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Abstract
Objective To investigate the impact of the COVID-19 pandemic on the health and well-being of UK ex-service personnel (veterans) before and during the pandemic, and to assess associations of COVID-19 experiences and stressors with mental health, alcohol use and loneliness.
Design An additional wave of data was collected from a longitudinal cohort study of the UK Armed Forces.
Setting Online survey June–September 2020.
Participants Cohort members were included if they had completed a questionnaire at phase 3 of the King’s Centre for Military Health Research health and well-being study (2014–2016), had left the Armed Forces after regular service, were living in the UK, had consented to follow-up and provided a valid email address. Invitation emails were sent to N=3547 with a 44% response rate (n=1562).
Primary outcome measures Common mental health disorders (CMDs) (measured using the General Health Questionnaire, 12 items—cut-off ≥4), hazardous alcohol use (measured using the Alcohol Use Disorder Identification Test, 10 items—cut off ≥8) and loneliness (University of California, Los Angeles, Loneliness Scale— 3 items-cut-off ≥6).
Results Veterans reported a statistically significant decrease in hazardous drinking of 48.5% to 27.6%, while CMD remained stable (non-statistically significant increase of 24.5% to 26.1%). 27.4% of veterans reported feelings of loneliness. The COVID-19 stressors of reporting difficulties with family/social relationships, boredom and difficulties with health were statistically significantly associated with CMD, hazardous drinking and loneliness, even after adjustment for previous mental health/hazardous alcohol use.
Conclusions Our study suggests a COVID-19 impact on veterans’ mental health, alcohol use and loneliness, particularly for those experiencing difficulties with family relationships. Veterans experienced the pandemic in similar ways to the general population and in some cases may have responded in resilient ways. While stable levels of CMD and reduction in alcohol use are positive, there remains a group of veterans who may need mental health and alcohol treatment services.
- COVID-19
- epidemiology
- mental health
Data availability statement
Data are available upon reasonable request. Data will be processed in accordance with the General Data Protection Regulation (GDPR) and the Data Protection Act 2018. We will not make any record-level data publicly accessible because we need to protect the confidentiality and security of the individual cohort members. You are welcome to contact us with proposals for collaborative research, which the investigators will consider on a case-by-case basis, and which will only occur as part of a legal collaborative agreement and after the collaborator has put in place the relevant research ethics, data protection and data access approvals.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
Recruitment from a longitudinal cohort study where underlying characteristics are known.
Rapid roll-out and use of validated measures for mental health and well-being outcomes aligned with our previous health and well-being study and other UK general population studies’ measures.
Only generalisable to veterans who were in military service during the Iraq/Afghanistan era.
The study is limited to the context of the COVID-19 pandemic in the UK, June–September 2020.
Introduction
The COVID-19 pandemic has led to large-scale societal changes all over the world, with governments implementing strict controls on movement and substantial restrictions to people’s personal and work lives.1 Despite the benefits to public health of containment strategies such as ‘lockdown’, self-isolation and social distancing (eg, slower spread of infection), the social, economic, well-being and health consequences are likely to be profound2 3 and felt in the short, medium and long term.
The uncertainty and unpredictable nature of the COVID-19 pandemic has had a general negative impact on psychological and mental health.4 The impact of COVID-19 is not uniform. Vulnerable groups, such as the elderly, young, women, and people with mental or physical ill health or on low income are at greater risk of social isolation and worse health outcomes.2 The analysis of longitudinal data from the UK Household Longitudinal Study (UKHLS), also known as ‘Understanding Society’ Study, indicated that mental health in the UK worsened substantially from prior wave 9 data collected January 2017–May 2019 with increased General Health Questionnaire (GHQ) scores of 10.8% on average in April 2020, and worse scores in wave 9 data for individuals with pre-existing mental health difficulties.5 Longitudinal data from the Office for National Statistics (ONS) also report that there has been a deterioration in mental health of the general population in Great Britain with 19.2% of adults reporting depression in June 2020 compared with 9.7% before the pandemic July 2019–March 2020.6
In Great Britain, there are an estimated 2.4 million ex-service personnel (veterans) making up 5% of household residents aged 16 years and over.7 It is currently unknown how UK veterans may experience the pandemic and the consequent effect on their health and well-being. Individuals with anxiety-related disorders (eg, anxiety or post-traumatic stress disorder) appear to be at higher risk of experiencing psychological distress during the ongoing pandemic.8 A proportion of the veteran population show increased risk of mental and physical health issues and barriers to help-seeking,9 10 and there has been some evidence of an increase in the number of wounded veterans who have struggled with their mental and physical health since the start of lockdown in the UK.11 Loneliness and social isolation are recognised problems for society in general, but ex-service personnel present with unique experiences of loneliness and social isolation, which for some can be linked to their poor reintegration into civilian life and the community.12 13 A study exploring how New Zealand veterans conceptualised loneliness during COVID-19 lockdown indicated that both social and physical isolation and health-related factors were significant drivers of loneliness.14 However, in contrast to the general population (excluding emergency responders), military personnel are trained to demonstrate readiness and resilience in the face of warfare operations and stressful environments.15 Therefore, it is unknown whether veterans’ military training may also create resilient responses in the face of COVID-19 uncertainties compared with the general population.
