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Sammanfattning

I samband med internationella militära insatser ställs officerare och soldater inför en variation av tjänsterelaterade stressorer, däribland traumatisk händelseexponering. Trots att post-traumatisk stresstörning (PTSD) generellt sett är välstuderat i en amerikansk militär kontext, vet man mindre om dess förekomst bland svenska militära utlandsveteraner som grupp. På likartat vis vet man lite om de hälsorelaterade effekterna av moraliskt utmanande situationer, samt vilka variabler som kan associeras med moraliska skador bland svenska militära utlandsveteraner.

Syftet med föreliggande studie var att bidra med fördjupad förståelse av hälsorelaterade utfall efter traumaexponering i samband med deltagande i svenska internationella militära insatser, med ett specifikt fokus på PTSD och moralisk skada.

Studien genomfördes som en enkätstudie. Data analyserades genom sambandsanalyser för att kartlägga potentiella statistiska samband mellan variabler av intresse. Data analyserades även med mellangruppsanalyser för att se om det fanns signifikanta skillnader mellan olika grupper som kan bidra till attförklara de orsakssamband som undersöktes. Relationen mellan PTSD och moralisk skada undersöktes också.

Erhållna resultat visar, liksom tidigare forskning på området, att svenska militära utlandsveteraner mår förhållandevis bra som grupp, samtidigt som det finns individuella variationer. En mindre grupp uppvisar förekomst av PTSD-indikation och en ännu mindre grupp förekomst av indikation på moralisk skada. Något fler än de som nådde upp till gränsvärdena för indikation, uppvisade aktiva symptom som kan relateras indikation på PTSD och moralisk skada. Risken för ohälsa tycks vara som störst efter traumaexponering när stressorer enligt Akriteriet(rädslo-/hotbaserad) och moralisk skada (skam, skuld, tillitsförlust) sammanfaller i en och samma händelse, samt då man själv varit direkt involverad ihändelsen och upplever att man själv gjort sig skyldig till något som står i kontrast till egna djupt hållna värderingar.

Studien visar även på flera individ- och arbetsrelaterade faktorer som tycks ha ett samband med långsiktiga hälsoproblem. Till exempel är individer som har sökt och erhållit olika former av stöd efter hemkomst från insats (såsom att ha sökt stöd, medicinerat för ångest, depression eller sömnsvårigheter, varit sjukskriven,etc.) överrepresenterade i den grupp som skattat sin hälsa som sämst under den senaste månaden. Den högre förekomsten av indikation på PTSD och MI trots att man erhållit stöd kan indikera ett behov av behandling specifikt inriktad mot moralisk skada.

Praktiska implikationer av erhållna resultat diskuteras.

Abstract

In the context of international military operations, officers and soldiers are exposed to a variety of service-related stressors, including traumatic event exposure. Although post-traumatic stress disorder (PTSD) is generally well-studied within an American military context, less is known about its prevalence among Swedish military veterans who have served abroad as a group. Similarly, little isknown about the health-related effects of morally challenging situations, as well as which variables may be associated with moral injury among Swedish military veterans.

The purpose of the present study was to contribute to a deeper understanding of health-related outcomes following trauma exposure in connection with participation in Swedish international military operations. This included a specific focus on PTSD and moral injury.

A survey study was conducted on Swedish military veterans who have served in international missions. Data was analyzed through statistical analyses including correlation analyses to map potential statistical relationships between variables of interest and subgroup comparisons to see if significant differences between different groups could help explain the relationships identified. The relationship between PTSD and moral injury was also examined.

The results obtained show, as with previous research in the field, that Swedish military veterans abroad are doing relatively well as a group, however, there are individual differences. A smaller group show elevated levels of PTSD indications, and an even smaller group show elevated indications of so-called moral injury. Some more individuals than those who met the cutoff thresholds for indication exhibited active symptoms that may be related to PTSD and moral injury. The risk of ill health appears to be greatest after trauma exposure that results in elevated symptoms related to both PTSD criterion A (fear-based) and moral injury symptoms (guilt, shame, loss of trust) in the same event. Specifically, when the individual has been the active party in the event and feels that they are guilty of something that is in contrast to their own deeply held values.

The study also shows several individual- and work-related factors that appearto be related to long-term health problems. For example, individuals who have sought and received various forms of support after returning from deployment (such as having sought support, taken medication for anxiety, depression or sleep difficulties, been on sick leave, etc.) are overrepresented in the group who rated their health as poorest in recent months. The higher prevalence of indications of PTSD and MI during the past month, despite having received various forms of support after returning from the deployment, may indicate a need for treatments pecifically targeted at moral injury.

Practical implications of the results are discussed.

Background: Comorbid anxiety and depression are common and can make the problems more complex and sometimes resistant to pharmacological treatment. In existing research, the diagnoses are often studied separately, and physical activity, healthy nutrition, psychoeducation, and social support have shown good effects. The aim of the present study was to explore the longitudinal effects of a comprehensive treatment on patients with comorbid anxiety and depression in a clinical context.

