Combat and operational stress programs and interventions: A scoping review using a tiered prevention framework.

Beginning in 1999, Department of Defense policy directed the military services to develop Combat and Operational Stress Control (COSC) programs to address prevention, early identification, and management of the negative effects of combat and operational stress. The aim of this study is to provide a narrative review of COSC programs and organize them into a prevention framework to clarify gaps and future directions. A systematic search was conducted to identify studies between 2001 and 2020 in peer-reviewed articles or government-sponsored reports describing an evaluation of COSC programs. The target population of these programs was US service members who had participated in an intervention designed to address combat or operational stress in a deployed, operational, or field setting. These programs then were rated for level of evidence and categorized using a tiered prevention model. This search identified 36 published evaluations of 19 COSC programs and interventions from. Most programs were described as effective in addressing target outcomes, with behavioral health outcomes reported for 13 of the 19 identified programs; the remaining six focused on knowledge base and behavior changes. Delivery of these prevention programs also ranged from peer-based implementation to formal treatment, including programs at all prevention levels. COSC interventions show promise for helping service members manage stress, with more than half of the programs showing evidence from studies using randomized designs. Future iterations of COSC program evaluations should explore the development of a joint curriculum using existing content in a tiered prevention framework.

Examination of military personnel’s changed psychological statesduring long-term deployment in a war zone

Una de las formas más eficaces para prevenir las consecuencias negativas del despliegue en la zona militar para la salud mental de los militares es diagnosticar su estado psicológico. En el presente estudio se determinan las particularidades de los cambios en el estado psicológico de los militares (n = 192) durante el despliegue de seis meses en la zona militar en el este de Ucrania. Los resultados obtenidos confirmaron ambas hipótesis formuladas: en cuanto a la posibilidad de determinar, sobre la base del diagnóstico del estado psicológico, el plazo recomendado para el despliegue de los militares en la línea de demarcación en el este de Ucrania, que es de tres meses. Así como también sobre las posibles diferencias significativas en la dinámica del estado psicológico de los militares que tienen y no tienen experiencia en el despliegue. Asimismo, se argumenta la necesidad de monitorear el estado psicológico de los militares durante el despliegue con el propósito de prevenir oportunamente las consecuencias negativas para su salud mental y para la ejecución exitosa de las tareas de la subunidad militar.(AU)

Examining military personnel’s psychological states is an effec-tive way to prevent negative mental health consequences during their de-ployment in a war zone. The present study identifies changes in the psy-chological states of military personnel (n=192) during a 6-month deploy-ment in a war zone in eastern Ukraine. The results confirmed both of our proposed hypotheses. First, with regard to time limits on military person-nel’s deployment on the front lines in eastern Ukraine on the basis of ex-amined psychological states, the estimated recommended deployment du-ration was three months. Second, we found significant differences in the dynamics of the psychological states of service members with versus with-out previous deployment experience. The results also substantiate that mil-itary personnel’s psychological states should be monitored during deploy-ment in order to prevent negative mental health consequences and to en-sure that military units successfully accomplish their tasks.(AU)

Psychophysiological Intervention to Improve Preparedness in Military Special Operations Forces.

BACKGROUND: Actual studies in military training support the use of new methodological approaches such as high intensity interval training and inverse periodization training rather than conventional approaches. However, the application and analysis of success of these new methodologies are as yet unknown.METHODS: The military adapted the civil reverse periodization training system, composed of 6 wk and five sessions per week. For the first 3 wk soldiers performed two sessions with the objective of increasing the maximal strength of the upper and lower body muscles, and three sessions of short high-intensity interval training (HIIT). In the following 3 wk they combined two endurance HIIT and two resistance HIIT sessions with military equipment while conducting a military task.RESULTS: After the training a significant body mass index decrease was found, along with an increase in lower limb muscular strength, aerobic and anaerobic performance, resilience, stress tolerance, and psychological flexibility. Regarding the ratio of acceptance there was an increased ratio compared to previous years of 7%. In addition, married soldiers with children presented greater resilience, stress tolerance, psychological flexibility, and a higher ratio of success.DISCUSSION: Accepted soldiers presented greater psychological status and stress tolerance, highlighting the importance of the work of the unit psychologists to reinforce and monitor the psychometric profile of the soldiers as well as their intrinsic characteristics of personality and emotionality. The greater baseline physical condition and higher performance in all physical tests proves how reverse periodization training models are a great stimuli and training approach in soldiers.Tornero-Aguilera JF, Gregório Pelarigo J, Clemente-Suarez VJ. Psychophysiological intervention to improve preparedness in military Special Operations forces. Aerosp Med Hum Perform. 2019; 90(11):953-958.

