Combat Injury, Limb Loss, Traumatic Brain Injury, and Psychosocial Outcomes Among Military Personnel

Importance Given the burden and rising number of injuries from recent conflict zones such as Ukraine and the Middle East, understanding the long-term health outcomes of those with physical traumatic injuries is critical. Objective To investigate psychosocial outcomes among UK military personnel who sustained physical combat injuries during deployments to Afghanistan and how traumatic amputation and traumatic brain injury (TBI) are associated with these outcomes. Design, Setting, and Participants This cohort study used data from a prospective cohort (Armed Services Trauma and Rehabilitation Outcome [ADVANCE]) that includes a group of participants who sustained physical combat injuries and a frequency-matched, demographically similar uninjured group. Data were assessed a median of 11 (IQR, 10-13) years following injury at the UK Defense Medical Rehabilitation Centre (Stanford Hall) from August 2018 to August 2023. Data were analyzed from March 2024 to July 2026. Exposures Physical combat injury, including injury profiles with and without limb loss or with deployment-related TBI of varying severity. Main Outcomes and Measures Psychometrically validated self-report questionnaire data indicating probable alcohol misuse, generalized anxiety, depression, posttraumatic stress disorder (PTSD), or mental health multimorbidity (MHM). Results A total of 1047 participants were included in the analysis (median age, 37 [IQR, 34-41] years; 100% male). A total of 523 had sustained combat injuries (141 with limb loss and 382 without, 225 with any TBI, 144 with mild TBI, and 81 with moderate to severe TBI), and 524 were in the uninjured group. Among nonofficers who sustained physical combat injuries, increases in the risk of reporting probable generalized anxiety (adjusted risk ratio [ARR], 1.92 [95% CI], 1.40-2.95]), depression (ARR, 1.78 [95% CI, 1.37-2.44]), PTSD (ARR, 2.00 [95% CI, 1.39-3.00]), and mental health multimorbidity (ARR, 2.05 [95% CI, 1.35-3.16]) were observed compared with participants who were not injured. Limb loss resulted in only small or inconclusive differences in the risk of reporting any mental health outcomes (lowest ARR for generalized anxiety, 1.24 [95% CI, 0.65-2.15]; highest ARR for MHM, 1.36 [95% CI, 0.63-2.59]), whereas greater risk was observed in those injured without limb loss (lowest ARR for depression, 1.95 [95% CI, 1.47-2.67]; highest ARR for MHM, 2.32 [95% CI, 1.52-3.60]). Injuries with mild TBI also resulted in greater risk (lowest ARR for depression, 2.31 [95% CI, 1.63-3.29]; highest ARR for MHM, 2.63 [95% CI, 1.62-4.80]), whereas moderate to severe TBI resulted in smaller elevations with greater uncertainty (lowest ARR for generalized anxiety, 1.52 [95% CI, 0.72-2.78]; highest ARR for MHM, 2.25 [95% CI, 1.11-4.21]). Co-occurring TBI increased observed risks in those injured with and without associated limb loss. All injury types investigated were associated with only small or inconclusive risks for reporting alcohol misuse. Conclusions and Relevance Specific injury profiles, namely deployment-related TBI or injuries without limb loss, were associated with elevated risk of poor mental health outcomes among UK military personnel. Injury profiles may be a key contextual factor in physical combat injury research for the identification of individuals at elevated risk of poor mental health outcomes.