The circumstances created by the COVID-19 pandemic may require a reconsideration of how healthcare and systems of support should be adapted to effectively accommodate the needs of the ex-service population, especially the most vulnerable within this population.16 The current study (Veterans-CHECK) aims to investigate the impact of the COVID-19 pandemic on the health and well-being of UK veterans, assessing mental health and alcohol use before and during the pandemic. It will measure veterans’ reports of loneliness during the pandemic and it will also assess the impact of COVID-19 experiences and stressors on mental health, hazardous alcohol use and loneliness outcomes. Understanding this impact will be important to the government, Armed Forces charities, and other stakeholders to target services and support and ensure current policy initiatives are fit for purpose in the context of the pandemic.
Method
Study design and participants
Participants were recruited from the King’s Centre for Military Health Research (KCMHR) health and well-being survey. This is a large-scale ongoing investigation of the physical and mental health and well-being of UK Armed Forces personnel from all three services (regulars and reservists) and includes personnel who were first surveyed before the recent conflicts in Iraq,17 as well as during and after the conflicts in Iraq and Afghanistan. There have been three phases of data collection—phase 1: 2004–2006, phase 2: 2007–2009 and phase 3: 2014–2016.9 18 19 Approximately 18 000 have taken part in the survey since it began. Individuals were invited to take part in the Veterans-CHECK Study if: they had completed a questionnaire at phase 3 of the health and well-being study, had left the UK Armed Forces, had regular service, were living in the UK, had consented to follow-up and provided a valid email address. Invitation emails were sent to N=3547 of individuals who met this eligibility criteria.
Procedure
Data collection was conducted online. Participants were asked to complete a questionnaire in their personal settings through REDCap, a secure web application for building and managing online surveys and databases.20 Consents were completed online on the REDCap platform. The questionnaire had sections including (a) sociodemographics; (b) COVID-19 experiences and stressors; (c) current mental health and well-being measures. A full description of the study protocol is available online.21
The COVID-19 experiences and stressors section included self-report of having COVID-19 (those who indicated a positive PCR test or reported they had ‘probably’ had COVID-19 were counted as having COVID-19 for analysis purposes), experiencing isolation, bereavement and other challenges, such as childcare arrangements and caring responsibilities during the pandemic. Participants were asked about employment changes since the start of the pandemic with two categories created of ‘no change/furlough’ and ‘change for worse’ which included those that reported unemployment, redundancy or reductions in salary. Individuals were asked whether they had experienced COVID-19 stressors in the past month, followed by a list of stressors they could endorse pertaining to finances, health and other difficulties. Education and military background information was taken from phase 3 of the cohort study9 (rank, service branch, length of service). A variable of ‘financial difficulties’ was constructed using three items from the list of COVID-19 stressors. Experiencing at least one of ‘another bill payer in your household lost their job or was unable to earn money’, ‘unable to pay bills’ or ‘other financial difficulties’ was categorised as experiencing ‘financial difficulties’. Symptoms of common mental health disorders (CMDs) were measured using the 12-item GHQ, cut-off scores for case status used were 4 or more (scores range from 0 to 12)22 ; 10-item Alcohol Use Disorder Identification Test (AUDIT) was used to measure alcohol use, cut-off scores of 8 or more were used for hazardous drinking (scores range from 0 to 40), and 16 or more defined as alcohol misuse (which is likely to be harmful to health),23 AUDIT-C score of 5 or more indicating risky drinking24 ; and the 3-item University of California, Los Angeles (UCLA) Loneliness Scale to measure feelings of loneliness with a cut-off of 6 or more (scores range from 3 to 925).