Sleep disturbances after deployment: National Guard soldiers' experiences and strategies.

Sleep deprivation and sleep disturbance are pervasive among military personnel during and after combat deployment. However, occupational and other constraints often influence military workers to decline behavioral health services and prescription pharmaceutical sleep aids. This article, drawing on ethnographic interviews with National Guard veterans of combat deployment, demonstrates that soldiers with sleep disturbance frequently manage symptoms without medical supervision and by using ad hoc methods including alcohol use. Findings suggest the potential significance of further research into the sleep management practices of military populations, who face both high risk for sleep disturbance and occupational and cultural constraints in effectively managing these serious health concerns.

Acute delivery of attention bias modification training (ABMT) moderates the association between combat exposure and posttraumatic symptoms: A feasibility study.

Combat deployment enhances risk for posttraumatic stress symptoms. We assessed whether attention bias modification training (ABMT), delivered immediately prior to combat, attenuates the association between combat exposure and stress-related symptoms. 99 male soldiers preparing for combat were randomized to receive either an ABMT condition designed to enhance vigilance toward threat or an attention control training (ACT) designed to balance attention deployment between neutral and threat words. Frequency of combat events, and symptoms of PTSD and depression were measured prior to deployment and at a two-month follow-up. Regression analysis revealed that combat exposure uniquely accounted for 4.6% of the variance in stress-related symptoms change from baseline to follow-up and that the interaction between ABMT and combat exposure accounted for additional 5.4% of the variance. Follow-up analyses demonstrate that ABMT moderated the association between combat exposure and symptoms. ABMT appear to have potential as a preventative intervention to reduce risk for stress-related symptoms associated with combat exposure.

Selective prevention of combat-related post-traumatic stress disorder using attention bias modification training: a randomized controlled trial.

BACKGROUND: Efficacy of pre-trauma prevention for post-traumatic stress disorder (PTSD) has not yet been established in a randomized controlled trial. Attention bias modification training (ABMT), a computerized intervention, is thought to mitigate stress-related symptoms by targeting disruptions in threat monitoring. We examined the efficacy of ABMT delivered before combat in mitigating risk for PTSD following combat. METHOD: We conducted a double-blind, four-arm randomized controlled trial of 719 infantry soldiers to compare the efficacy of eight sessions of ABMT (n = 179), four sessions of ABMT (n = 184), four sessions of attention control training (ACT; n = 180), or no-training control (n = 176). Outcome symptoms were measured at baseline, 6-month follow-up, 10 days following combat exposure, and 4 months following combat. Primary outcome was PTSD prevalence 4 months post-combat determined in a clinical interview using the Clinician-Administered PTSD Scale. Secondary outcomes were self-reported PTSD and depression symptoms, collected at all four assessments. RESULTS: PTSD prevalence 4 months post-combat was 7.8% in the no-training control group, 6.7% with eight-session ABMT, 2.6% with four-session ABMT, and 5% with ACT. Four sessions of ABMT reduced risk for PTSD relative to the no-training condition (odds ratio 3.13, 95% confidence interval 1.01-9.22, p < 0.05, number needed to treat = 19.2). No other between-group differences were found. The results were consistent across a variety of analytic techniques and data imputation approaches. CONCLUSIONS: Four sessions of ABMT, delivered prior to combat deployment, mitigated PTSD risk following combat exposure. Given its low cost and high scalability potential, and observed number needed to treat, research into larger-scale applications is warranted. The ClinicalTrials.gov identifier is NCT01723215.

El impacto de la guerra en la salud de la infancia siria / Impact of the war in Syrian childhood health

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Adverse health consequences of the Vietnam War.

The 40th anniversary of the end of the Vietnam War is a useful time to review the adverse health consequences of that war and to identify and address serious problems related to armed conflict, such as the protection of noncombatant civilians. More than 58,000 U.S. servicemembers died during the war and more than 150,000 were wounded. Many suffered from posttraumatic stress disorders and other mental disorders and from the long-term consequences of physical injuries. However, morbidity and mortality, although difficult to determine precisely, was substantially higher among the Vietnamese people, with at least two million of them dying during the course of the war. In addition, more than one million Vietnamese were forced to migrate during the war and its aftermath, including many "boat people" who died at sea during attempts to flee. Wars continue to kill and injure large numbers of noncombatant civilians and continue to damage the health-supporting infrastructure of society, expose civilians to toxic chemicals, forcibly displace many people, and divert resources away from services to benefit noncombatant civilians. Health professionals can play important roles in promoting the protection of noncombatant civilians during war and helping to prevent war and create a culture of peace.