Method: Eighty inpatients (15 men and 65 women) in age range 23–65 years receiving psychiatric treatment in Norwegian clinic participated in the longitudinal study. Treatment was person-centered and was most frequently given for anxiety and depression, e.g., pharmacological treatment and psychotherapy, individually and in groups. In combination with this, physical activity, healthy nutrition, psychoeducation and social support in contacts with authorities and relatives were also a part of treatment. Depression and anxiety were assessed using the Beck Anxiety Inventory and Beck Depression Inventory at three points in time: baseline, at the end of treatment, and 3 months after treatment. The answers were categorized and combined into four groups according to severity of anxiety and depression to measure effects on comorbidity. Mann Whitney U test, Chi-square, Friedmans test, and McNemar test were used to analyze the data.

Result: The results showed a significant increase of frequencies in the group with mild anxiety and depression 3 months past treatment compared to baseline.

Conclusion: Through the comprehensive, person-centered treatment more patients had low levels of both anxiety and depression 3 months after treatment. We suggest that clinics working with comorbid depression and anxiety patients should add physical activity, nutrition advice, social support, and psychoeducation to the traditional treatment regimes. More research concerning comorbid anxiety and depression are urgent to further expand the treatment possibilities.

A high number of military veterans seek professional help at primary healthcare centers for mental health problems. The main aim of this study was to map veterans’ perception of the quality of the care they received when seeking such help after their last tour of duty. A secondary aim was to explore personality and mission-related characteristics of veterans who seek professional help for mental health problems after missions. Questionnaire responses were obtained from 2512 Swedish veterans (43.4% response rate). Among the responders, 210 individuals had sought help for mental health problems at primary healthcare centers. Their perception of the quality of the healthcare was measured using the Quality from the Patient’s Perspective (QPP) questionnaire, which is derived from a theoretical model. Comparisons between the military help seekers and an age and gender matched group of civilian outpatients showed that the military group perceived the information they had received, and the commitment, empathy and respect shown by the physicians, considerably more negatively than the civilian patients. Comparisons between the help-seeking veterans and those who had not sought help, showed that the help seekers were younger and scored significantly lower on emotional stability and higher on conscientiousness. In addition, they perceived the leadership of their immediate commander during the last tour of duty more negatively and they reported fewer daily uplifts and more daily hassles during the tour. It was concluded that a more extensive collaboration between the armed forces and the healthcare system is strongly recommended and that it is necessary to provide education to healthcare providers.

Although the last few decades have witnessed a shift from conscription to all-volunteer forces in many European countries, recent changes in the European security environment have raised new concerns and prompted several countries to reconsider conscription. However, modern conscription systems have also had to adapt to changing societies and an increasing emphasis on individualistic and neoliberal values. This study aims to examine the various forms of military conscription and illuminate the continuing viability of the conscription model in six European countries: Estonia, Finland, Lithuania, Norway, Sweden, and Switzerland. Four of these countries have consistently maintained conscription (Estonia, Finland, Norway, and Switzerland), while Lithuania and Sweden have recently reinstated conscription. Although conscription systems differ among these countries, there is overall an increasing emphasis on conscript motivation and female participation. Three key aspects are identified to describe different conscription systems: the proportion of conscripted individuals in the birth cohort, motivation to serve, and the approach to female conscripts. Combining these aspects, the study identifies three types of conscription system in these six countries. This article demonstrates that conscription has evolved and adapted to changing societies and security situations instead of merely retaining its traditional form.

This article gives a brief insight into the types of problems encountered by, and the well-being and health of, Swedish veterans who have deployed abroad since 1990 and onwards. More specifically, it gives an overview of work-related stressors and health outcomes among Swedish deployed military veterans related to (a) trauma exposure, PTSD, and moral distress/moral injury; (b) milder stress reactions/symptoms and everyday hassles and uplifts; and (c) social outcomes in terms of deployment implications on family and close relationships.

Drawing on previous research, two hypotheses were tested: (1) the higher the frequency of daily uplifts and use of functional coping strategies, and the lower the frequency of daily hassles and use of dysfunctional coping strategies, the lower the prevalence of stress‐related symptoms will be, and vice versa; and (2) the direct relationship between the personality dimension emotional stability and stress‐related symptoms, will be moderated by daily hassles, daily uplifts and coping processes. A quantitative test of a qualitatively developed model was performed. A questionnaire was sent to all Swedish military veterans who had served in the period 2011–2015 and 1859 individuals (1,614 men and 199 women, 46 individuals did not mark gender) responded (40.5% total response rate). All analyses were made separately for men and women. Comparisons between theoretically favorable and unfavorable profiles across the model variables, daily uplifts, daily hassles, functional coping and dysfunctional coping (based on a cluster analysis), showed considerable differences regarding the prevalence of stress‐related symptoms as predicted by the model and supporting the first hypothesis. Regression and moderation analyses yielded limited support for the second hypothesis. As predicted, female veterans reported a higher frequency of physical, emotional and cognitive stress‐related symptoms than male veterans. The main conclusion is that the theoretical model stood up well when empirically tested and offers a promising approach to future studies on everyday stress and health. The results contribute with new knowledge of military veterans compared to the main stream PTSD, depression and drug abuse‐oriented studies.