between 80% and 85% of individuals with a diagnosis of PTSD also meet

criteria for at least one other psychiatric condition (Creamer et al, 2001). A meta-

analysis of psychopathology following civilian trauma suggested that increased rates

of generalised anxiety disorder, substance abuse, phobias, and major depressive

disorder occur following exposure to traumatic events (Brown et al, 2000). The

military literature confirms that symptoms from which soldiers may be at risk include

depression, anxiety, anger, sleep disturbance, somatisation, substance misuse,

dissociation and sexual problems (Goff et al, 2007). Currently, the literature indicates

that these additional symptoms (particularly depression and anxiety symptoms) are

higher in soldiers with PTSD than those without. Research conducted by Hoge et al

(2004) and Hoge (2005) reported an increase in post-deployment rates of PTSD

symptoms and anxiety in soldiers after deployment from Iraq and Afghanistan.

Studies which report symptoms, rather than diagnoses, imply a much higher level of

psychopathology. Lapierre et al (2007), having followed up US troops from Iraq and

Afghanistan, reported that about 44% of soldiers had symptoms of depression, and

post-traumatic stress. The available literature on the prevalence of these other

psychiatric conditions following combat-related injury however is very limited. Few

studies report prevalence and, of those that do, many do not clarify whether the

diagnosis is the sole condition or comorbid with PTSD or another diagnosis.

Moreover, quality of life, perception of recovery, and return to work are generally not

systematically indexed by researchers. Yet, the validity of findings based solely on

psychopathology is questionable in that they fail to address other major parameters

relevant to this population (O’Donnell et al, 2003).

The ‘ripple effect’ of trauma

Military personnel returning from Afghanistan face psychological challenges that can

exert profound effects on families and couples (Erbes et al, 2008). Particular

symptoms of Post-Traumatic Stress Disorder (PTSD), such as feelings of detachment,

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or estrangement from others, restricted affect, irritability, and outbursts of anger, may

adversely affect the interpersonal relationships of service members with their spouses/

partners. In dealing with such problems, family members may experience a burden of

care, and may themselves develop psychological symptoms. Thus, the impact of a

traumatic event is not limited to the traumatized person but can also impact on their

spouse/partner or family member; a concept which has been referred to as the “Ripple

Effect” of trauma (Klein & Alexander, 2005) or secondary traumatisation (Figley,

1998). Whilst evidence suggests that an accumulation of secondary traumatic stress

can lead to emotional exhaustion and emotional burnout, little is known about the

factors that bring about secondary traumatisation (Dirkzwager et al, 2005). There is

some evidence to suggest that combat or other military-related traumatic experiences

may be particularly detrimental to marriage. Cook and colleagues (2004) reported that

31% of World War II prisoners of war with PTSD reported marital distress compared

with 11% of those without PTSD. Research focussing on the perspective of the

spouse/partner of war veterans also reports higher levels of impairment in marital,

family and social relations (e.g., Dirkzwager et al, 2005). A major limitation of this

research however is the undue emphasis placed on the diagnosis of PTSD to the

detriment of identifying problems associated with other post-traumatic

psychopathology such as substance abuse, depression, relationship conflict, and

occupational dysfunction that are more common and potentially more troublesome to

service members and their families (Batten & Pollack, 2008).

In a subsequent investigation of reasons for the excess of ill health in

reservists, Browne et al (2007) included problems at home (readjustment or

relationship difficulties) and marital satisfaction. Following deployment, reservists

reported experiencing significantly more major problems and readjustment difficulties

than regulars. Because couple and family relationships may serve as either a vital

support or challenging obstacle to recovery from combat-related pathology, including

recovery from physical injury, research is required to identify factors associated with

adjustment and recovery. Collins and Kennedy (2008) further extend this particular

approach to the case of service members experiencing multiple and severe injuries,

requiring treatment in the poly-trauma system of care, due to the substantial burden

which may be placed on family members in fulfilling an unexpected caretaking role.

In summary therefore, there is a need to adopt a dual focus on the individual needs of

the service member in his or her rehabilitation and on the support and functioning of

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the care-giving spouse/ partner (Sammons & Batten, 2008). It represents a highly

topical issue as it concerns an “invisible healthcare system” which constitutes the core

long-term care in the community. Despite increasing recognition by policy makers of

the need to consider such effects (e.g., National Service Framework for Mental Health

[Department of Health 1999]), relatively few studies have systematically pursued a

focus on this important aspect of trauma care, and none has specifically examined this

issue with regards to combat-injured personnel despite the likelihood that the welfare

of partners or immediate family members will impact on the rehabilitation and

adjustment of the injured.

Study aims and research questions

The primary aims of this unique research study were to identify in combat-injured

personnel the:

1. durability of psychiatric and psychosocial gains from rehabilitation following

combat-related injury, and

2. impact of combat-related injury on the partner of military personnel in terms

of mental health, psychosocial adjustment, and relationships.

In fulfilling the first of these aims the study addressed the following research

questions with respect to military personnel admitted to the DMRC.

a) What are the long-term effects of rehabilitation of combat-injured personnel

following admission to the Defence Medical Rehabilitation Centre, Headley

Court?

b) What factors either compromise or facilitate the durability of therapeutic gain?

In fulfilling the second aim of this study, we addressed the following research

question with respect to partners of military personnel admitted to the DMRC.

c) What is the association between the durability of therapeutic gain and the

‘Ripple Effect’ of trauma?

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Study design

There are a number of well-established difficulties and common methodological

problems associated with the study of military cohorts (Hotopf & Wessely, 2005),

(O’Donnell et al, 2003). Difficulties associated with low response rates, recall bias,

self-selection of participants and lack of comparable ‘non-combat’ control groups

consistently affect the validity and reliability of such studies. This study sought to

avoid these difficulties and common methodological problems by seeking to: facilitate

high participation rates; minimise selection bias; enhance the interpretation of the

relationship between combat-related injury and outcome; minimise recall bias through

the inclusion of a prospective cohort; employ multimodal assessments, which include

objective measures, and provide a suitable ‘homogeneous’ control group for

comparison.

In order to effectively answer all three of the research questions the study

design also incorporated the linked and parallel study of military personnel admitted

to the DMRC with combat-related injuries (patient study) and their partners (partner

study).

Population and samples

In order to achieve the first of the research aims, the patient study consisted of a 36-

month case-control design to facilitate the effective comparison of complex trauma

patients with combat-related injury (study group) and an exact age- and gender-

matched control group of musculoskeletal patients with non-combat-related injury

(control group). In order to ensure a sufficient sample and adequate numbers for

follow-up this study utilised both prospective and retrospective cohorts.

Within the patient study, the prospective cohort consisted of individuals

admitted to the DMRC for the first time as in-patients during the designated 18-month

recruitment period3. In contrast, the retrospective cohort consisted of individuals

discharged from their final cycle of treatment in the 6 to 24 months preceding the

prospective recruitment period4. The utilisation of both prospective and retrospective

cohorts was intended to effectively extend the period studied from initial in-patient

admission to 36 months post-admission (see Table 1: 36-Month study period). The

inclusion of both prospective and retrospective cohorts within the study was intended

3 The eighteen month recruitment period from the 3rd January 2010 and the 30th June 2011 was agreed by Col. Jeremy Tuck, the

then Commanding Officer of the DMRC, Col. John Etherington, Director of Defence Rehabilitation and Prof. David A. Alexander and Prof. Susan Klein, the Principal Investigators. 4 1st January 2008 to 31st June 2009

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to facilitate higher response rates (by maximising participation) and to minimise the

effects of recall bias. Initial estimates of participant numbers, based on previous in-

patient admission to the DMRC, predicted that up to 340 patient participants across

both cohorts (prospective and retrospective) and both groups (study and control)

could be expected during the 18-month period.

Table 1: 36-Month study period

Prospective Group

(Days/Months post admission to

DMRC)

Retrospective Group

(Months post discharge from DMRC)

Recruitment

Within 7 days of first admission 6 12 18 24 Baseline

Assessment

Six-Month

Assessment 6 12 18 24 30

12-Month

Assessment 12 18 24 30 36

In order to achieve the second of the study aims a parallel 36-month case-control

study of partners was incorporated within the design. Once again, in order to ensure a

sufficient sample and adequate follow-up of partner participants the study made use of

both prospective and retrospective cohorts. In order to ensure sufficient numbers for

analysis following the anticipated attrition of partners due to unsuitability, refusal to

participate or loss at follow-up, initial estimates suggested that up to 300 partner

participants would be required across both cohorts (prospective and retrospective) and

both groups (study and control).

As the study design incorporated the linked and parallel study of military

personnel admitted to the DMRC and their partners (patient study and partner study)

and utilised both study and control groups as well as prospective and retrospective

cohorts, eight distinct study groups may be described. For the purpose of the report,

however, discussion of the study groups will be limited to the four main groupings:

Prospective Patient Group (01PG); Retrospective Patient Group (01RG); Prospective

Partner Group (02PG) and the Retrospective Partner Group (02RG) (see Table 2:

Study groups).

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Table 2: Study groups

Patient Study (01) Partner Study (02)

Prospective

Cohort (PG)

Retrospective

Cohort (RG)

Prospective

Cohort (PG)

Retrospective

Cohort (RG)

Study

Group(S) 01PG 01RG 02PG 02RG

Control

Group(C)

Selection criteria

Within the patient study, participants were required to be a minimum of 18 years of

age at recruitment and able to give full informed consent. Study group patient

participants had to have sustained an operational (combat-related) injury and this

injury must have been the cause of their admission to the DMRC. Alternatively,

members of the control group were required to have been the victims of a non-

combat-related injury sustained out-with the operational environment, occurring

either on or off military duty (e.g., road traffic incident, sporting injury or other

accident). This injury also must have been the cause of their admission. Recruitment

of both study and control groups from a core population of DMRC in-patients was

intended to ensure the provision of a suitable ‘homogeneous’ control group. A

summary of selection criteria is presented in Table 3: Summary of selection criteria

(all groups).

Potential patient participants meeting the selection criteria were invited to

participate in the study unless otherwise presenting with moderate or severe

Traumatic Brain Injury (TBI)5 or other identifiable cerebral impediment likely to

compromise their understanding of, or ability to respond to, verbal and written

assessments. Moderate or severe traumatic brain injury has previously been identified

as a confounding factor in the assessment of post-injury mental health (Hill, Mobo, &

Cullen, 2009). Those individuals presenting with traumatic brain injury often exhibit

symptoms consistent with PTSD and considerable overlap in presentation and

sequelae serves only to complicate their diagnosis and management (Vasterling et al,

2009).

Within the partner study, participants were also required to be: able to give full

informed consent and; a minimum of 18 years of age at time of recruitment. Potential

5 The criteria utilised for the identification of traumatic brain injury in participants was that adopted by the World Health

Organisation (WHO) and employed within the Centre for Mental and Cognitive Health at DMRC. For the purpose of this study,

therefore, mild TBI (mTBI) was defined as injury resulting from, or being represented by, a Glasgow Coma Scale (GCS) score of >12 within 30 minutes of injury; a loss of consciousness of <30 minutes, and posttraumatic amnesia <24 hours. This

definition includes complex mTBI where focal lesions may be evident.

17

partner participants were those identified as being in what they themselves regarded

as being a ‘committed relationship’ with an index patient enrolled on the patient study

(in either study or control group) and that index patient must have given prior consent

for the partner to be approached. Potential partner participants who were non-

English-speaking, or presented with impediments that may have limited their

understanding of the purpose and nature of the study were excluded from

participation. Where potential partner participants were involved in legal proceedings

against the patient participant or were the co-victim of the index trauma (e.g. road

traffic incident) they were also excluded from participation.

Table 3: Summary of selection criteria (all groups)

Study Group/Cohort Inclusion Criteria Exclusion Criteria

General Criteria (All Groups)

Must be able to give informed consent.

Must be aged eighteen years and above at

time of recruitment to the study.

Patient Participants

Study Group

Both Prospective and

Retrospective Cohorts

Victim of an operational

combat-related injury Moderate or severe TBI

Cerebral impediment

Discharged from DMRC outwith the

previous six to twenty-four months Patient Participants

Control Group

Both Prospective and

Retrospective Cohorts

Victim of non-combat-related injury

Partner Participants

Prospective and Retrospective

Cohorts

In a committed relationship

with an index patient

Non-English speaking

Impediments to understanding the

purpose of the project

Involved in legal proceedings

against the patient

Co-victim of the index trauma

Recruitment

Patient Group (Prospective cohort)

Potential prospective patient participants were identified in collaboration with the

complex trauma team at the DMRC and their initial eligibility was determined by the

clinical summary of injuries presented in the weekly complex-trauma admission list.

Medical and psychiatric opinions were available regarding the suitability of potential

participants in the event of any uncertainty or disagreement regarding their

competence or their ability to participate. During the agreed 18-month prospective

recruitment period (3rd January 2010 to 30th June 2011) every complex trauma

patient admitted to the DMRC during their first cycle of inpatient care who met the

selection criteria was approached by the Headley Court Fellow (HCF) in order to

further assess their eligibility. It is a considerable strength of the study design that

every patient admitted to the complex trauma patient group at the DMRC was

18

assessed and, if meeting the selection criteria, invited to participate. The study design

incorporated face-to-face recruitment of consecutive admissions in order to facilitate

maximum participation, maximum response, and to minimise problems associated

with selection bias.

Eligible potential participants were approached within the first week of their

initial admission to the DMRC and the purpose and nature of the research project was

explained to them. During this initial approach, potential participants were provided

with a patient-information leaflet in a ‘commonly asked questions’ format in support

of this initial briefing and were provided with the opportunity to ask questions.

Eligible potential participants were subsequently left for a minimum of 24 hours to

consider their participation before being approached a second time. Those eligible

potential participants willing to participate at second contact with the HCF were taken

through the consent process, enrolled into the study and provided with the baseline

assessment document.

Patient Group (Retrospective cohort)

Potential retrospective participants were initially identified through the Defence

Patient Tracking System operated by the Defence Analytical Services Agency

(DASA) and Joint Medical Command (JMC). The contact information for potential

retrospective participants meeting the study selection criteria was then requested from

the Service Personnel and Veterans Agency (SPVA) and each potential participant

was subsequently written to by the HCF, informed about the purpose of the study and

invited to participate. Letters of invitation were accompanied by patient information

leaflets, consent forms and self-addressed envelopes to allow the return of the

appropriate documentation. Retrospective patient participants returning completed

consent forms and patient information documents were then sent the baseline

assessment document by post.