Data collection
One invitation email was sent to participants in June 2020 with up to three email reminders sent in June, July and August 2020, with data collection closing at the end of September 2020.
Analyses
To calculate response weights, we used social and military demographic data collected at previous phases of the KCMHR cohort study including sex, age, education level, rank (most recent when serving), service branch, marital status, role when serving (combat/support) and cohort sample (sampled originally at phases 1, 2 or 3). We constructed a binary response variable such that 0=did not respond and 1=responded. We carried out univariable logistic regression to determine which of these demographic/military variables was statistically associated with response at the p<0.05 level. The variables found to be associated were entered into a multivariable logistic model. The probability of responding given these characteristics was ascertained, and response weights calculated as the inverse of the probability of responding. The variables in the final response weights model were age, sex, rank, service branch, education level and cohort sample.
The sociodemographic and military characteristics of the sample were described. Mental health and alcohol use during COVID-19 were compared with previous mental health and alcohol use from phase 3 of our health and well-being survey.9 Logistic regression analyses were conducted to assess the associations between the outcomes of interest (CMD, hazardous drinking and loneliness) and COVID-19 experiences and stressors. Logistic regression analyses were adjusted for sex, age, education, marital status, rank and service. Further analyses were adjusted additionally for previous CMD or hazardous drinking status at phase 3 of our health and well-being study. All statistical analyses were performed using the statistical package, Stata (V.16.026), with survey commands used to account for weighting. Weighted percentages and ORs are presented in tables to account for response weights, together with unweighted cell counts.
Patient and public involvement
Veterans who sit on our research board provided feedback on the content and flow of the questionnaire; the questionnaire was amended and refined accordingly. Findings from the study will be disseminated to study participants through a newsletter, social media outlets and our stakeholders that represent veteran communities.
Results
The response rate was 44% (1562 of 3547). Responders were more likely to be older, officers, of higher educational status, have served in the Royal Air Force (RAF), were less likely to have reported alcohol misuse, but more likely to have reported multiple physical symptoms, and poor/fair health at phase 3 of the cohort (online supplemental table 1). Table 1 describes the sociodemographic and military characteristics of those who participated in the study. The majority of participants were male, non-commissioned officers, had served in the Army, were educated to A-level or degree level, and in a relationship. Over half the sample had left service 10 or more years ago and the majority were in employment before the pandemic. The majority of respondents lived in England (85.8%, n=1334).
Supplemental material
Sociodemographic and military characteristics of sample (N=1562)
Before and during COVID-19 pandemic: mental health and alcohol use
Overall, the percentage of participants meeting the threshold for CMD remained stable from pre-pandemic levels, increasing only slightly from 24.5% (n=354) to 26.1% (n=376), where this increase was not statistically significant (table 2). All measures of alcohol use were statistically significant reductions from pre-pandemic levels. Veterans reported hazardous drinking reductions from 48.5% (n=642) to 27.6% (n=367), alcohol misuse reductions of 9.2% (n=119) to 3.7% (n=50) and high-risk consumption reductions of 73.0% (n=987) to 49.2% (n=649). In further analysis (available upon request), female veterans in the sample reported similar trends as male veterans mirroring the stability in CMD levels and statistically significant reductions in alcohol use.
Pre-pandemic and during pandemic mental health and alcohol use outcomes
Loneliness, COVID-19 experiences and stressors
A total of 27.4% (n=395) of the sample reported feelings of loneliness. Tables 3 and 4 describe COVID-19 experiences and stressors. A total of 14.8% (n=226) of the sample reported definitely or probably having COVID-19, with 16.5% (n=249) of the sample having to self-isolate. A total of 18.5% (n=286) of the sample knew someone who died from COVID-19. The large majority of the sample had no change in employment or were furloughed (91.6%, n=1425). Just under half of the sample reported being key workers (46.3%, n=674), with 19% (n=131) of these key workers being health and social care key workers.
