Our research shows that treatment targeting both alcohol and mental health problems improves outcomes for veterans experiencing both conditions but is not a common practice.
The report provides recommendations to improve care, including the need for:
- Approaches that use integrated services, provide flexible and holistic care, and remove abstinence-only policies.
- Increased awareness of available support for veterans with co-occurring alcohol and mental health problems.
- Approaches such as national campaigns and local strategies which aim to reduce stigma.
More than 30,000 former Service personnel experience both mental health and alcohol problems, but this group is more likely to delay seeking help than the general population. People with common mental health problems – such as depression, anxiety, or post-traumatic stress – are twice as likely to report an alcohol problem but they are often excluded from mental health services until they have stopped drinking. Former Service personnel can also face additional challenges, such as difficulties recognising how severe problems are, stigma, and service providers being unaware of the potential impact of unique military experiences.
As part of the research, we conducted a series of studies, including a review of existing international evidence, interviews with treatment-seeking former service personnel with co-occurring problems, an analysis of routine data from an NHS Military Veterans’ Mental Health Service, and focus groups and an online survey with service providers to produce recommendations to improve care.
We found that integrated interventions were better at improving mental health and alcohol outcomes than treatment-as-usual (i.e. no change to usual care). Alcohol-focused treatments were equally as effective as integrated interventions, and also better than treatment-as-usual, for improving alcohol outcomes (few studies looked at mental health outcomes). Integrated interventions were more beneficial than alcohol-focused treatment alone for mental health outcomes.
The analysis of data from the NHS Military Veterans’ Mental Health service showed that veterans with co-occurring common mental health and alcohol problems show similar levels of improvement and recovery from mental health treatment, compared to veterans with a common mental health problem alone. However, veterans with co-occurring problems faced more challenges staying engaged in treatment.
In the interviews, veterans shared that military cultural norms around masculinity can contribute to stigma, which prevents them from seeking help. They also said that heavy drinking can sometimes mask mental health symptoms.
“Drinking makes you chaotic… half the time, you’re not able to identify, ‘I might be depressed’… you’re self-medicating.”
Veterans also talked about key barriers to getting support, such as abstinence policies meaning they couldn’t access mental health support until they stopped drinking, not knowing where to access support for co-occurring alcohol and mental health problems, and civilian services lacking an awareness of unique military experiences.
“I had a young girl [IAPT services]… fresh out-of-the-box… some of the stuff I was saying was actually frightening her… by the 4th or 5th session I just stopped going.”
In contrast, there were examples of good integrated and flexible approaches, particularly through veteran-specific services. Participants described care as most effective when providers understood military culture and “spoke the same language”.
Focus groups with service providers largely echoed these findings, describing the mental health and alcohol care system as fragmented and disjointed. The rigid abstinence policies within mental health services mean that veterans often disengage from treatment.
“They say to clients… go and have the substance use issues sorted first and then come back to us… the majority never come back.”
Integrated and co-ordinated treatment of both conditions, ideally within a single service or through collaboration, was widely regarded as the most effective but not common practice.
“By adding in the addictions work alongside the mental health work, they have suddenly flown and get better from both counts.”
The focus group activities and the Delphi study led to the development of 15 key recommendations to improve care and guide professionals on how to set up more helpful treatment pathways.
Commenting on the study, Dr Laura Goodwin, Senior Lecturer at Lancaster University, said: “Our research shows that veterans with co-occurring common mental disorders and alcohol use disorders can benefit from psychological therapies and recover, particularly if the treatment targets both conditions. This supports our recommendations for “no wrong door approaches”, removing abstinence-only policies in mental health services to reduce barriers for veterans. Where possible, common mental disorders and alcohol use disorders should be treated concurrently.”
Dr Patsy Irizar, Senior Lecturer at Liverpool John Moores University, said: “Veterans face unique challenges when seeking support for co-occurring common mental disorders and alcohol use disorders, such as stigma (linked to military cultural norms of masculinity), being unaware of what support is available to them, and a lack of veteran-informed care in some mainstream services. Our recommendations call for national campaigns and local strategies which aim to reduce stigma and increase awareness of services that provide support for veterans with co-occurring common mental disorders and alcohol use disorders.”
Andrew Misell, Director for Wales at Alcohol Change UK, said: “This study highlights an issue that’s common across the population: that many people with co-occurring mental health and alcohol problems still struggle to get the support they deserve. It also highlights the very particular support needs of military veterans. People who have served in the armed forces have often had experiences that civilian practitioners don’t fully understand, and they may use different language to describe those experiences. It’s vital that treatment services recognise this, and adapt their approaches accordingly, in order to ensure equal access for all.”
Read the full report on the Forces in Mind Trust website via this link.