Partner Group (Prospective and retrospective cohorts)

Potential partner participants in both prospective and retrospective cohorts were

identified through their existing relationship with index patient participants. During

the consent process, patient participants were asked to identify whether or not they

were in a ‘committed relationship’ and whether or not they would consent to their

partner being approached by the HCF in order to invite them to participate in the

partner study. For prospective patient participants the request was made during the

19

face-to-face consent process, and for retrospective patient participants the request was

made by post. Where patient participants consented to their partner being

approached, contact details were obtained and letters of invitation accompanied by

partner information leaflets, consent forms and self-addressed envelopes, to allow the

return of the appropriate documentation, were sent to potential partner participants.

Data collection

Following their identification, consent and recruitment, a three staged follow up of

participants was undertaken using a comprehensive multimodal participant

assessment previously piloted by the HCF at the DMRC6. Each patient and partner

participant was assessed initially at baseline and then again at six months and 12

months using one of 12 standardised questionnaires (see Table 4: Participant

assessments). Each of the participant questionnaires consisted of a number of

validated objective measures and supporting questions and, with the exception of the

baseline assessment of the prospective patient group, was administered as a postal

self-report questionnaire. In order to minimise participant burden and to avoid

causing unnecessary distress only those measures deemed essential in order to fulfil

the aims of the study were included.

Table 4: Participant assessments


Prospective

Cohort (PG)

Retrospective

Cohort (RG)

Prospective Cohort

(PG)

Retrospective

Cohort (RG)

Baseline

Assessment (BA) 01-PG-BA 01-RG-BA 02-PG-BA 02-RG-BA

Six-month

Assessment (6M) 01-PG-6M 01-RG-6M 02-PG-6M 02-RG-6M

12-month

Assessment (12M) 01-PG-12M 01-RG-12M 02-PG-12M 02-RG-12M

Participant assessments

In order to comprehensively answer the stated research questions the study design

made use of a combination of clinical outcome and standardised self-report data.

Clinical data obtained through outcome measure assessments conducted at the DMRC

during day to day practice were utilised in order to assess spinal injury, mobility, pain,

6 The baseline assessment document was piloted at the DMRC in December 2009 with a representative sample of twenty-five

complex-trauma patients with both combat-related and musculoskeletal injury. The pilot study consisted of individuals from all

three Services, male and female participants, and UK and Foreign and Commonwealth personnel. The response rate of the pilot study was 60%, and a number of revisions to the proposed assessment documents were made in response to comments from

participants and clinicians and the analysis of completed pilot assessment documents.

20

balance, anxiety and depression, quality of life and functional capability in patient

participants. Data regarding injury severity and neurological status of participants

following their injury were obtained through the Academic Department of Military

Emergency Medicine (ADMEM). Self-report data, collected during the 12-month

follow-up phase, provided information on participants’ socio-demographic

background, military experience and exposure to traumatic events as well as self-

reported physical health, resilience, perceived social support, general trauma-related

psychopathology and quality of life.

Clinical outcome data

The systematic review of medical, nursing, occupational therapy and physiotherapy

case notes in addition to the interrogation of a number of electronic sources, i.e. the

Defence Medical Information Capability Programme (DMICP) and the UK Joint

Theatre Trauma Registry (JTTR) facilitated the collection of a range of clinical

outcome data. A summary of the clinical outcome measures is to be found in Figure

1: Summary of clinical outcome data. The clinical outcome data was collected at

baseline, six months and at 12 months, or during the nearest admissions to those

dates.

Figure 1: Summary of clinical outcome data

DASA/JTTR Data

o Injury severity (ISS, NISS)

o Head injury (GCS)

DMRC Clinical Outcome Data

o ASIA Score (Spinal cord injury)

o Mobility Scores

SIGAM mobility grades,

Six-minute timed walk,

Stair Assessment,

AMPQ

o Pain Score

o Balance

Fregley & Graybiel balance, Y balance test

o Mental health

Hospital Anxiety and Depression Scale (HADS)

o Quality of life

SF-36, Independence in Activities of Daily Living;

o Functional performance

FIT-HaNSA,

Return to driving,

Return to work

o Patient satisfaction

21

Self-report data

Self-report data were collected through the administration of the participant

questionnaires described above. The objective measures used within the standardised

questionnaires were intended to provide a comprehensive assessment of participant

health and well-being and facilitated the collection of: socio-demographic data;

physical health data; resilience and social support data as well as data regarding

general and trauma-related psychopathology, quality of life and caregiver strain. A

summary of these measures and an example of their use is contained in Table 5:

Participant assessment schedule and summary of self-report measures (Patient

Group).

Socio-demographic variables

The collection of socio-demographic data was achieved through the administration of

a modified version of the Accident Assessment Interview Schedule (AAIS), (Alexander

et al, 1995) and the Partner Semi-Structured Interview (PSSI), (Klein & Alexander,

2005). These measures were incorporated into the baseline assessment of both patient

and partner participants, and were intended to provide information on: the socio-

demographic characteristics of participants; the specific details of the incident and of

the injury sustained, as well as the reactions of participants to their injury and specific

predictors of general psychopathology.

As patient participants are, or have been, members of a military cohort,

permission was obtained from the King’s Centre for Military Health Research

(KCMHR)7 to incorporate sections of the Health & wellbeing survey of serving & ex-

serving members of the UK Armed Forces: Phase 2 within the participant

assessments. Utilisation of elements of the ‘Phase 2’ study, including those in respect

of participants’ previous deployment history, experience of operations and exposure

to traumatic events, provided a sound ‘military context’ for this study and helped to

ensure the comparability of results with the existing KCMHR database.

Physical health variables

The Physical Symptom Checklist (PSC), (Unwin et al, 1999) and the Chalder Fatigue

Scale (CFS), (Chalder et al, 1993) were included in all participant assessments in

order to assess somatisation and to measure fatigue symptoms across both studies and

all groups of participants.

7 Approval has been obtained from Professor Simon Wessely (Director, KCMHR) to incorporate elements of the Phase 2 study

questionnaire.

22

Resilience variables

‘Resilience’ refers to positive adaptation in the face of stress or trauma (Luthar et al,

2000), and two standardised measures thereof have been employed within the study

design to assess participant resilience.

Dispositional Resilience Scale-15 (DRS-15), (Bartone, 2007).

This brief 15-item scale was developed in order to measure the three

personality traits of hardiness, i.e. commitment, control and challenge, and has

been included in the baseline assessment of patient participants.

Connor-Davidson Resilience Scale-10 (CDRIS-10), (Connor & Davidson,

2003). This 10-item scale was developed from the original 25-item self-report

scale that measures the ability to cope with adversity and is used within each

of the participant assessments.

Social support variables

In order to measure perceived social support in both patient and partner groups the

Social Support Inventory (SSI), (Holeva et al, 2001) has been included within patient

and partner participant assessments. The social support inventory is a 5-item measure

of perceived social support based on an expanded version of the Perceived Criticism

Scale (Hooley & Teasdale, 1989).

General and trauma-related psychopathology variables

The collection of data regarding participants’ general mental health and, more

specifically, any symptoms of PTSD was achieved through the administration of the

General Health Questionnaire (GHQ-12), (Goldberg & Williams, 1988) and the

PTSD Checklist-Civilian Version (PCL-C), (Blanchard et al, 1996).

General Health Questionnaire (GHQ-12; Goldberg & Williams, 1988)

This 12-item version has been widely used to measure symptoms of common

mental disorder among individuals in community settings and in non-

psychiatric settings.

PTSD Checklist-Civilian Version (PCL-C; Blanchard et al, 1996)

The PCL-C measure is a 17-item checklist that can be used to screen

individuals for PTSD, as a diagnostic tool, or to monitor symptom change

during and after treatment. While a dedicated military version of the PCL

exists, the civilian version (PCL-C) has been utilised within this study to

23

facilitate the direct comparison of symptoms of PTSD in both patient and

partner groups and to ensure the compatibility of collected data with the

existing KMHCR database.

Quality of life and lifestyle variables

The Short Form-36 health survey measure (SF-36), (Ware et al, 1993) constitutes a

generic self-report measure of quality of life that has been widely used to provide an

assessment that is not specific to age, disease or treatment group (Fayers & Machin,

2001). As a measure, it places emphasis upon physical, social, and emotional

functioning.

While the primary measure of quality of life variables remains the Short Form-

36 measure (SF-36), the study design makes use of a number of other lifestyle

variables including a brief measure of alcohol consumption to assess the extent and

pattern of alcohol misuse (Alcohol Use Disorders Identification Test (AUDIT; Babor

et al, 2001)).

Caregiver burden variables

Caregiver Strain Index-Modified (CSI-M), (Robinson, 1983) is a 16-item index used

to identify the level of strain experienced by partners in relation to the provision of

care for the patient in respect of the, emotional, financial, physical, social and time

‘costs’ and strains. Each item is framed to ensure that any change is attributable to the

patient’s injury.

24

Table 5: Participant assessment schedule and summary of self-report measures (Patient Group)

Baseline Assessment Six-month Assessment 12-month Assessment

PG/RG Prospective

Cohort

Retrospective

Cohort

Prospective

Cohort

Retrospective

Cohort

Prospective

Cohort

Retrospective

Cohort

Clinical Variables DMRC DMRC

Socio-demographic

variables

AAIS/KCMHR

(Phase 2)

AAIS/KCMHR

(Phase 2)

Physical health

variables

PSC

CFS

PSC

CFS

PSC

CFS

PSC

CFS

PSC

CFS

PSC

CFS

Resilience

variables

DRS-15

C-DRIS-10

DRS-15

C-DRIS-10 C-DRIS-10 C-DRIS-10 C-DRIS-10 C-DRIS-10

Social support

variables SSI SSI SSI SSI SSI SSI

General and trauma-

related

psychopathology

variables

GHQ-12

PCL-C

GHQ-12

PCL-C

GHQ-12

PCL-C

GHQ-12

PCL-C

GHQ-12

PCL-C

GHQ-12

PCL-C

Quality of Life

variables SF-36* SF-36 SF-36 SF-36 SF-36 SF-36

*SF-36 included with baseline assessment of retrospective cohort only

Research governance

By virtue of the fact that this study involved participants who may have suffered

traumatic injury, and investigated topics about which some participants may have

been sensitive, embarrassed or upset, it is recognised that participation in this project

may be harmful. At each stage, measures were taken to minimise the potential risk to

participants and the study was conducted in full compliance with the Research Ethics

Policy of The Robert Gordon University (RGU). The study was reviewed by the

Surgeon General’s Research Strategy Group and has been granted full ethical

approval by both the Ministry of Defence Research Ethics Committee (MODREC)8

and the National Research Ethics Service – North of Scotland (NRES) Committee9.

8 Ethical approval from the Ministry of Defence Research Ethics Committee (MoDREC) was granted on the 1st October 2009

(MoDREC references, 62/Gen/09 (Patient study) and 63/Gen/09 (Partner study)). 9 A favourable ethical opinion was granted by the National Research Ethics Service Committee – North of Scotland (NRES) on

the 29th July 2009 (NRES reference number 09/S0801/47).

25

Participant consent

Informed written consent was obtained from each participant prior to their enrolment

in the study. For the purpose of the study, written consent included permission from

the participant to access their medical and resettlement records and, where

appropriate, to contact their partner. During the induction process, participants were

provided with a verbal briefing, informed as to the nature, aims and risks of the study

and provided with a detailed patient information sheet. Participants were reminded

that they were entitled to ask questions on any aspect of the study that may occur to

them at any time during their participation.

Potential pressures

As potential patient participants were currently, or had previously been, in receipt of

treatment from the DMRC and because they may continue to serve in the armed

forces, it was feasible that some individuals might feel compelled to participate in the

study. Participants were informed, therefore, that although the study was being

conducted in collaboration with the DMRC and was being funded and supported by

the Headley Court Trust, the researchers remained independent of these bodies and

that participation in the study was entirely voluntary. Participants were reminded also

that they would retain the right to withdraw their consent at any time during the study

without prejudicing either their medical care or their military career (or medical care

or military career of their partner).

Confidentiality, Anonymity and Data Storage

Participants were assured that their responses would remain confidential throughout

and that on completion of the study; no personally identifying information would be

released into the public domain. Participants were informed that no individual would

be identified in reports or publications and that all findings would be reported on the

basis of aggregated data.

As participants were asked to consent to the storage of personal information it

was also made clear that any data collected would be used only for the purpose of the

current study and that their information would be handled in accordance with the Data

Protection Act 1998.

Computerised data (which may be militarily sensitive and/or clinically

confidential) have been stored on an encrypted hard-disk that remains accessible only

by authorised members of the research team. As MoDREC requires the retention of

the original hard copy of participant assessments for a period of not less than 100

26

years, hard copy information is stored in a locked cupboard within the secure ACTR

site which is accessible only by designated RGU staff.

Data analysis

The statistical analysis of data collected through the participant assessments was

carried out using the software package SPSS for Windows (Version 17). The primary

outcome (dependent) variables for both patient and partner study were the GHQ-12,

PCL-C, and the SF-36, and the analysis of these measures fulfilled the primary

descriptive aim of the study (the estimate of the prevalence of general and trauma-

related psychopathology and quality of life and its variation by group, socio-

demographic characteristics, clinical, psychosocial and resilience status).

A series of univariate analyses (such as the paired t-test or non parametric

equivalents if deemed appropriate) were conducted to identify the variables most

closely associated with outcome in terms of group and postulated risk factors.

27

Results

Recruitment


Between the 3rd of January 2010 and the 30th of June 2011 details of 234 potential in-

patient admissions to the DMRC were published by the complex-trauma team.

During the recruitment phase 224 individuals were admitted to the complex-trauma

group. Non-admission (n=10) was as a result of: improvement in patient condition

following the initial review by the DMRC consultant; referral to a regional

rehabilitation centre, or to a facility other than the DMRC, or death at the Queen

Elizabeth Hospital in Birmingham during acute management.

An initial assessment, by the HCF, of those presenting as in-patients at the

DMRC resulted in the exclusion of a further ten potential participants due to their

unsuitability or failure to meet the selection criteria (e.g. those presenting at the

DMRC following elective procedures, as medical admissions, or those admitted to an

rehabilitation group other than to complex-trauma or by virtue of their being non UK

nationals or civilians).

Two-hundred and fourteen potential patient participants were approached by

the HCF and invited to participate in the study. One-hundred and ninety-nine

individuals (92.99%) consented to participate (see Figure 2: Participant recruitment).