Association between CMD, hazardous drinking and loneliness and COVID-19 experiences
Association between CMD, hazardous drinking and loneliness and COVID-19 stressors
The large majority of the sample lived with their spouse/partner (84.6%, n=1328). Just under a quarter of the sample were responsible for two or more children under the age of 18 years old (24.2%, n=320). Just under half of those who had children they were responsible for had to change childcare arrangements because of the pandemic (47.6%, n=214) and 44.7% (n=94) reported the change in childcare arrangements had a negative impact on their life. A total of 17.9% (n=271) reported extra or new caring responsibilities because of the pandemic. The most frequently reported COVID-19 stressors were boredom (24.9%, n=352), having to change or delay major plans (23.7%, n=364) and difficulties with family/other social relationships (19.5%, n=278).
Association of mental health outcomes and COVID-19 experiences and stressors
Tables 3 and 4 present ORs (adjusted OR) for the association between CMD symptoms, hazardous drinking and loneliness adjusted for sex, age, education, marital status, rank and service.
Common mental disorders
Increased odds of reporting symptoms of CMD were associated with self-report of definitely or probably having COVID-19, knowing someone who died from COVID-19, reporting a change for worse in employment during the pandemic (compared with no change/furlough), not being a key worker, living alone, being responsible for two or more children under 18 years of age (compared with no children), having to change childcare arrangements because of the pandemic, having usual caring responsibilities (compared with none) or extra/new caring responsibilities because of the pandemic (table 3). Increased odds of reporting CMD were associated with all COVID-19 stressors (table 4). The stressors with the largest effect sizes included having difficulties with health, difficulties with family/other social relationships, work difficulties and having financial problems.
Hazardous drinking
Increased likelihood of reporting drinking at hazardous levels was associated with having difficulties with health, difficulties with family/other social relationships and experiencing boredom.
Loneliness
Increased reporting of loneliness was associated with knowing someone who died from COVID-19, being a health and social care key worker (compared with other key workers), living alone, being responsible for one or two or more children (compared with none), and having usual caring responsibilities (compared with none) (table 3). Increased reporting of loneliness was associated with several COVID-19 stressors (table 4), the largest effect sizes were reporting difficulties with family/other social relationships, difficulties with health and experiencing boredom.
Adjusting for previous CMD and hazardous drinking
Adjusting for previous CMD or hazardous drinking case status reported at phase 3 of our health and well-being study attenuated the association of CMD and of hazardous drinking with COVID-19 experiences and stressors, but it did not change the direction of association, and the majority of associations remained significant at the 95% level (online supplemental table 2). For four COVID-19 experiences or stressors, the associations become non-significant, yet their effect size remained large. These included the association of reporting CMD symptoms and living alone, difficulty accessing enough food, difficulty accessing medication and losing someone close to you (online supplemental table 2).
Discussion
Compared with pre-pandemic levels taken in 2014–2016, levels of CMDs in UK veterans remained stable. Veterans reported statistically significant reductions in levels of hazardous drinking during the pandemic compared with pre-pandemic levels. A total of 27.4% reported feelings of loneliness. Just under 15% of people in the study self-reported definitely or probably having COVID-19. Half of individuals with children who they were responsible for reported that changes in childcare negatively affected their life and nearly one-fifth of individuals had new or extra caring responsibilities because of the pandemic. The most common COVID-19 stressors reported were boredom, having to change major life plans, and difficulties with family or other social relationships. The COVID-19 stressors of difficulties with family or other social relationships, boredom and difficulties with health were all associated with veterans reporting CMD, hazardous drinking and loneliness. Adjustment for previous CMD or hazardous alcohol use did not change the direction of association and the majority of associations remained statistically significant. Our study identifies there may be a specific impact of COVID-19 experiences and stressors on veterans’ CMD, alcohol use and loneliness outcomes.
CMD levels have remained stable with a small, statistically non-significant increase. This should be compared with population data showing significant increases in CMD in the general population. For example, ONS figures found a 9.5% increase in depression from the period July 2019–March 2020 to June 20206 ; the UKHLS reported a 7.6% increase in CMD between 2017–2019 and April 2020.4 Veterans’ pre-pandemic CMD levels were higher than the general population levels (Veterans-CHECK phase 3 2014–2016: 24.5% vs UKHLS 2018–2019: 18.9%4) but were similar during the pandemic (UK studies ranging from 26.0% to 30.6%4 27 28). The absence of a similarly large increase in CMD caseness in the veteran group may indicate resilient responses in this group who have been previously trained in readiness for deployments, resilience and coping strategies.15 29 30
From further analyses of the veteran sample (available upon request), of the 373 CMD cases, 214 (56.6%) of these were new cases since 2014–2016 (with a similar number of remitting cases). Hence, while numbers potentially needing clinical treatment remain similar, there may be new individuals who need to engage with services. Additionally, as a majority of the COVID-19 experiences and stressors (particularly difficulties with health, work or family/other social relationships) were associated with CMD symptoms, it may be this veteran group with CMD particularly impacted by COVID-19 pressures. Similar COVID-19 pressures on families and negative associations with mental health outcomes are reported in US samples.31 As found in our study, the UKHLS finds negative mental health impacts for parents with childcare responsibilities and home schooling requirements during the pandemic.32 One-fifth of our sample had extra or new caring responsibilities during the pandemic which may have added to family stress levels. Previous research has shown how important social connection is for carers’ mental health outcomes33 and lockdown and social distancing needs may have disrupted support for carers in this sample.