The Defence Patient Tracking System (DPTS) provided details of 126 individuals,

previously treated at the DMRC, who met the study selection criteria. The Service

Personnel and Veterans Agency (SPVA) provided contact information for each of

those 126 individuals, and they were contacted by post by the HCF and invited to

participate in the study. From the initial tranche of 126 potential retrospective patient

participants, 20 (15.87%) responded to the invitation either on initial contact or

following a subsequent reminder letter, and were enrolled on to the study.


Contact information for potential partner participants was obtained through index

patient participants enrolled in both the prospective or retrospective cohorts. Within

the prospective patient cohort (n=199), 139 (69.85%) individuals identified

themselves as being in a ‘committed relationship’ and 107 (76.98%) of them

28

consented to having their partner approached10. Within the retrospective patient

cohort, of those responding to the invitation to participate in the study, 14 (70.00%)

consented to having their partner approached.

Following the identification of potential prospective and retrospective partner

participants, 121 invitations to participate in the study were posted by the HCF.

Following either the initial approach or a subsequent reminder letter, 30 (24.79%)

potential partner participants consented to participate and were enrolled onto the

study. A summary of the participant recruitment for all four main study groups is

presented in Figure 2: Participant recruitment.

10 Sixty of the 199 enrolled prospective participants identified themselves as being single (30.15%) when they were initially

approached by the HCF and 32 (16.08%) did not consent to the approach of their partner.

Potential prospectivepatient participants

(n=234)

Non-admissions to Complex-Trauma

Group

(n=10)

Admitted to Complex-Trauma Group

(n=224)

Excluded

(n=10)

Approached

(n=214)

01PG

Consented

(n=199)

Not in a 'committed relationship'

(n=60)

In a 'committed relationship'

(n=139)

Refused consent to approach partner

(n=32)

Consented to partner being approached

(n=107)

Potential prospective partner participants

approached

(n=107)

02PG

Consented

(n=27)

Did not repond to invitation

(n=80)

Refused

(n=15)

Potential retrospectivepatient participants

(n=126)

Potential retrospective patient participants

approached

(n=126)

Responded to invitation

(n=20)

01RG

Consented

(n=20)

Not in a 'committed relationship'

(n=6)

In a 'committed relationship'

(n=14)

Consented to partner being approached

(n=14)

Potential retrospective partner participants

approached

(n=14)

02RG

Consented

(n=3)

Did not respond to invitation

(n=11)

Refused consent to approach partner

(n=0)

Did not respond to invitation

(n=106)

Retrospective Cohort Prospective Cohort

Figure 2: Participant recruitment

29

Response Rates

During the 12-month follow-up phase, participant assessments in both patient and

partner studies were administered at baseline (BA), at six months (6M) and again at

12 months (12M). With the exception of the prospective patient participant baseline

assessment (01PGBA), which was administered directly at the DMRC, the participant

assessments were administered by post. A summary of response rates for all groups is

presented in Table 6: Response rates (all groups).


The response rate on the prospective patient baseline assessment (01PGBA) was

good, and achieved a return of 56.28% (n=112). The postal administration of the six-

month (01PG6M) and 12-month (01PG12M) prospective patient assessments,

however, achieved a significantly lower response. Of the six-month assessments

administered (n=199) only 14.57% (n=29) were returned. Expressing the response

rate of the 01PG6M assessments as a percentage of number of those completing the

original 01PGBA assessment (n=112), improves the rate to 25.89%. The response

rate for the 01PG12M assessment, expressed as a percentage of the total number of

12-month assessments administered (n=199), is 11.56% (n=23) and as a percentage of

those completing the 01PGBA assessment (n=112), 20.54%.


The response rate on the retrospective patient baseline assessment (01RGBA) was

also good, achieving a return of 65.00% (n=13). In contrast to the prospective patient

baseline assessment (01PGBA) the baseline assessment for the retrospective group

(01RGBA) was administered by post in the same way as the six-month and 12-month

follow-up assessments for that group. The administration of the six-month

(01RG6M) and 12-month (01RG12M) retrospective patient assessments also achieved

a better response rate than those of the prospective patient study, albeit in much lower

numbers. Of the 20 six-month assessments administered by post eight were returned.

The response rate for the 01RG12M assessment was 25.00% (n=5).


The response rate to the partner baseline assessments in both prospective (02PGBA)

and retrospective cohorts (02RGBA) was 70.37% (n=19) in prospective partners and

66.66% (n=2) in retrospective partners. The administration of the six-month

(02RG6M) and 12-month (02RG12M) prospective partner assessments was 44.44%

30

(n=12) and 37.04% (n=10) respectively. Within the retrospective partner group there

were no six-month (02RG6M) or 12-month (02RG12M) returns.

Table 6: Response rates (all groups)


Prospective Group

(PG)

Retrospective

Group (RG)

Prospective Group

(PG)

Retrospective

Group (RG)

Baseline

Assessment (BA)

Administered 199* 20 27 3

Returned (Rate) 112

(56.28%)

13

(65.00%)

19

(70.37%)

2

(66.66%)

Returns as % of

previous N/A N/A N/A N/A

Six-month

Assessment (6M)

Administered 199 20 27 3

Returned (Rate) 29

(14.57%)

8

(40.00%)

12

(44.44%)

0

(0.00%)

Returns as % of

previous 25.89% 61.53% 63.16% 0%

12-month

Assessment

(12M)

Administered 199 20 27 3

Returned (Rate) 23

(11.56%)

5

(25.0%)

10

(37.04%)

0

(0.00%)

Returns as % of

previous 79.31% 62.50% 83.33% 0%

*Baseline Assessment (BA) for the Patient Study Prospective Group was administered at the DMRC

Demographics

Ethnicity

The majority of patient participants enrolled in the patient study (both prospective and

retrospective cohorts) identified themselves as being ‘White: British’ (89.9%, n=197).

The remainder of the participants identified themselves as being either ‘White: Irish’

(2.5%, n=5), ‘White: Other’ (1.5%, n=3,) or as being either ‘Asian or Asian British’

(3.0%, n=6) or ‘Black or Black: British: African’ (3.6%, n=8). The distribution of

ethnic origin was roughly in line with that reported by the DASA (2012) in respect of

UK Regular Forces at 1st April 2011 where, for the NATO ranks of OF3 and below,

91.36% (n=164,980) were identified as being ‘White’ and 6.71% were reported as

being ‘Black and Minority Ethnic’. Those participants reporting their ethnicity as

‘White: Other’ were exclusively South African and, while the use of UK Census

categories for ethnicity is not particularly useful in identifying Nepalese participants,

the majority of those identifying themselves as ‘Asian or Asian British: Other’ were

31

Ghurkha participants (2.28%, n=5). A summary of patient participant ethnicity is

presented in Table 7: Ethnicity of participants (01PG) and (01RG).

Table 7: Ethnicity of participants (01PG) and (01RG)

Frequency Percent Valid Percent Cumulative Percent

White: British 197 89.9 89.9 89.9

White: Irish 5 2.3 2.3 92.2

White: Other 3 1.4 1.4 93.6

Asian or Asian British: Other 6 2.7 2.7 96.4

Black or Black British: African 8 3.6 3.6 100.0

Total 219 100.0 100.0

Within the partner study, 86.6% (n=26) of participants identified themselves as

‘White: British’. One partner participant identifying herself as being ‘Asian or Asian

British: Other’ and was Nepalese in origin and the partner of a Ghurkha patient

participant. A summary of partner participant ethnicity is presented in Table 8.

Table 8: Ethnicity of participants (02PG) and (02RG)


White: British 26 86.6 86.6 86.60

White: Irish 1 3.33 3.33 89.93

White: Other 1 3.33 3.33 93.26

Asian or Asian British: Other 1 3.33 3.33 96.59

Black or Black British: African 1 3.33 3.33 100.0

Total 30 100.0 100.0

Gender

The vast majority of participants within the patient study were male (98.6%, n=216).

Only three female participants took part in the patient study (1.4%). This distribution

of gender is not representative of the overall distribution of gender in UK Regular

Forces11 but is more likely to be representative of the gender distribution of those

undertaking combat duties (see Table 9: Gender and incident type). Only one of the

female participants in the patient study sustained injuries on military operations and

those injuries were sustained during a mortar attack on Shaibah Logistics Base (SLB)

rather than on foot patrol or while deployed in forward areas (Patrol Base (PB) or

Forward Operating Base (FOB)).

11 At 1 April 2011 there were 168,500 (90.4 per cent) male and 17,850 (9.6 per cent) female UK Regular Forces personnel.

32

Table 9: Gender and incident type (01PG) and (01RG)

CDS3 - Type of incident

Total Combat related Non-combat-related

CDS1 - Gender Male 179 30 209

Female 1 2 3

Total 180 32 212

Participants within the partner study were exclusively female. While there were three

female participants in the patient study, only one of them consented to the HCF

contacting their partner and, in this case, the male partner did not respond to the

invitation letter or subsequent follow-up.

Age

Patient participants ranged in age between 19 and 56 years on first admission to the

DMRC (range=37 years, minimum age 19 years and maximum age 56 years.). The

mean age of patients at first admission to the DMRC was 26.33 years (see Table 10:

Age at first admission to the DMRC (01PG) and (01RG)). At 1st April 2011, the

mean age of those serving in the UK Regular Forces as ‘Other Ranks’ was 29 years

and as ‘Officers’, 37 years of age. The mean age of patient participants is noticeably

lower therefore than that of the general UK Regular Forces figure, but this is most

likely a reflection of the ‘junior’ nature (in both age and rank) of those deployed in

forward areas on operations. A summary of age and age distribution is presented in

Figure 3: Age at first admission to DMRC (01PG) and (01RG).

Table 10: Age at first admission to the DMRC (01PG) and (01RG)

N Valid 210

Missing 9

Mean 26.33

Range 37

Minimum 19

Maximum 56

Within the partner study (02PG) and (02RG) the mean age of participants was 28.4

years (range=25 years, minimum age 19, maximum age 44).

33

Figure 3: Age at first admission to DMRC (01PG) and (01RG)

Relationship Status

Overall, within both prospective and retrospective patient cohorts 125 participants

(64.8%) regard themselves as being in ‘committed relationship’ at baseline and either

describe themselves as being ‘married’ (27.2%, n=34), ‘living with a partner’ (10.4%,

n=13) or ‘in a long-term relationship’ (27.2%, n=34). The remaining 35.2% of

participants (n=44) report being ‘Single’, ‘Separated’ or ‘Divorced’. A summary of

the relationship status of patient participants is presented in Table 11: Relationship

status (01PG) and (01RG) (n=226) and the distribution of relationship status of

participants (less those failing to report the relationship status) is presented in Figure

4: Relationship status (01PG) and (01RG) (n=125).

Table 11: Relationship status (01PG) and (01RG) (n=226)

Relationship Status Frequency Percent Valid Percent Cumulative Percent

Valid

Married 34 15.0 27.2 27.2

Living with a partner (cohabiting) 13 5.8 10.4 37.6

In a long term relationship 34 15.0 27.2 64.8

Single (never married) 36 15.9 28.8 93.6

Separated 4 1.8 3.2 96.8

Divorced 4 1.8 3.2 100.0

Total 125 55.3 100.0

Missing System 101 44.7

Total 226 100.0

34

Figure 4: Relationship status (01PG) and (01RG) (n=125)

Financially dependent children

The definition of ‘financially dependent children’ is difficult and does not rely solely

upon residential status. Participants were asked, firstly, whether or not they regarded

themselves as having any financially dependent children. If they answered ‘yes’ they

were then asked: how many financially dependent children they had; their ages; their

gender and whether or not the children lived with them. The majority of patient

participants reported that they did not have financially dependent children (74%,

n=91). The numbers of children reported by the remaining 26% (n=32) of

participants varied from one child to six children (mean number of children per

family=1.81). The ages of the reported children ranged from two weeks to 23 years

of age, with a mean age of 6.5 years. A summary of ‘family size’ and distribution of

financially dependent children is presented in Table 12: Financially dependent

children (01PG) and (01RG).

35

Table 12: Financially dependent children (01PG) and (01RG)


Valid

0 91 41.6 74.0 74.0

1 15 6.8 12.2 86.2

2 12 5.4 9.8 96.0

3 3 1.4 2.4 98.4

4 1 .5 .8 99.2

6 1 .5 .8 100.0

Total 123 56.2 100.0


Highest level of education

Within the patient study, participants were asked to report their highest level of

education attainment. The majority of participants (70.2%, n=87) reported that the

completion of secondary school was their highest level of education. Of those

reporting the completion of secondary school as their highest level of educational

achievement, almost one quarter reported leaving school with A-Level or equivalent

qualifications (24.1%, n=21).

Figure 5: Highest level of educational achievement (01PG) and (01RG)

Overall, 29.8% of patient participants reported completing post-secondary education,

18.5% (n=23) completed further education gaining a college certificate, diploma or

equivalent qualification, and 10.5% (n=13) completed a programme of higher

education to certificate (0.8%, n=1), degree (8.9%, n=11) or to higher degree (0.8%,

n=1) level. A significant percentage of participants (13.7%, n=17) left secondary

school prior to sixteen years of age with no formal qualification. A summary of these

36

results can be found in Figure 5: Highest level of educational achievement (01PG)

and (01RG) and Table 13: Highest level of educational achievement (01PG) and

(01RG).

Table 13: Highest level of educational achievement (01PG) and (01RG)


Valid Left school before age 16 (No

formal qualifications)

17 7.8 13.7 13.7

Left school with GCSE/CSE/O-

Level or equivalent

49 22.4 39.5 53.2

Left school with A-Level or

equivalent qualification(s)

21 9.6 16.9 70.2

College certificate or diploma 22 10.0 17.7 87.9

University degree 11 5.0 8.9 96.8

Higher university degree (e.g. MSc,

PhD)

1 .5 .8 97.6

City and Guilds Certificate 1 .5 .8 98.4

Overseas Qualification (Nepal) 1 .5 .8 99.2

Certificate of Higher Education 1 .5 .8 100.0

Total 124 56.6 100.0


Total 219 100.0

Within the partner study, 23.8% (n=5) of participants reported the completion of

secondary school as their highest level of educational achievement. Of those partners

who reported completion of secondary school as their highest level of educational

achievement only one participant reported having left school with A-Level or

equivalent qualifications (n=1, 4.8%).

37

Figure 6: Highest level of educational achievement (02PG)

In contrast to the patient participants, a higher percentage of partner

participants (51.8%, n=14) reported further education or higher education as their

highest level of educational achievement. Within this group, a significantly higher

number of participants identified completion of higher education to degree level

(38.1%, n=8) or to post-graduate certificate level (4.8%, n=1). While none of the

partner participants reported having left secondary school without any formal

qualification, one participant reported the completion of GCSE/CSE/O-Level or

equivalent in Further Education.

Table 14: Highest level of educational attainment (02PG)


Valid Left school with GCSE/CSE/O-

Level or equivalent

4 14.8 19.0 19.0

Left school with A-Level or

equivalent qualification(s)

1 3.7 4.8 23.8

College certificate or diploma 5 18.5 23.8 47.6

University degree 8 29.6 38.1 85.7

Overseas Qualification (Nepal) 1 3.7 4.8 90.5

GCSE/CSE/O-Level or equivalent

in Further Education

1 3.7 4.8 95.2

Postgraduate Certificate 1 3.7 4.8 100.0

Total 21 77.8 100.0


Total 27 100.0

38

Employment status (02PG) and (02RG)

Partner participants were asked about their current occupation, employment status and

whether or not they worked full- or part-time (Table 15: Employment status (02PG)

and (02RG)). The majority of partner participants indicated that they were employed

full-time (67%, n=14) and a significant proportion of those partners further reported

working in a professional or managerial role (64%, n=9). Four partner participants

identified themselves as being in full-time education (19%) while three reported

working in a semi-skilled role. The remaining number of partner participants reported

being either unemployed (n=2) or being employed as a house-person.

Table 15: Employment status (02PG) and (02RG)

Do you work (or study)?

Total Full-Time Part-Time Not Applicable

What is your employment

status?

Professional/Managerial 9 1 0 10

Semi-Skilled 1 2 0 3

Student 4 0 0 4

House-person 0 0 2 2

Unemployed 0 0 2 2

Total 14 3 4 21

Military Service

Both prospective and retrospective patient participants were asked if they were

currently serving in the Armed Forces and, if they were, to which branch of the

Armed Forces they belonged (see Table 16: Military service by type). Within the

patient study, those in the prospective cohort, as first time in-patient admissions to the

DMRC, were all currently serving in the Armed Forces. The retrospective cohort, by

contrast, having been recruited six to 24 months after discharge from the DMRC,

consisted a number individuals who were ‘ex-forces’ (2.4%, n=3) in addition to those

individuals who where currently still in the Armed Forces. Of those participants still

serving in the Armed Forces, 91.2% (n=114) were either in regular service or on full-

time reserve service (FTRS). Members of the Reserve Forces, i.e. Territorial Army

(TA), Royal Auxiliary Air Force (RAuxAF), Royal Naval Reserve (RNR) or Royal

Marine Reserve (RMR) formed 6.4% (n=8) of the overall patient participant sample.

Those patient participants identifying themselves as members of the Reserve Forces

were all members of the Territorial Army.

39

Figure 7: Military service by type

Table 16: Military service by type

Frequency Percent Valid Percent Cumulative

Percent

Valid A regular or on full-time reserve

service (FTRS)

114 50.4 91.2 91.2

A volunteer reserve (e.g. TA,

RAuxAF, RNR or RMR (mobilized

or not))

8 3.5 6.4 97.6

Ex forces 3 1.3 2.4 100.0

Total 125 55.3 100.0


Total 226 100.0

Branch of service

All branches of the Armed Forces were represented in the study (see Table 17: Branch

of service). For the purposes of the report, and to ensure comparability with the

existing KMHCR ‘Phase 2’ dataset, the Army and the Royal Marines were regarded

as one group and constituted the majority of participants with complex trauma injuries

(96%, n=120). Members of the Royal Navy represented 1.6% (n=2) of those with

complex-trauma injuries (all non-combat-related). Royal Air Force personnel

belonging to the Royal Air Force Regiment presented with a combination of combat-

related and non-combat-related injury and constituted 2.4% of the sample (n=3).

40

Figure 8: Branch of service

Table 17: Branch of service


Valid Royal Navy 2 .9 1.6 1.6

Army and Royal Marines 120 54.8 96.0 97.6

Royal Air Force 3 1.4 2.4 100.0

Total 125 57.1 100.0


Total 219 100.0

Current rank

The rank range of those serving in the Army and Royal Marines was Private (Pte),

(NATO rank OR1) to Captain (Capt), (NATO rank OF2). While, as is traditional,

Private Soldiers of different cap badges and regiments (as well as of different Corps,

trades or occupations) report their rank differently depending on their Regimental or

Corps affiliations. The rank of Private Soldier was used to describe individuals

holding rank equivalent of NATO rank OR1, e.g. Gunner, Drummer, Ranger, Marine,

Rifleman etc. Within the Army and Royal Marine grouping 44.0% (n=55) of

participants reported their rank as being equivalent to Private Soldier. Junior Non-

Commissioned Officers (JNCOs’, i.e. Lance Corporals and Corporals) constituted

34.4% (n=43) of the Army and Royal Marine group and Senior Non-Commissioned

Officers (SNCOs’, Sergeant to Warrant Officer Class 1) constituted 10.4% (n=13).

41

Junior Officers (Second Lieutenant (2Lt) to Captain (Capt)) made up 8.8% (n=11) of

the sample (see Table 18: Current rank).

Royal Naval participants (n=2) were ranked Petty Officer (PO) and Warrant

Officer Class 1 (WO1) and comprised 1.6% of the sample and the Royal Air Force

participants reporting their rank between Senior Aircraftman (SAC) and Lance

Corporal (LCpl).

Figure 9: Current rank (or rank at completion of service)

Table 18: Current rank


Valid Pte 55 24.3 44.0 44.0

AC/LAC/SAC/JT 1 .4 .8 44.8

L/Cpl to Cpl 43 19.0 34.4 79.2

Sgt to WO1 13 5.8 10.4 89.6

2Lt to Capt 11 4.9 8.8 98.4

PO to WO1 2 .9 1.6 100.0

Total 125 55.3 100.0 100.0


Total 226 100.0

Length of Service

Those patient participants reporting that they currently served as regular members of

the Armed Forces or that they were undertaking Full-time Reserve Service (FTRS)

had a mean length of service of 6.88 years (range from one to 23 years of service).

Those patient participants serving in the Reserve Forces had periods of service

42

ranging from two to 35 years of service and the mean length of service was 11.71

years.

The length of service for regular members of the Armed Forces and for those serving

on FTRS was biased toward the lower end of the range and 47.5% of patient

participants had served in the Armed Forces for five years or fewer and 20.3% had

served for two years or fewer.

Table 19: Length of service

Length of Service

(Regular/FTRS)

(YEARS)

Length of Service

(Reservist)

(YEARS)

N Valid 118 7

Missing 101 212

Mean 6.8814 11.7143

Range 22.00 33.00

Minimum 1.00 2.00

Maximum 23.00 35.00

Figure 10: Length of service (01PG) and (01RG) - Regular and FTRS

43

Figure 11: Length of service (01PG) and (01RG) - Reservists

Type and nature of incident

The majority of patient participants within the study were admitted to the DMRC as a

result of a combat-related injury (84.9%, n=180) and non-combat-related injury

accounted for the remaining 15.1% (n=32) of admissions where the type of incident is

known. Within the retrospective patient participant group (01RG) there were a

number of individuals who failed to report the type of incident causing their injuries

and where the non-availability of medical records (from which this information could

have been recovered) has resulted in unknown or ‘missing’ values (n=7, 3.2%). Table

20: Type of incident (01PG) and (01RG) and Figure 12: Type of incident (01PG) and

(01RG)) present the distribution of combat-related and non-combat-related injury.

Table 20: Type of incident (01PG) and (01RG)


Valid Combat related 180 82.2 84.9 84.9

Non-combat-related 32 14.6 15.1 100.0

Total 212 96.8 100.0


Total 219 100.0

44

Figure 12: Type of incident (01PG) and (01RG)

Closer examination of the nature of the incident indicates that 68.4% (n=145) of

patient participants (both 01PG and 01RG) sustained combat-related injuries resulting

from explosion/blast causes, i.e. Improvised Explosive Device (IED), Rocket

Propelled Grenade (RPG), Anti-Personnel Mine (APM) or through Grenade strike.

Thirty five patient participants (16.5%) report having been injured as a result of a

Gunshot Wound (GSW). Within the non-combat-injury category incidents involving

vehicles (predominantly motorcycles) were the most common cause of injury (6.6%,

n=14). A summary of the reported causes of injury in the patient participant study is

presented in Table 21: Nature of incident (01PG) and (01RG) and in Figure 13:

Nature of incident (01PG) and (01RG).

45

Table 21: Nature of incident (01PG) and (01RG)


Valid Explosion / Blast (IED, RPG, APM,

Grenade)

145 66.2 68.4 68.4

Fragment 1 .5 .5 68.9

Bullet 35 16.0 16.5 85.4

Fall 5 2.3 2.4 87.7

Vehicle 14 6.4 6.6 94.3

Sport 7 3.2 3.3 97.6

Other: Alcohol Related 1 .5 .5 98.1

Other 4 1.8 1.9 100.0

Total 212 96.8 100.0


Total 219 100.0

Figure 13: Nature of incident (01PG) and (01RG)

Range of injuries

The range of injuries sustained by patient participants admitted to the DMRC is broad

and diverse. In order to best describe the range of injuries for the purpose of this

report, participant injuries are identified using following categories: ‘Gunshot Wound’

(GSW); ‘Spinal Injury’ (SI); ‘Blast/Fragmentation Injuries’ (BFI); ‘Single Traumatic

Amputation’, ‘Double Traumatic Amputation’ and ‘Triple Traumatic Amputation’

(STA, DTA and TTA); ‘Other’ injuries, and ‘Unknown’.

The three largest categories of injury are single traumatic amputation

(44.22%), blast and fragmentation injuries (39.2%) and gunshot wounds (36.12%).

46

Double traumatic amputation accounts for 34.17% of the injuries sustained by the

study group and triple traumatic amputation accounts for a further 9.4% of injuries.

Spinal injuries and ‘Other’ injuries account for 33.62% of admissions to the DMRC

during the study period. The category ‘Other’ includes sporting injuries; injuries

related to Road Traffic Accident (RTA), burns, falls and crush injuries.

Figure 14: Injury category

Primary outcome variables – ‘independent samples’

The primary outcome variables identified for both patient and partner studies were the

General Health Questionnaire (GHQ-12), the civilian version of the Post-Traumatic

Checklist (PCL-C) and the Short-Form Health Survey (SF-36). While the SF-36

measure has been designed to capture data regarding a range of health concepts (both

physical and mental), it was identified that, in respect of the military rehabilitation

population, it lacked the sensitivity and specificity required to provide meaningful

results and the DMRC discontinued its clinical use during the early stages of this

research study. Consequently, the partial SF-36 dataset will be excluded from this

analysis.

The analysis of the remaining measures is intended to fulfil the primary

descriptive aims of the study and to provide an estimate of the prevalence of general

and trauma-related psychopathology and quality of life. The resilience status of

participants is to be estimated using the Dispositional Resilience Scale (DRS-15) and

the Connor-Davidson Resilience Scale (CDRIS-10).

36, 18%

44, 22%

34, 17%

9, 4%

39, 20%

10, 5%

23, 12%

4, 2%

Gunshot Wound

Single Traumatic Amputation

Double Traumatic Amputation

Triple Traumatic Amputation

Blast and Fragmentation Injuries

Spinal Injuries

Other

Unknown

47

PCL-C

The civilian version of the Post-Traumatic Checklist (PCL-C) was used at baseline, at

six months and again at 12 months to estimate the prevalence of PTSD within each of

the study groups. Within this study the PCL-C was used as a screening, rather than as

a diagnostic tool, and the total severity score for each participant was calculated and

compared against a predetermined normative threshold. For the purpose of this report

a cut-off score of 50 was used as the normative threshold and those participants

scoring 50 or more were taken to have met the screening criteria for PTSD. A cut-off

score of 50 was used to ensure consistence with the data reported by KMHCR.

Considering the baseline, six-month and 12-month assessments of the PCL-C as

independent samples provides an effective estimate of the prevalence of PTSD at each

stage.

Patient participants (01PG)

The baseline assessment of PCL-C for the prospective patient group (01PG) returned

a mean score of 31.27 (range=58, scores from 17 to 75). Of the total number of

participants completing the PCL-C assessment at baseline (n=108) 11 participants

achieved scores greater than, or equal to, 50 providing an estimated prevalence of

PTSD within the group of 10.18% (see Figure 15: PCL-C - Baseline (01PG)). While

the six-month assessment of PCL-C returned a higher mean score of 35.28 (range=65,

scores from 17 to 82) it did so for a considerably smaller number of participants

(n=29). Six patient participants achieved scores greater than, or equal to, 50 yielding

an estimated prevalence of 20.69% at six months (see Figure 16: PCL-C - Six months

(01PG)). At 12 months the total number of participants returning completed PCL-C

questionnaires was 23 and the mean PCL-C score was 37.82 (range=64, scores from

18 to 82). Four of the patient participants achieved scores greater than, or equal to, 50

providing an estimated PTSD prevalence of 18.18% at this stage (See Figure 17:

PCL-C - 12 months (01PG)).

Table 22: PCL-C – Baseline, six months and 12 months (01PG)

Baseline Six Months 12 Months

N Valid (Meets criteria)* 108 (11) 29 (6) 22 (4)

Missing 91 170 177

Mean 31.27 35.28 37.82

Range 58 65 64

Minimum 17 17 18

Maximum 75 82 82

*Screening criteria for PTSD defined as a score on PCL-L of ≥ 50

48

Figure 15: PCL-C - Baseline

(01PG)

Figure 16: PCL-C - Six months

(01PG)

Figure 17: PCL-C - 12 months

(01PG)

Partner participants (02PG)

The PCL-C was also used to estimate the prevalence of PTSD within the partner

group. The baseline assessment of PCL-C for the prospective partner group (02PG)

returned a mean score of 34.07 (range=33, scores from 21 to 54). Of the total number

of participants completing the PCL-C assessment in the partner group at this stage

(n=14) only one achieved a score greater than, or equal to, 50 providing an estimated

prevalence of PTSD of 7.14% (see Figure 18: PCL-C - Baseline (02PG)). The six-

month assessment of PCL-C in partners returned a mean score of 37.17 (range=41,

scores from 17 to 58). At six months however, the number of partner participants

meeting the screening criteria for PTSD increased to four, and yields an estimated

prevalence of 33.33% (Figure 19: PCL-C - Six months (02PG)). At 12 months the

mean PCL-C score in partner participants was 30.20 (range=41, scores from 17 to 58)

and the number of those meeting the screening criteria for PTSD had returned to one,

providing an estimated PTSD prevalence of 10.00% (Figure 20: PCL-C - 12 months

(02PG)). A summary for partner participants is presented in Table 23: PCL-C -

Baseline, six months and 12 months (02PG).