Compared with veterans’ drinking behaviours pre-pandemic in 2014–2016, levels of hazardous drinking and alcohol misuse reduced (hazardous drinking: 48.5% vs 27.6% and alcohol misuse: 9.2% vs 3.7%, respectively). However, we found the Veterans-CHECK sample to be consuming alcohol, as measured by the AUDIT-C, at higher levels than the general population in England during the pandemic (Veterans-CHECK 49.2% vs 38.3%34). Hence, despite reductions in hazardous drinking and alcohol misuse for veterans in this sample, and increases in general population high-risk drinking, a higher proportion of veterans are still in high-risk drinking categories. This finding continues to mirror previous studies that find veterans drinking at higher levels than the general population.35
There may be several explanations for the reduction in hazardous drinking. Alcohol has often been used as a social bonding tool in Armed Forces community,36 37 therefore the closing or restrictions placed on the hospitality business may explain the reduction in alcohol consumption. Alternatively, this may represent a general population trend observed in the UK population where high-risk drinkers have reduced their alcohol consumption.28 34 The COVID-19 Social Study reports that drinking less during the pandemic was associated with being male,38 and our sample is predominantly male. The study identified that responders were less likely to have reported alcohol misuse before the pandemic, however differences in reported alcohol use between responders and non-responders were minimal. Non-responders may have mirrored general population trends of male and high-risk drinkers’ reduction efforts28 34 38 and therefore also followed this reduction trend. Few COVID-19 stressors were associated with hazardous drinking and therefore we could surmise that alcohol was not being used as a coping mechanism in this community during the pandemic.
Our veteran sample reported lower levels of loneliness compared with a UK general population sample from the COVID-19 Social Study (27.4% vs 39%)39 and similar levels to another study (27%).40 An explanation could be that our study collected data during June–September when lockdown restrictions were less than in March–May when the other studies collected their data. Additionally, the veteran sample may have a level of protection against loneliness due to a majority being in a relationship. Of note are the findings that individuals with children under 18 years of age, and those with caring responsibilities, were more likely to report feelings of loneliness. We, therefore, see a pattern of extra pressures on those with family responsibilities, who would not have had the usual social support networks due to restrictions. The finding that key workers in health and social care were more likely to report feeling lonely compared with other key workers highlights the extra support that healthcare key workers may need in the pandemic.41
As seen elsewhere, boredom was common in veterans during the pandemic and was strongly associated with CMD, hazardous alcohol use and loneliness,42 and has been associated with psychological distress for individuals who reported ‘high meaning in life’, as defined as stable sense of purpose and fulfilment in life.43 With restrictions reintroduced in the winter of 2020 and into 2021, the long-term effect of boredom on veterans’ well-being, identity, purpose and fulfilment remains to be seen.3
While CMD levels in our veteran group have not risen from pre-pandemic levels, there are still a significant minority of veterans who may need mental health treatment and support. Due to the nature of COVID-19 lockdowns and restrictions in the UK, the National Health Service and charitable providers should particularly focus on the benefits of telemedicine for veterans into the future.16 44 45 Our study demonstrates an impact of the pandemic on veteran families increasing their stress, relationship/caring difficulties and responsibilities. There has been success in the USA promoting parenting skills for veteran families under COVID-19 pressures,46 while in the UK, resources created by King’s College London and partners offer practical support for families (‘Families Under Pressure’) which could be used by veteran groups.47 As with the general population, innovative ways are needed to tackle loneliness and improve social networks and support during the pandemic, particularly focused on those with mental health needs.48 49