Table 23: PCL-C - Baseline, six months and 12 months (02PG)


N Valid (Meets criteria)* 14 (1) 12 (4) 10 (1)

Missing 12 14 16

Mean 34.07 37.17 30.20

Range 33 41 41

Minimum 21 17 17

Maximum 54 58 58

*Screening criteria for PTSD defined as a score on PCL-L of ≥ 50

49

Figure 18: PCL-C - Baseline

(02PG)

Figure 19: PCL-C - Six months

(02PG)

Figure 20: PCL-C - 12 months

(02PG)

GHQ-12

The 12-item General Health Questionnaire (GHQ-12) is used to identify psychiatric

‘caseness’ in participants and is sensitive to short-term mental health disorder rather

than to the long-standing attributes of the respondent. The GHQ-12 is scored by

calculating the sum of the scores for each individual scale item and then comparing

the total score achieved against a pre-determined threshold12. There are two methods

of scoring the GHQ-12, the Likert method (where individual items are scored 0-1-2-3)

and the GHQ (binary) method (where items are scored 0-0-1-1). While the test

authors (Goldberg et al, 1997) advocate the use of the GHQ (0-0-1-1) scoring method

for identifying caseness, both methods have been included within this report. As with

the PCL-C, the GHQ-12 was administered at baseline, at six months and at 12 months

in each of the four study groups in order to produce an estimate of the prevalence of

common mental health disorder. While the GHQ-12 is not sensitive enough to

identify the nature of the common mental health disorder it is able to identify caseness

in participants, and this allows an estimate of prevalence to be made.

The recommended threshold level for GHQ-12 is 11/12 (max score 36) using

the Likert method and 1/2 (max score 12) using the GHQ method. For the purpose of

this report, those participants scoring ≥ 12 using the Likert method or ≥ 2 using the

GHQ method were deemed to have met the criteria for caseness. Once again, the

baseline, six-month and 12-month assessments of the GHQ-12 will be considered as

independent samples to provide an effective estimate of prevalence of common

mental health disorder at each stage.

12 Within GHQ-12 each of the 12 scale items have a 4 point scoring system that ranges from a 'better/healthier than normal'

option, through a 'same as usual' and a 'worse/more than usual' to a 'much worse/more than usual' option. The exact wording will

depend upon the particular nature of the item.

50

Patient participants (01PG)

At baseline, the prospective patient group (01PG) returned mean GHQ-12 scores of

13.17 (Likert) and 3.62 (GHQ). Within the group (n=110) 57 individuals met the

criteria for caseness using the Likert method and 73 met the criteria using the

recommended GHQ scoring method (see Figure 21: GHQ-12 - Baseline using Likert

and GHQ scoring methods (01PG)) producing an estimate of the prevalence of

common mental health disorders within the prospective patient group of 51.81%

(Likert) or 66.36% (GHQ).

Figure 21: GHQ-12 - Baseline using Likert and GHQ scoring methods (01PG)

At six months the assessment of GHQ-12 returned mean scores of 13.61 (Likert) and

3.64 (GHQ) within the group (n=28) and again the majority of participants met the

criteria for caseness (n=18 using Likert method and n=16 using the GHQ method)

producing an estimate of prevalence of common mental health disorder at six months

of 64.29% (Likert) and 57.14% (GHQ).

51

Figure 22: GHQ-12 - Six-months using Likert and GHQ scoring methods (01PG)

At 12 months the calculated mean scores for GHQ-12 remained high 13.00

(Likert) and 2.74 (GHQ) and 12 patient participants met the criteria set for caseness

from an overall group of 23. The estimate of prevalence of common mental health

disorders at 12 months was the same for both Likert-scoring and GHQ scoring

methods (52.17%).

Table 24: GHQ-12 - Baseline, six months and 12 months (01PG)) provides a

summary of GHQ-12 scores at each stage.

52

Figure 23: GHQ-12 - 12-months using Likert and GHQ scoring methods (01PG)

Table 24: GHQ-12 - Baseline, six months and 12 months (01PG)


GHQ12

TOTAL

(Likert)

GHQ12

TOTAL

(GHQ)

GHQ12

TOTAL

(Likert)

GHQ12

TOTAL

(GHQ)

GHQ12

TOTAL

(Likert)

GHQ12

TOTAL

(GHQ)

N Valid (Meets criteria)* 110 (57) 110 (73) 28 (18) 28 (16) 23 (12) 23 (12)

GHQ Caseness 51.81% 66.36% 64.29% 57.14% 52.17% 52.17%

Missing 89 89 171 171 176 176

Mean 13.17 3.62 13.61 3.64 13.00 2.74

Range 34 12 27 12 31 12

Minimum 2 0 4 0 5 0

Maximum 36 12 31 12 36 12

*Criteria for GHQ-12 caseness defined as scores of 1/2 (max score 12) using the GHQ method (0-0-1-1) and 11/12 (max score 36) using the Likert method (1-2-3-4).

Partner participants (02PG)

The prospective partner group (02PG) returned mean GHQ-12 scores of 16.00

(Likert) and 4.35 (GHQ) at baseline and within the group (n=20) 17 individuals met

the criteria for caseness using the Likert method and 13 met the criteria using the

recommended GHQ scoring method (see Figure 24: GHQ-12 - Baseline using Likert

and GHQ scoring methods (02PG)) producing an estimate of prevalence of common

mental health disorder of 85.00% (Likert) or 65.00% (GHQ).

53

Figure 24: GHQ-12 - Baseline using Likert and GHQ scoring methods (02PG)

At six months the assessment of GHQ-12 returned mean scores of 15.25 (Likert) and

4.42 (GHQ) within the group (n=12) and again the majority of participants met the

criteria for caseness (n=10 using Likert method and n=8 using the GHQ method)

producing an estimated prevalence of common mental health disorder at six months of

83.33% (Likert) and 66.66% (GHQ).

Figure 25: GHQ-12 - Six-months using Likert and GHQ scoring methods (02PG)

At 12 months the calculated mean scores for GHQ-12 within the partner group

were 15.00 (Likert) and 4.11 (GHQ). Four patient participants met the caseness

criterion using the Likert scoring method and five met the criterion using the GHQ

scoring method from an overall group of nine participants. Estimated prevalence of

common mental health disorders at 12-months was therefore 44.44% (Likert) and

55.55% (GHQ). Table 25: GHQ-12 - Baseline, six-months and 12-months (02PG)

provides a summary of GHQ-12 scores at each stage.

54

Figure 26: GHQ-12 - 12-months using Likert and GHQ scoring methods (02PG)

Table 25: GHQ-12 - Baseline, six-months and 12-months (02PG)


GHQ12

TOTAL

(Likert)

GHQ12

TOTAL

(GHQ)

GHQ12

TOTAL

(Likert)

GHQ12

TOTAL

(GHQ)

GHQ12

TOTAL

(Likert)

GHQ12

TOTAL

(GHQ)

N Valid (Meets criteria)* 20 (17) 20 (13) 12 (10) 12 (8) 9 (4) 9 (5)

GHQ Caseness 85.00% 65.00% 83.33% 66.66% 44.44% 55.55%

Missing 6 6 14 14 17 17

Mean 16.00 4.35 15.25 4.42 15.00 4.11

Range 20 12 21 11 20 11

Minimum 6 0 5 0 7 0

Maximum 26 12 26 11 27 11

*Criteria for GHQ-12 caseness defined as scores of 1/2 (max score 12) using the GHQ method (0-0-1-1)

and 11/12 (max score 36) using the likert method (1-2-3-4).

DRS-15

The Dispositional Resilience Scale (DRS-15) is a brief 15-item scale used to measure

the three personality traits of hardiness, i.e. commitment, control and challenge in

both patient participant groups (01PG) and (01RG). The DRS-15 measure was

administered in order to provide a baseline measure of the hardiness of participants.

The baseline assessment of prospective patient participants (n=105) returned a mean

DRS-15 score of 26.24 with a SD of 4.389 (Range=13 to 35).

55

CDRIS-10

The Connor-Davidson Resilience Scale-10 (CDRIS-10) is a 10-item scale that

measures the ability of participants to cope with adversity. The CDRIS-10 scale was

administered at each stage of the participant patient assessments (01PG) and (01RG)

and the mean scores at each stage calculated. Comparison of mean CDRIS-10 scores

at baseline, six months and 12 months will provide insight into the role and effect of

resilience as well as the effect of traumatic injury upon resilience.

At baseline assessment the mean CDRIS-10 score for the prospective patient

group (01PG) was 31.33 (SD= 7.220). At six months the mean resilience of the group

had decreased to 28.72 (SD=8.799) and at 12 months had increased slightly to 28.87

(SD=8.915). Once again, the number of participants returning completed CDRIS-10

scales decreased significantly over time (n=109 at baseline, n=29 at six months and

n=23 at 12 months). Table 26 CDRIS-10 - Baseline, six-months and 12-months

(01PG)and Figure 27: CDRIS-10 - Baseline, six-months and 12-months (01PG)

provide a summary of CDRIS-10 scores.

Table 26 CDRIS-10 - Baseline, six-months and 12-months (01PG)


N Valid 109 29 23

Missing 90 170 176

Mean 31.33 28.72 28.87

Std. Deviation 7.220 8.799 8.915

Range 35 35 39

Minimum 5 5 1

Maximum 40 40 40

56

Figure 27: CDRIS-10 - Baseline, six-months and 12-months (01PG)

Primary outcome variables – ‘Paired samples’

In order to answer effectively the first two research questions regarding the long-term

effects of rehabilitation and the factors which either compromise or facilitate the

durability of therapeutic gain, a strict panel of only those participants who responded

to the questionnaires at all three stages (baseline, six months and 12 months) was

required. Due to poorer response rates at six months and at 12 months there were

only 12 such participants, and it should be noted that due to the small sample size it is

difficult to draw strong conclusions from the data.

Repeated Measures Analysis (RMA) was performed on PCL-C, CDRIS-10

and GHQ-12 scores for the panel of 12 participants. For all three measures, there was

no significant time effect observed. In other words, average levels of these measures

over the three time periods fail to show any significant pattern. Friedman’s non-

parametric tests were also performed since the sample size is small. Non-parametric

tests also indicate that there is no significant time effect for these measures.

PCL-C and CDRIS-10

Figure 28 and Figure 29 show the pattern of mean and median PCL-C scores along

with those of the Connor-Davidson Resilience scale (CDRIS-10) for the prospective

patient participant group (01PG). While higher scores on the PCL-C indicate higher

severity of PTSD, higher CDRIS-10 scores indicate greater resilience in participants.

57

Figure 28: PCL-C and CDRIS-10 - Means for panel sample (n=12)

Figure 29: PCL-C and CDRIS-10 - Medians for panel sample (n=12)

Amongst the 12 participants represented in this sample one participant shows a very

large PCL-C score (82). This partly explains the reason for the 12-month mean PCL-

C score being the highest (Figure 28: PCL-C and CDRIS-10 - Means for panel sample

(n=12)). The means indicate that there is a steady worsening of PTSD over the

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follow-up period; however, focusing on medians rather than means (Figure 29: PCL-

C and CDRIS-10 - Medians for panel sample (n=12)) shows that while there is a

worsening of PTSD at the six month point, during the next six months, the average

level of PTSD (as represented by the median PCL-C score) falls back to a level

similar to baseline. A similar explanation holds for the CDRIS-10 also in that there is

one participant with a very low score (1) at the 12-month assessment which accounts

for a further drop in the mean level at this point (Figure 28: PCL-C and CDRIS-10 -

Means for panel sample (n=12)) rather than a slight improvement as indicated by the

median level.

Following the profile depicted by medians, it may be reasonable to conclude

that over a six-month period there is a worsening of PTSD and deterioration in

resilience, but by another six months these outcome measures return to baseline

levels.

PTSD and GHQ

The following figures (Figure 30 and Figure 31) show the pattern of median and mean

GHQ scores overlaid on the corresponding PTSD scores.

Figure 30: PCL-C and GHQ-12 Medians for panel sample (n=12)

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Figure 31: PCL-C and GHQ-12 Means for panel sample (n=12)

Both the median (Figure 30: PCL-C and GHQ-12 Medians for panel sample (n=12))

and mean scores (Figure 31: PCL-C and GHQ-12 Means for panel sample (n=12)) of

GHQ indicate that over the 12-month period from baseline, there has been a steady

improvement in general health, although PTSD, at best, has not changed.

PTSD – Paired comparisons

There is tentative evidence to suggest that there may have been a significant

worsening of PTSD during the first six months of the study. The tables below (Table

27: Paired samples statistics and Table 28: Paired samples tests) show parametric

comparisons among all possible pairings of the three study periods. As can be seen,

there is a significant (p=0.015) increase in mean PTSD score from 25.38 at baseline to

33.57 at the six-month assessment. This is also confirmed by a non-parametric test

(Wilcoxon Signed Ranks test with 2-tailed asymptotic significance of 0.015). Given

that the baseline and 12-month comparison does not show a significant difference,

this may suggest that experience of PTSD worsens in the short term before levelling

off.

These observations must be treated with caution since only a few cases used within a

pairing appear consistently in all pairings. However, the median levels of PTSD as

shown in Figure 29: PCL-C and CDRIS-10 - Medians for panel sample (n=12) and

28.3333.00 35.67

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Figure 30: PCL-C and GHQ-12 Medians for panel sample (n=12) appear to

substantiate this finding.

Table 27: Paired samples statistics (PCL-C)

PTSD Mean N Std. Deviation Std. Error Mean

Pair 1 Baseline 25.38 21 7.839 1.711

6-month 33.57 21 13.710 2.992

Pair 2 6-month 35.71 14 17.652 4.718

12-month 39.00 14 20.138 5.382

Pair 3 Baseline 29.00 19 11.609 2.663

12-month 35.05 19 16.067 3.686

Table 28: Paired samples tests (PCL-C)

Pair 1 Pair 2 Pair 3

PTSD Baseline – 6month 6month – 12month Baseline - 12month

Paired Differences

Mean -8.190 -3.286 -6.053

Std. Deviation 14.073 11.180 16.827

Std. Error Mean 3.071 2.988 3.860

95% Confidence

Interval of the

Difference

Lower -14.597 -9.741 -14.163

Upper -1.784 3.169 2.058

t -2.667 -1.100 -1.568

df 20 13 18

Sig. (2-tailed) .015 .291 .134

CDRIS-10 – Paired comparisons

Paired comparisons were also done on mean levels of the CDRIS-10 scores (Table 29:

Paired samples statistics (CDRIS-10) and Table 30: Paired samples tests (CDRIS-

10)). As in the case with PTSD, a significant worsening was observed at the six-

month assessment as measured by mean levels of the CDRIS-10 measure. This is

also confirmed by the non-parametric equivalent – the Wilcoxon Signed Ranks Test

with asymptotic significance of 0.036.

61

Table 29: Paired samples statistics (CDRIS-10)

CDRIS-10 Mean N Std. Deviation Std. Error Mean

Pair 1 Baseline 33.14 21 5.944 1.297

6-month 28.76 21 8.123 1.773

Pair 2 6-month 28.93 14 8.426 2.252

12-month 27.29 14 10.462 2.796

Pair 3 Baseline 31.60 20 6.541 1.463

12-month 30.00 20 8.473 1.895

Table 30: Paired samples tests (CDRIS-10)


CDR Baseline – 6month 6month – 12month Baseline - 12month

Paired

Differences

Mean 4.381 1.643 1.600

Std. Deviation 9.319 8.688 11.170

Std. Error Mean 2.034 2.322 2.498

95%

Confidence

Interval of the

Difference

Lower .139 -3.373 -3.628

Upper 8.623 6.659 6.828

t 2.154 .708 .641

df 20 13 19

Sig. (2-tailed) .044 .492 .529

GHQ-12 – Paired comparisons

For the sake of completeness, paired comparisons were also done for GHQ-12, but no

significant pairings were found (using both parametric and non-parametric tests).

Table 31 and Table 32 show the results of the paired comparisons.

Table 31: Paired samples statistics (GHQ-12)

GHQ Mean N Std. Deviation Std. Error Mean

Pair 1 Baseline 13.10 21 7.300 1.593

6-month 12.57 21 6.577 1.435

Pair 2 6-month 13.57 14 8.680 2.320

12-month 12.64 14 7.249 1.938

Pair 3 Baseline 13.85 20 6.722 1.503

12-month 13.05 20 7.430 1.661

62

Table 32: Paired samples tests (GHQ-12)


GHQ Baseline – 6month 6month – 12month Baseline - 12month

Paired

Differences

Mean .524 .929 .800

Std. Deviation 7.061 5.567 9.036

Std. Error Mean 1.541 1.488 2.020

95% Confidence

Interval of the

Difference

Lower -2.690 -2.286 -3.429

Upper 3.738 4.143 5.029

t .340 .624 .396

df 20 13 19

Sig. (2-tailed) .737 .543 .697

Health and lifestyle variables

In Section Seven of the participant questionnaires (Your health and lifestyle)

participants were asked a series of questions regarding their use of alcohol, smoking

habits and their social life and relationships. Following the analysis of the primary

outcome variables, the health and lifestyle variables were analysed in order to identify

any significant associations with those primary outcome variables that may indicate

factors which are conducive to, or preventative of, effective rehabilitation.

Alcohol consumption

The World Health Organisation (WHO) ‘Alcohol use disorders identification test’

(AUDIT) was used to assess alcohol consumption at baseline, at six months and at 12

months. The AUDIT measure consists of a ten-item scale designed to reflect

participant’s relative level of risk related to their alcohol use. An AUDIT score of

eight or more is recommended by the WHO as an indicator of hazardous and harmful

alcohol use, as well as of possible alcohol dependence (higher scores indicating

greater likelihood of hazardous and harmful drinking). While the WHO recommend

the use of a cutoff score of eight, they acknowledge also that a secondary cut-off score

of ten provides greater specificity in terms of hazardous and harmful drinking, albeit

at the expense of sensitivity (Babor et al, 2001). Table 33 provides a summary of

mean AUDIT scores achieved by the prospective patient participants (01PG) at

baseline, six months and 12 months.

63

Table 33: AUDIT scores (01PG)

Number of

cases Mean Median Std. Deviation Minimum Maximum

WHO - BA - AUDIT -

Totals

93 9.80 9.00 5.272 2 29

WHO - 6m - AUDIT

TOTALS

26 9.00 8.50 5.044 1 22

WHO - 12m - AUDIT

TOTALS

20 8.05 8.00 3.677 2 16

While the mean scores achieved by the prospective patient group (01PG) are greater

than the cutoff of eight recommended by the WHO, they are below the secondary

cutoff score of ten. In respect of the mean AUDIT scores achieved by participants,

there is evidence to suggest that over the follow-up period, rates of hazardous or

harmful alcohol use decrease (as evidenced by a fall in mean and median scores).

There is therefore also some evidence to suggest a general reduction in alcohol

consumption over the follow up period as evidenced by a decrease in the maximum

levels of intake.

In respect of the primary outcome measures (PCL-C, GHQ-12 and CDRIS-10)

there is also evidence to suggest that (at baseline at least) outcomes are worse for total

abstainees from alcohol compared with non-abstainees (see Table 34). Mean PCL-C

scores for abstainees at baseline were significantly higher (Mean=45.08) when

compared to non-abstainees (Mean=29.38). Mean GHQ-12 scores at baseline,

similarly, were significantly higher for abstainees (Mean=16.85 (Likert)) when

compared to non abstainees (Mean=12.68)).

Table 34: Mean outcome measures for Abstainees compared with non-abstainees

Abstainees vs. Non-Abstainees N Mean Std. Deviation Std. Error Mean

BA - PCL-C - TOTAL

SEVERITY SCORE

0 13 45.08 18.549 5.145

1 95 29.38 10.944 1.123

BA - CDRIS10 - TOTAL 0 13 27.15 9.245 2.564

1 96 31.90 6.764 .690

BA - DRS15 - TOTAL 0 13 23.69 5.266 1.461

1 92 26.60 4.159 .434

BA - GHQ12 - TOTAL

(Likert)

0 13 16.85 8.774 2.433

1 97 12.68 5.940 .603

64

Table 35: Mean outcome measures for abstainees and non-abstainees (non-parametric tests)

BA - PCL-C -

TOTAL SEVERITY

SCORE

BA - CDRIS10 -

TOTAL

BA - DRS15 -

TOTAL

BA - GHQ12 -

TOTAL (Likert)

Mann-Whitney U 316.500 418.000 407.000 435.500

Wilcoxon W 4876.500 509.000 498.000 5188.500

Z -2.845 -1.930 -1.864 -1.809

Asymp. Sig. (2-tailed) .004 .054 .062 .070

a. Grouping Variable: Abstainees vs Non-Abstainees

While there is strong evidence to suggest that PTSD is worse for abstainees, these

results remain inconclusive with regard to resilience even on the CDRIS-10 scale

which shows borderline significance (Table 35). While DRS-15 and GHQ-12 scores

at baseline indicate worse results for abstainees rather than for non-abstainees these

results are not statistically significant at a 5% criterion of rejection of null hypothesis.

Findings were based upon non-parametric tests rather than upon their

parametric equivalents suggest that consuming alcohol (which includes the associated

social aspects and benefits) may be contributing towards lower levels of PTSD and

raising levels of resilience at baseline.

Organisations and social activities before injury

Participants were asked, in regard to their social life and relationships, which

organisations they belonged to and in which social activities they participated

regularly outside of work (see Table 36).

Table 36: Regular social activities outside of work (01PG)

Number % of sample of 110

Going to pubs/clubs 81 73.6%

Visiting family/friends 80 72.7%

Going to gym with friends 71 64.5%

Team sports / outdoor pursuits 71 64.5%

Going to watch sporting events with friends 52 47.3%

Social or hobby-related clubs 23 20.9%

Further Education 18 16.4%

Religious gatherings / societies 7 6.4%

Voluntary services 3 2.7%

Social activities including ‘going to the pubs/clubs’ (73.6%, n=81) and ‘visiting

family and friends’ (72.7%, n=80) were the main regular social activities out of work.

Similarly ‘going to the gym with friends’ (64.5%, n=71) and ‘team sports/outdoor

pursuits’ (64.5%, n=71) featured significantly in responses. This is perhaps to be

expected in the population and is consistent with the common perception of ‘the

military lifestyle’. When asked about their social life prior to their injury 56.9%

65

(n=64) of those responding (n=109) indicated that most of the people that they

socialised with were involved with the military (see Table 37).

Table 37: Were most of the people you socialised with involved with the military? (Prior to injury)


Valid Yes 62 31.2 56.9 56.9

No 47 23.6 43.1 100.0

Total 109 54.8 100.0


Total 199 100.0

Further analysis of social activities prior to injury suggested that there may have been

some significance in the (baseline) response ‘going to the gym with friends’13. An

initial analysis of the primary outcome measures (PCL-C, GHQ-12, DRS-15 and

CDRIS-10) as independent samples indicated a statistically significant effect (see

Table 38).

Table 38: Social activity prior to injury - going to the gym with friends (Baseline)

Going to the gym with friends Baseline 6-Month 12-Month

Mean (n) Mean (n) Mean (n)

PCL-C Yes 30.32 (69) 33.83 (12) 32.09 (11)

N/A 32.43 (37) 32.00 (8) 39.43 (7)

GHQ12 Yes 12.17 (70) 11.83 (12) 11.67 (12)

N/A 14.95 (38) 13.75 (8) 15.29 (7)

DRS15 Yes 27.13 (68)

N/A 24.51 (35)

CDRSI10 Yes 32.01 (71) 30.08 (12) 31.25 (12)

N/A 30.06 (36) 26.88 (8) 28.86(7)

Cells highlighted in red are statistically significant results on both parametric (independent samples t-tests), and non-parametric (independent samples Mann-Whitney) tests.

When taken as independent samples, those who did not report ‘going to the gym with

friends’ prior to their injury appeared to fare worse on all outcome measures at the 12-

month point when compared with baseline. Prospective patient participants who

reported ‘going to the gym with friends’ prior to their injury at baseline, appeared to

fare better in terms of their resilience (CDRIS-10) and mental health (GHQ-12). This

‘improvement’ was not observed in respect of participants symptoms of PTSD (PCL-

C).

13 The baseline response to the question “Before your injury, which of the following organisations did you belong to or which social activities did you regularly choose to do outside of work” was used in preference to the same question asked at six months

and at 12 months as it was felt that responses at baseline would be a better reflection of participants actual social activity.

66

While a statistically significant difference was observed, on the DRS-15 and

GHQ-12 measures, between those who reported ‘going to the gym with friends’ and

those who did not report ‘going to the gym with friends’ at baseline, these results are

not based on a consistent panel sample. As a result, the sample of individuals

responding to this item at each time-point is treated as representative of those

responding at baseline. As the subsequent analysis of this phenomenon using the

strict panel of participants who responded to the question at each stage was

inconclusive and failed to verify the finding, it is recommended that these results be

verified with a larger panel.

Relationships and social support

Within the prospective patient group (01PG), 66.1% (n=74) of participants regard

themselves as being in ‘committed relationship’ at baseline and either describe

themselves as being ‘married’ (26.8%, n=30), ‘living with a partner’ (10.7%, n=12) or

‘in a long-term relationship’ (28.6%, n=32). Participants were asked about their

satisfaction with their current relationship, prior to their injury, at baseline, at six

months and again at 12 months. Taking a strict panel of participants responding to

these questions at each stage (n=11) indicated that while there was some increase in

marital dissatisfaction in individual cases, the general level of satisfaction was

unchanged at 12 months (see Table 39).

Table 39: Marital/relationship satisfaction for panel (n=11)

Prior to injury Baseline (01PGBA) Six months (01PG6M) 12 months (01PG12M)

Frequency % Frequency % Frequency % Frequency %

Extremely

satisfied 5 45.5 4 36.4 3 27.3 5 45.5

Satisfied 2 18.2 4 27.3 5 45.5 3 27.3

Neither

satisfied nor

dissatisfied

Dissatisfied 1 9.1

Extremely

dissatisfied 1 9.1

N/A 4 36.4 4 36.4 2 18.2 2 18.2

In respect of social support offered by partners, the Social Support Inventory (SSI)

was used to assess: perceived and received criticism, social support and total social

support inventory score. Using the same strict panel of participants (n=11), mean

scores on the perceived and received criticism sub-scale suggested that participants

tended to perceive their relationships as becoming less critical over time.

67

Alternatively, mean scores achieved on the social support sub-scale suggest that

participants were less satisfied with the support they were receiving from their

partners at six months and 12 months. Table 40: SSI - Baseline, six months and 12

months for strict panel (n=11) (01PG) provides a summary of mean SSI scores.

Analysis of these findings in relation to the primary outcome measures (PCL-C,

GHQ-12, CDRIS-10) indicated that there were no correlations between those

outcomes and perceived social support. Again it is it is recommended that these

results be verified with a larger panel.

Table 40: SSI - Baseline, six months and 12 months for strict panel (n=11) (01PG)

Mean Baseline (01PGBA) Six Months (01PG6M) 12 Months (01PG12M)

Perceived and

received criticism 11.45 10.45 9.91

Social support 6.27 7.18 7.17

SSI Total Score 17.73 17.64 17.09

Qualitative findings (Partner study)

Initial direct comparison of prospective patient participants (01PG) and prospective

partner participants (02PG) mean PCL-C and GHQ-12 (GHQ) scores at baseline, six

months and 12 months demonstrates higher mean PCL-C scores at baseline and six

months in partner participants and consistently higher GHQ-12 scores (GHQ) than

patient participants throughout the follow up period. Despite the relatively small

sample of participants in the prospective partner study, analysis of the primary

outcome variables does indicate a clinically significant level of psychopathology in

partners. Further examination of the partner ‘experience’ is therefore warranted.

As part of the overall assessment process partner participants were asked a

series of open questions at each stage designed to provide some insight into their

experience. Partner participants were asked, in general terms, about their experience

of the DMRC, about changes in their relationship with their partner and about their

perception of their own ability to cope.

Experience of the DMRC

Partner participants were asked if they had been to visit their partners at the DMRC

and 71% (n=15) indicated that they had, while 28.6 (n=6) indicated that they had not.