The study strengths include recruitment from a cohort whose previous mental health status is known, rapid roll-out, and use of validated measures for mental health and well-being outcomes aligned with our previous study and other UK general population studies’ measures. Study limitations include recruitment from a specific veteran cohort serving during the Iraq/Afghanistan era and therefore we cannot comment on the experiences of veterans outside of this era. Only a minority of veterans in this sample were newly transitioned to civilian life and therefore this study may not capture the experiences of those who have recently left service, some of whom may be negatively impacted by this pressure point.50 There were only a small number of younger ‘other ranks’ in this sample who may be more likely to experience financial issues,51 and therefore the extent of negative associations between COVID-19 stressors and outcomes may not be fully represented. The study identified that responders were less likely to have reported alcohol misuse before the pandemic and therefore the direction of alcohol use of non-responders is unknown which may underestimate reductions in alcohol use during the pandemic. While we were able to identify similar trends in female veterans for CMD and drinking compared with male veterans in this sample, the number of women in the sample was insufficient to robustly examine associations of COVID-19 stressors and outcomes. While the study captures data from veterans regarding their family experiences, such as relationship, childcare and caring pressures, the study was not able to collect data from veterans’ partners/spouses and children themselves. The study is limited by the majority of responses arising from veterans living in England and limited to the context of the pandemic in the UK, June–September 2020.
Conclusions
Our study suggests a COVID-19 impact on veterans’ mental health, alcohol use and loneliness, particularly for those experiencing difficulties with family or social relationships. Veterans experienced the pandemic in similar ways to the general population and in some cases may have responded in resilient ways. While stable levels of CMD and reduction in alcohol use are positive, there remains a group of veterans who may need mental health and alcohol treatment services. There is a need to continue to follow up the health and well-being of this veteran group to assess developments’ longer term over the pandemic.
Data availability statement
Data are available upon reasonable request. Data will be processed in accordance with the General Data Protection Regulation (GDPR) and the Data Protection Act 2018. We will not make any record-level data publicly accessible because we need to protect the confidentiality and security of the individual cohort members. You are welcome to contact us with proposals for collaborative research, which the investigators will consider on a case-by-case basis, and which will only occur as part of a legal collaborative agreement and after the collaborator has put in place the relevant research ethics, data protection and data access approvals.
Ethics statements
Ethics approval
Full ethical approval was obtained from the King’s College London Research Ethics Committee (Ref: HR-19/20-18626).
Acknowledgments
We acknowledge the contribution to the framing of the protocol for this research by Dr Sharon Stevelink, Dr Daniel Leightley and Rupa Bhundia through their work with the KCL-CHECK and NHS-CHECK Studies. We thank the KCMHR colleagues and the veterans who helped to shape the survey questionnaire.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
M-LS and DS are joint first authors.
Twitter @MarieLouiseLu
Contributors M-LS, DS, MJ, HB, DP, LH, DP, DM, SW and NTF were involved in the original concept and design of the study. NTF and SW have overseen the conduct of all aspects of the study. M-LS led the formulation of the questionnaire and associated measures, with substantial contributions from all authors in shaping the final questionnaire. DP led the online survey design, format and flow. DS led the ethics submission with substantial contributions from all authors. MJ, HB and LH led the design of participant materials including the participant invite and information sheet with input from all authors. MJ led the data analysis plan and conducted the data analysis with input from all authors. M-LS and DS led the writing of the research paper, with drafting and revision input from all authors. M-LS, DS, MJ, HB, DP, LH, DP, DM, SW and NTF have all seen and approved the final version of this paper and accept accountability for all aspects of the work. SW and NTF secured the funding from OVA for this work.
Funding This work was funded by the Office of Veterans’ Affairs, Cabinet Office, UK Government (Contract Ref: CCZZ20A51).
Competing interests SW is Honorary Civilian Consultant Advisor in Psychiatry for the British Army (unpaid). SW is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King’s College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University. NTF is a trustee (unpaid) of The Warrior Programme, an independent advisor to the Independent Group Advising on the Release of Data (IGARD), a member of Independent Scientific Pandemic Insights Group on Behaviours (SPI-B) and their salary is part grant funded by the MoD. DM is a trustee of the Forces in Mind Trust (unpaid) and is employed as the Head of Research for Combat Stress, a UK Veterans Mental Health Charity.
Provenance and peer review Not commissioned; externally peer reviewed.
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