When asked ‘in general terms how convenient has it been to visit your partner at

DMRC: Headley Court?’ 50% (n=10) indicated that it had been ‘Very convenient’ or

‘Convenient’. Six partner participants indicated that it had been ‘Inconvenient’ to

68

visit. When asked what had made it inconvenient to visit, partner participants

indicated that: time factors; difficulty in securing time away from work and distance

had been the main factors. Those partner participants indicating that it had been

inconvenient to visit reported a general feeling that it was easier to wait for their

partners to return home at the weekends from the DMRC than for them to travel there.

One partner participant indicated that she did not feel that the DMRC “was a very

warm and friendly environment” and reported finding it “quite clinical”. One partner

participant indicated that she had not visited because her partner did not like her to

visit him at the DMRC.

Attitude of staff

When asked, ‘in general terms, how would you describe the attitude of the staff at

DMRC: Headley Court towards you?’ 66.7% of partner participants reported that the

staff at the DMRC had been either ‘Very supportive’ or ‘Supportive’ (n=10). One

third of partner participants (33.3%) indicated that the staff at the DMRC had been

‘Unsupportive’ (n=1) or ‘Very Unsupportive’ (n=3) or that they had not spoken to any

staff at the DMRC at all (n=1).

Perception of care

When asked about their perception of the level of care provided at the DMRC: 80%

(n=12) rated the care as being either ‘Good’ or ‘Very good’; 13.3% indicated that they

though that the care had been ‘Average’ (n=2) and one participant indicated that they

though that the level of care had been ‘Poor’. When asked to what extent had the

level of care affected their ability to cope with their partner since his or her injury the

majority of partner participants (60%, n=9) suggested that it made coping with their

partner ‘A little easier’ or ‘Much easier’. While one participant felt that the level of

care provided at the DMRC made no difference to their ability to provide care for

their partner at home, five participants (33.3%) suggested that it had made caring for

their partner at home ‘A little harder’ or ‘Much harder’.

Emotional support (Positive)

Partner participants were asked ‘Overall, in terms of the emotional support that you

may have received from staff at DMRC, what has been most helpful?’ Fifteen

partner participants provided responses to this question, and a number of themes were

identifiable within those responses. There were six generally negative responses to

69

this question; seven generally positive responses, and two responses that were neither

positive nor negative.

Staff

While one partner participant reports never having been to the DMRC, a number of

the others who had, reported having no contact with staff at all during the time that

their partner was an inpatient there (n=4). Four of the responses state that the staff at

the DMRC provided no emotional support and one partner participant suggests that,

as a girlfriend rather than as a wife or live-in partner, the support offered by the staff

at the DMRC “did not extend as far as me”. One partner participant indicated that

while she had no contact with staff when her partner was an inpatient at the DMRC

she had had contact with them subsequently, and that her partner’s Occupational

Therapist had been ‘the greatest support’.

One partner participant expressed the view that she felt ‘a lot easier knowing

that there was at least one friendly face’ to whom her partner could turn at Headley

Court. Those partner participants who reported positive experiences of support

indicated that “the willingness of certain staff” to “include and explain” was the most

helpful thing. In general terms, the staff identified as being most helpful were the

Social Work staff (n=5), Occupational Therapy staff (n=2), Prosthetics Department

(n=2) and the Physiotherapy staff (n=1). Neither Medical nor Nursing Staff were

mentioned in responses to this question. In their responses to this question, partner

participants did not make any distinction between Military and Civilian Staff.

Significant Moments

A number of partner participants indicated that the provision of information and an

orientation tour of the DMRC had been helpful in providing emotional support, and a

number of participants reported ‘significant moments’ like this or ‘milestones in care’

as being important in terms of their emotional support. Examples of ‘significant

moments’ identified by partner participants such as the witnessing of the fitting of

prosthetics and seeing their partner walk again, along with realising that their partner

‘wasn’t the odd one out’ were most helpful.

Emotional support (Negative)

Partner participants were asked ‘Overall in terms of emotional support that you may

have received from staff at DMRC, what has been least helpful?’ While eight partner

participants provided responses to this question, three of the responses were the same

70

as those they provided in the previous question. Once again, a number of themes

emerged.

Staff

While a number of members of staff were identified as being helpful in respect of the

provision of emotional support, concerns were raised by partner participants in

relation to the staff at the DMRC and their willingness to involve partner participants

in care. The lack of interaction also appeared to be a consistent concern for partner

participants in regard of staff, and one participant indicated that despite initial support,

promised regular contact was not forthcoming.

Slow Progress

While a number of partner participants indicated that ‘significant moments’ or

‘milestones in care’ were helpful in respect of their emotional support one partner

identified that, “The slow progress of my partner’s treatment and rehab, does nothing

for his self esteem and also for his anger issues which in turn does not help me

emotionally”, and it would appear that problems associated with frustration and anger

on the part of the patient participants over time constitutes a significant problem.

Provision of information

Partner participants were asked a series of specific questions in respect of the

provision of information by staff at the DMRC. These questions related to the overall

management of care; their partners’ future recovery; the psychological aspects of their

partners’ injury, and the potential sources of help available (see Figure 32). While

52.6% (n=10) of partner participants acknowledge that it was easy to obtain

information from staff when they requested it, eleven of the fourteen responses to this

question served to highlight problems or shortcomings associated with the provision

of information. A consistent view expressed by partner participants was that there

was a general lack of information provided by staff at the DMRC at all three stages of

the follow up process (see Figure 32: Provision of information to partners (02PG)).

Quality, quantity and timing of information

As a follow-up to the questions regarding the provision of information, those partners

who indicated that they had been provided with information were asked to comment

on the quality, quantity and timing of that information. On balance, those partner

participants responding indicated that the information provided in respect of the

overall management of their partners care, their partners’ future recovery and the

71

psychological impact of their partners’ injuries had been of poor quality and had often

been provided ‘too late’. In contrast, the majority of partner participants commenting

on the quality, quantity and timing of information regarding possible sources of help

and support (n=6) characterised the quality, quantity and timing of this information to

be ‘about right’ (66.7% - 88.3%, n=4 and n=5). It should be noted that the numbers

of participants responding to the questions regarding quality, quantity and timing of

information were very small and that it is difficult to draw general conclusions from

such a small number.

In terms of your

partners overall

management at DMRC, have you received any

information?

Did you receive any

information from the

staff regarding your partners future in terms

of recovery?

Did you receive any


staff with regard to how your partner might

react psychologically to

the injury?

Did you receive any


staff in terms of possible help available

to you or to your

partner?

Yes (Baseline) 4.80% 4.80% 9.50% 23.80%

No (Baseline) 95.20% 95.20% 90.50% 76.20%

Yes (Six months) 8.30% 8.30% 8.30% 8.30%

No (Six months) 91.70% 91.70% 91.70% 91.70%

Yes (Twelve months) 40.00% 10.00% 10.00% 30.00%

No (Twelve months) 60.00% 90.00% 90.00% 70.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Pro

vid

ed

wit

h i

nfo

rma

tio

n?

(%)

Figure 32: Provision of information to partners (02PG)

72

Conclusions

Recruitment

Within the prospective patient participant group (01PG) recruitment rates were

encouraging, and it seems likely that the high recruitment rate in that group (92.99%,

n=199) was due, in the most part, to the face-to-face contact between potential

participants and the HCF at the DMRC. Generally speaking, potential participants

demonstrated considerable willingness to participate in the research study when they

were first contacted and expressed a strong desire ‘to help anyone else who is injured

in the future’. It could also be argued that the willingness of those individuals to

participate in the research study could be explained by the fact that the HCF

approached each of the potential participants early in their first admission to the

DMRC, and as potential patient participants were approached in uniform (Combat 95)

this further facilitated the formation of a ‘credible military relationship’. While it

could also be argued that approaching potential participants in uniform may be

regarded as being coercive (as it served to highlight a significant rank differential

between the HCF (Major Forbes) and the majority of potential participants) it was felt

that the wearing of uniform on the part of the HCF would facilitate improved

participation and a more efficient integration within the DMRC.

As the invitation to participate in the study was extended to the retrospective

patient participant group (01RG) and to both partner groups (02PG) and (02RG) by

post, the recruitment rates within these groups are consequently considerably lower

(01RG=15.87%, 02PG=25.23% and 02RG=21.43%) than that of the prospective

patient participant group.

Observations

1. Future funded research within the DMRC setting should include provision for

a ‘military research fellow’ as face-to-face contact between a credible military

researcher and potential participants appears to facilitate effective recruitment

and higher levels of participation.

2. In order to establish a credible military relationship with participants, the

military research fellow should conduct research, wherever practicable, in

uniform. The wearing of military uniform also serves to facilitate access to

the clinical area and effective interaction with clinical staff. The military

research fellow must be of sufficiently high rank and of sufficient clinical

73

standing to allow effective interaction with military medical consultants and

other senior staff but not to limit interaction with potential participants.

Response rates

The response rates achieved within the prospective patient group (01PG) were

encouraging at baseline (56.28%). Whereas at six months (14.57%) and at 12 months

(11.56%) the percentage of assessments returned was disappointing. It could be

argued that the disappointing response at these stages may be due to a number of

factors. Firstly, it is possible that the effect of face-to-face contact achieved during

the recruitment phase of the study contributed to the higher response rates in the

prospective patient participant group (01PG) at baseline as the assessments used at

this stage were handed directly to participants and, in a large proportion of the cases,

were handed directly back to the HCF once complete. Secondly, as the six-month and

the 12-month response rates relied upon the prospective patient participants receiving

assessments by post, to be completed on home sick leave and then returning them by

post, the response rates at six and at 12 months are more likely to reflect the well

established difficulties associated with postal surveys.

Finally, throughout the follow-up period there were consistent difficulties

associated with the ‘tracking’ of prospective patient participants and a significant

number of assessments were returned “undelivered” at six months and at 12 months.

The difficulties associated with achieving sufficient returns within a military study are

well recognised (Fear et al, 2010). While best efforts were made to maintain the

patient contact database using information obtained from the DMICP database and

directly from participants, the return of undelivered assessments represents a

significant difficulty.

In contrast to the prospective patient participant group (01PG) the response

rates achieved by the retrospective patient (01RG) and prospective partner group

(02PG) at six months and 12 months tended to be consistently higher and it seems

likely that this may be due to their initial committment to the study. While the

recruitment rates achieved in the retrospective patient (02RG) and prospective partner

(02PG) groups were significantly lower than those achieved in the prospective patient

group (01PG), it may be that, once committed to participating in the study, these

groups were more willing to complete the 12 month follow up.

74

Observations

1. Where possible, future research should employ direct assessment of

participants at the DMRC in order to minimise these difficulties and to

maximise participation.

2. Where the research requires the use of a study design incorporating less direct

methods of assessment, e.g. with geographically distant retrospective

participants or partners, the research team should consider seeking consent

from those participants to contact them by telephone during the study in order

to establish and maintain a research relationship likely to improve

participation.

Demographics

Ethnicity and gender

The majority of prospective patient participants (01PG) and prospective partner

participants (02PG) identified themselves as being ‘White: British’, ‘White: Irish’ or

‘White: Other’ and given the small numbers of those recruited to the study and

participating in the follow-up who identify themselves as belonging to the ‘Asian or

Asian British: Other’ or the ‘Black or Black British: African’ categories it is difficult

to draw any reliable conclusions based on the ethnicity of participants. One

observation that was made in respect of ethnicity was that approximately half of those

reporting themselves as abstainees from alcohol identified themselves as being ‘Asian

or Asian British: Other’ and the ‘Black or Black British: African’

As almost all of participants in the patient study were male (98.6%), and only

one of those female participants initially recruited onto the study (n=3) completed the

prospective participant assessments (baseline and six-months only), it is impossible to

draw any conclusions based on gender within the patient participant group. Likewise

in the prospective partner group (02PG) there were no male partner participants

recruited onto the study.

It is difficult to make any sound recommendations in respect of the

observations regarding the ethnic and gender bias of this study. As the study design

incorporated face-to-face recruitment of consecutive admissions in order to facilitate

maximum participation, maximum response, and to minimise problems associated

with selection bias the low numbers of female personnel and personnel from other

ethnicities remains a limitation of the study and could not be avoided.

75

Age, relationship status and financially dependent children

Within the prospective patient participant group (01PG), the mean age of participants

was 26.33 years and within the prospective partner group (02PG) it was 28.4 years.

Within each of these groups the youngest participant was 19 years of age and 10.2%

of the patient group was aged 20 years or less. The mean age of patient participants

(both prospective and retrospective groups) is representative of that of the general UK

Regular Forces14 and, as previously commented, this is most likely a reflection of the

‘junior’ nature (in both age and rank) of those deployed in forward areas on

operations.

Almost two-thirds of the patient participants (64.8%, n=125) regarded

themselves as being in a ‘committed relationship’ and in order to estimate how well

established these relationships were, the prospective partner participants were asked

how long they had been with their partner prior to his or her injury: 71.4% (n=15) of

the partners reported having been in their relationship for 48 months or less. While,

again, it should be noted that the number of partner participants responding to this

question makes it difficult to draw any reliable and generalizable conclusions

regarding the durability of the relationships of the population as a whole, given the

relative age of participants, it seems reasonable to suggest that the majority of

participants were in ‘new’ relationships.

Twenty-six percent (n=32) of prospective patient participants reported having

financially dependent children (mean=1.81 children, which is roughly in line with the

national UK average) and the mean age of children within the group was 6.5 years.

It seems likely therefore that given: the relatively low age of prospective

patient participants and their partners; the fact that the majority of participants in

relationships appear to be in relatively new relationships and that those with

financially dependent children have relatively young families, the additional

difficulties placed upon those relationships and families associated with coping with

combat-related injury only serve to compound the social and personal challenges

faced by both patient and partner participants.

Observations

1. The appointment of, or redeployment of an existing member of military staff

as a ‘Family Liaison Officer’ in order to support the current service offered by

14 At 1st April 2011, the mean age of those serving in the UK Regular Forces as ‘Other Ranks’ was twenty-nine years and as

‘Officers’, thirty-seven years of age.

76

the Social Work Department would provide a valuable link between patients,

their families and potential sources of support in the voluntary sector.

2. Further research establishing the impact of combat-related injury on the wider

family, i.e. the children and parents of those with combat-injuries who may be

regarded as ‘cross-generational’ carers would further enhance understanding

of the ‘ripple effect’ of trauma.

Highest level of education and employment

Within the prospective patient group (01PG), 70.2% (n=87) of participants report the

completion of secondary school as their highest level of education attainment.

Further examination of this sub-group indicates that 13.7% (n=17) of those

participants left school with no formal educational qualifications, while 39.5% (n=49)

achieved GSCE/CSE or O-Level equivalent qualifications and 19.9% (n=21) achieved

A-Level qualifications. A further 29.8% (n=37) of prospective patient participants

report post-secondary educational achievement within further and higher education

and are qualified to degree and to post-graduate level.

In contrast, only 23.8% (n=5) of the prospective partner group (02PG) report

the completion of secondary school as their highest level of educational attainment

and a significantly higher percentage of partners indicate that they have achieved the

completion of studies in further or higher education (51.8%, n=14) gaining diploma

(23.8%), degree (29.6%) or post-graduate level qualification (4.8%). While it may be

the case that the level of academic attainment reported here is not representative of the

partner population as a whole, it is consistent with the higher percentage of partner

participants within the study reporting the nature of their employment as ‘professional

or managerial’ (94%, n=9).

While the vast majority of patient participants are employed as regular

members of the armed forces (91.2%, n=118) only 67% (n=14) of the prospective

partner group report being employed in a full-time capacity.

It seems increasingly clear that the outcome of rehabilitation for those

individuals with disabilities incompatible with continued military service is medical

discharge. It also seems reasonable to suggest, therefore, that the future employability

of those patient participants deemed unfit for continued military service will be

dependent upon: the severity of their injuries; the nature of any resulting disability;

their existing skill set and their previous educational and professional qualifications as

77

well as, at a general level, their individual motivation and the level of support they are

offered prior to discharge. It may be argued that those with higher levels of disability

and lower levels of educational qualifications may be regarded as being less

‘employable’ in the future.

Primary outcome variables

PTSD and common mental health disorders

The civilian version of the Post-Traumatic Checklist (PCL-C) was used to estimate

the prevalence of PTSD within each of the study groups. Using a cut-off score of 50

as the normative threshold provided an estimate of the prevalence of PTSD within the

patient participant group (01PG) of 10.18% at baseline, 20.69% at six months and

18.18% at 12 months. Within the partner participant group (02PG) the estimate of the

prevalence of PTSD over the same period was 7.14%, 33.33% and 10.00%

respectively.

In addition to the estimation of PTSD within the study, the prevalence of

common mental health disorder was also established using the General Health

Questionnaire (GHQ-12). The GHQ-12 measure is used to assess psychiatric

‘caseness’ in participants and, while it is not sensitive enough to identify individual

pathologies, it does provide a useful means by which to estimate prevalence. Within

the patient participant group (01PG) the prevalence of common mental health disorder

was estimated as being, 66.36% at baseline, 57.14% at six months and 52.18% at 12

months. Likewise, within the prospective partner group (02PG) the prevalence of

common mental health disorder was estimated as being, 65.00% at baseline, 66.66%

at six months and 55.55% at 12 months.

In respect of the prospective patient participants, the prevalence of PTSD was

significantly higher than that reported in previous studies of UK troops returning from

operations (minus combat-related injury) i.e. Hotopf et al (2006) and this serves to

confirm the findings from earlier studies (e.g., Kulka et al, 1990 and Michaels et al,

1999) that indicate that bodily injury is a risk factor – rather than a protective one –

for PTSD.

In addition to these findings, the high levels of common mental health disorder

identified in both patient and partner participant groups further serve to confirm that

comorbidity in PTSD is the norm rather than the exception (O’Donnell et al, 2004)

and that a significant proportion of those individuals with a diagnosis of PTSD also

78

meet the criteria for at least one other psychiatric condition (Creamer et al, 2001).

Once again, while the use of GHQ-12 does not serve to identify what these individual

psychopathologies may be, the literature confirms that other symptoms from which

soldiers may be at risk include depression, anxiety, anger, sleep disturbance,

somatisation, substance misuse, dissociation and sexual problems (Goff et al, 2007).

In order to provide an effective estimate of the durability of any rehabilitative

gain in respect of PTSD and common mental health disorder a strict panel of only

those participants who responded to the questionnaires at all three stages (baseline, six

months and 12 months) was required. Due to poorer than expected response rates at

six and 12 months the panel of prospective patient participants consisted of only 12

individuals. The strict panel of prospective partner participants completing both PCL-

C and GHQ-12 at all three stages consisted of only four individuals and has been

excluded from this discussion.

Repeated Measures Analysis (RMA) was performed on mean PCL-C, and

GHQ-12 scores for the panel and the average levels of scores over the three time

periods fail to show any significant pattern. However, an analysis of those primary

outcome measures using the median scores rather than the mean scores (intended to

eliminate the bias introduced by the most extreme scores on either end of the scale)

indicates that it may be reasonable to conclude that over the initial six-month period

of the follow up there is a worsening of symptoms of PTSD, but that by 12 months

these symptoms return to baseline levels and that there has been a steady

improvement in general mental health of the prospective patient participants as

indicated by the GHQ-12. These findings are consistent with existing research

reporting delayed onset of symptoms (Hoge et al, 2004).

Direct comparison of prospective patient participant (01PG) and prospective

partner participants (02PG) mean PCL-C and GHQ-12 scores at baseline, six months

and 12 months appears to demonstrate that partner participants achieve higher mean

PCL-C scores at baseline and six months and consistently higher GHQ-12 scores than

patient participants.

Resilience (DRS-15 and CDRIS-10)

The Dispositional Resilience Scale (DRS-15) was utilised within the prospective

patient participant group (01PG) to establish a baseline measure of resilience in

participants. The administration of the DRS-15 was conducted through the

79

prospective patient baseline assessment (01PGBA) within one week of admission to

the DRMC. Given the timing of the administration of the DRS-15, however, a degree

of caution must be exercised in its interpretation, and it is reasonable only to suggest

that the individual DRS-15 scores achieved provide a baseline measure of resilience

‘at admission’ rather than as a baseline assessment of the resilience of the individual

participants as a whole. A simple analysis of the total time elapsed from ‘incident’ to

‘admission’ to the DMRC demonstrates that (for ninety-five percent of the group)

between one and 27 weeks may have elapsed (mean time between ‘injury’ and

‘admission’=12.74 weeks). It seems likely that during this time a combination of

personal and environmental factors will have had an effect upon overall resilience.

The comparison of the mean DRS-15 score achieved by the prospective patient group

(01PG) at admission to the DMRC (mean=26.24) and the norms cited by the scale

author (Bartone et al, 2007) for a generally comparable group of U.S. military

academy students (mean= 29.15) further supports this conclusion.

The Connor-Davidson Resilience Scale (CDRIS-10) was used with the patient

participant group (01PG) to estimate the relative levels of resilience for the population

at each of the three stages. A comparison of the mean CDRIS-10 scores at each stage

(when taken as independent samples) indicates that levels of resilience decline from

baseline (mean=31.33, n=109) to six months (mean=28.72, n=29) but stabilise

between six months and 12 months (mean=23, n=23). A further analysis of mean

levels of CDRIS-10 scores (paired samples tests: baseline to six months; six months

to 12 months and baseline to 12 months) confirms that there is a statistically

significant worsening of resilience at six months (these results were confirmed by

Wilcoxon Signed Ranks Test (asymptotic significance=0.036)).

Observations

1. A detailed evaluation of the ‘Post-Traumatic Rehabilitation Course (PTRC)

currently offered at the DMRC in order to establish its effectiveness in the

promotion of psychological resilience and management of those identified as

being ‘at risk’ in respect of Post-Traumatic Stress Disorder and Common

Mental Health Disorders and may provide a useful insight into promoting

resilience in the military cohort.

80

2. Further research is required within the general service population in order to

identify those factors influencing the development of resilience in UK military

personnel.

Health and lifestyle variables

Alcohol consumption

There is limited evidence to suggest that over the follow-up period there is a general

reduction in alcohol consumption as evidenced by a decrease in the maximum levels

of intake in the prospective patient participants. There is also evidence to support the

conclusion that rates of hazardous or harmful alcohol use decrease (as evidenced by a

fall in mean and median scores) over the same period. An initial analysis of the use of

alcohol appears to suggest that those individuals that reported themselves as

abstaining from the consumption of alcohol have higher mean PCL-C, and GHQ-12

scores and there is tentative evidence that suggests that the consumption of alcohol

(which includes the associated social aspects and benefits) may result in lower

reported levels of PTSD and raised levels of resilience at baseline. One explanation

of this phenomenon may be that levels of PTSD and common mental health disorder

are masked by the use of alcohol and that alcohol is employed as a coping

mechanism. In respect of the apparent positive effect of alcohol on resilience, it is

possible that the social aspect of alcohol and benefits that derive from the use of

alcohol within the military environment reinforce the positive effects of comradeship

and that the sense of ‘membership of the military family’ that this brings has a

positive effect of resilience.

Observation

1. The use of alcohol could potentially mask the symptoms of PTSD and

common mental health disorder in those with combat-injury. In addition to

the existing alcohol screening conducted at the DMRC by the Mental Health

team, alcohol screening conducted at ward level as part of the induction

process at each inpatient admission using the WHO’s AUDIT measure (Ware

et al, 1993) may provide an early indication of the adoption of alcohol as a

coping strategy in patients.

Organisations and social activities before injury

An initial analysis of the social activities engaged in by patient participants prior to

their injury suggested that ‘going to the gym with friends’ may have a positive effect

81

on their level of resilience at baseline but that it may have a negative effect on their

mental health in the longer term. In contrast, those patient participants who did not

report ‘going to the gym with friends’ had lower levels of resilience at baseline but

appeared to fare significantly better in terms of their mental health (GHQ-12).

Analysis of the primary outcome measures (PCL-C, GHQ-12, DRS-15 and CDRIS-

10) as independent samples at baseline, six months and 12 months indicated that the

effect might be statistically significant (see Table 38). While a statistically significant

difference was observed between those who reported ‘going to the gym with friends’

and those who did not report ‘going to the gym with friends’ prior to injury, these

results were NOT based on a consistent panel sample. The subsequent analysis of this

phenomenon using a consistent panel of participants failed to verify the finding.

While the subsequent analysis of these findings did not support the original

observation, one possible explanation offered of this initial observation was that

‘going to the gym with friends’ again promoted a sense of comradeship or

‘membership of the military family’ in participants as well as physical fitness and it

was these effects combined that promoted resilience at baseline. Participant

‘expectation’ was cited as an explanation for the observed difference in mean GHQ-

12 scores at baseline and it was suggested that those participants who reported ‘going

to the gym with friends’ prior to their injury had more difficulty in adjusting to their

injuries and to the alteration of their body-image and that perceived physical

limitations had a more profound effect on them than it had on those who had not

reported ‘going to the gym with friends’ prior to their injury.

Observation

2. Further research is required within the general service population in order to

confirm these findings and to further identify those factors influencing the

development of resilience in military personnel.

Relationships and social support

While there was some increase in relationship dissatisfaction reported by individuals

within the prospective patient group (01PG), the general level of satisfaction was

unchanged at 12 months. Use of the Social Support Inventory (SSI) to further assess

‘perceived and received criticism’ and patient participants’ perception of the ‘social

support’ offered by their partner indicated that the patient participants consistently

perceived their relationships as becoming less critical over the 12-month followed up.

82

In contrast, the analysis of the ‘social support’ sub-scale of the SSI indicated that

patient participants were generally less satisfied with the emotional and practical

support offered by their partners at six-months and at 12-months. While there was no

evidence to support the suggestion that there was a correlation between the reduction

in satisfaction measured and the primary outcome variables, the strict sample used to

analyse the differences in SSI over the 12 months was limited in size (n=11) and it is

recommended that these results be verified with a larger panel.

Qualitative findings (Partner study)

While it is difficult to draw any reliable conclusions from the qualitative data

provided by the partner participants, a number of themes emerge. While the partner

participants report a significant level of distress, as indicated by GHQ-12 and PCL-C

scores, their care is not the primary concern of the DMRC. The relationship between

the DMRC and the partners of those service-personnel treated there, may however be

contributing to those reported levels of distress. It must also be noted that the number

of partners responding to the open questions asked at baseline, six months and 12

months was very small and the effect of negativity bias must be considered.

Generally speaking, the partner participants reported a positive experience of

the care at the DMRC at baseline: 66.7% (n=10) reported that they found the staff to

be ‘very supporting’ or ‘supportive’: 80% (n=12) reported their perception that the

care provided to their partner was ‘good’ or ‘very good’ and 60% (n=9) reported that

they felt that the level of care provided made it ‘easier’ or ‘much easier’ to care for

their partner at home. These levels of satisfaction were not significantly different at

six months or 12 months.

In respect of the support offered to partner participants, a small number (n=4)

report having had no contact with staff at the DMRC and a similar number report not

having received any form of support. One consistent response indicates that the

provision of support does not extend to partners who were neither ‘wives’ nor ‘live-in

girlfriends’. Conversely, a number of partner participants report positive experiences

of support and identify individual members of staff whose willingness to “include and

explain” was significant in terms of providing positive emotional support.

Significantly, neither medical nor nursing staff were identified as providing positive

emotional support by partners and no distinction was made between civilian and

military staff in terms of this kind of support.

83

Partner participants consistently report a less positive experience of the

DMRC in relation to the provision of information regarding the care of their partner,

his or her recovery and the psychological impact of his or her injury (see Figure 32).

It should be recognised, however, that the provision of clinical information without

the consent of the patient would constitute a breach of patient confidentiality, and it

may be that patient participants were unwilling to give consent for the sharing of

clinical information with their partners.

Recommendations

We would like to make the following recommendations:

1. Extend the provision of care to the ‘wider’ family, e.g. to the partners of those

with combat-injuries, in order to further strengthen mutual social support and

to minimise the impact of those injuries on partner health.

2. Develop strategies designed to improve the longer-term employability of

patients following their discharge from the Defence Medical Rehabilitation

Centre (DMRC) and/or medical discharge from the Armed Forces.

3. Enhance the participation of partners of those with combat-injuries in the

delivery of their care, i.e. participation in consultation, direct care delivery and

through a more effective passage of information.

4. Develop and implement best-practice strategies designed to promote the

psychological resilience of those with combat-injuries in order to minimise the

risk of post-traumatic stress and common mental health disorders.

5. Identify and implement strategies designed to monitor alcohol consumption

and identify hazardous or harmful alcohol use by those with combat-injuries

during each period of inpatient admission at the DMRC.

84

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Aberdeen Centre for Trauma Research, Faculty of Health & Social Care, The Robert Gordon University, Garthdee Road, ABERDEEN AB10 7QG

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