Postdeployment resilience as a predictor of mental health in operation enduring freedom/operation iraqi freedom returnees.

BACKGROUND: Much of the research on the impact of trauma exposure among veterans has focused on factors that increase risk for mental health problems. Fewer studies have investigated factors that may prevent mental health problems following trauma exposure. This study examines resilience variables as factors that may prevent subsequent mental health problems. PURPOSE: To determine whether military service members returning from Afghanistan and Iraq who exhibit higher levels of resilience, including hardiness (encompassing control, commitment, and challenge), self-efficacy, and social support after returning from deployment are less vulnerable to subsequent mental health problems, alcohol, and drug use. METHODS: A national sample of 512 service members was surveyed between 3 and 12 months of return from deployment and 6-12 months later. Data were collected in 2008-2009 and analyzed in 2013. Regression analyses ascertained whether resilience 3-12 months after return predicted later mental health and substance problems, controlling for demographic characteristics, mental health, and risk factors, including predeployment stressful events, combat exposure, and others. RESULTS: Greater hardiness predicted several indicators of better mental health and lower levels of alcohol use 6-12 months later, but did not predict subsequent posttraumatic stress symptom severity. Postdeployment social support predicted better overall mental health and less posttraumatic stress symptom severity, alcohol, and drug use. CONCLUSIONS: Some aspects of resilience after deployment appear to protect returning service members from the negative effects of traumatic exposure, suggesting that interventions to promote and sustain resilience after deployment have the potential to enhance the mental health of veterans.

Behavioral health leadership: new directions in occupational mental health.

The impact of stress on mental health in high-risk occupations may be mitigated by organizational factors such as leadership. Studies have documented the impact of general leadership skills on employee performance and mental health. Other researchers have begun examining specific leadership domains that address relevant organizational outcomes, such as safety climate leadership. One emerging approach focuses on domain-specific leadership behaviors that may moderate the impact of combat deployment on mental health. In a recent study, US soldiers deployed to Afghanistan rated leaders on behaviors promoting management of combat operational stress. When soldiers rated their leaders high on these behaviors, soldiers also reported better mental health and feeling more comfortable with the idea of seeking mental health treatment. These associations held even after controlling for overall leadership ratings. Operational stress leader behaviors also moderated the relationship between combat exposure and soldier health. Domain-specific leadership offers an important step in identifying measures to moderate the impact of high-risk occupations on employee health.

Predictors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

IMPORTANCE: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality. OBJECTIVES: To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations. DESIGN, SETTING, AND PARTICIPANTS: Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009. MAIN OUTCOMES AND MEASURES: Death by suicide or accident during active Army service. RESULTS: The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army's increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides. CONCLUSIONS AND RELEVANCE: Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.

Evolution of the combat and operational stress control detachment.

Medical units designed to provide combat and operational stress control services have evolved since World War II into the current Combat and Operational Stress Control (COSC) detachments. Yet the structure of these COSC detachments differ greatly between what is authorized in the table of organization and equipment (TO&E) and what is doctrinally described in the current field manual guiding combat and operational stress control operations. We therefore explore the evolution of the COSC detachment, compare the organizations found in current doctrine with that currently authorized on the TO&E, and conclude with a proposed structure of a modern COSC detachment that is functionally modular with more clear chains of command.

Field procedures in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study of unprecedented size and complexity designed to generate actionable evidence-based recommendations to reduce US Army suicides and increase basic knowledge about determinants of suicidality by carrying out coordinated component studies. A number of major logistical challenges were faced in implementing these studies. The current report presents an overview of the approaches taken to meet these challenges, with a special focus on the field procedures used to implement the component studies. As detailed in the paper, these challenges were addressed at the onset of the initiative by establishing an Executive Committee, a Data Coordination Center (the Survey Research Center [SRC] at the University of Michigan), and study-specific design and analysis teams that worked with staff on instrumentation and field procedures. SRC staff, in turn, worked with the Office of the Deputy Under Secretary of the Army (ODUSA) and local Army Points of Contact (POCs) to address logistical issues and facilitate data collection. These structures, coupled with careful fieldworker training, supervision, and piloting, contributed to the major Army STARRS data collection efforts having higher response rates than previous large-scale studies of comparable military samples.

The use of biomarkers in the military: from theory to practice.

This paper provides a summary of relevant issues covered in the conference, "The Use of Biomarkers in the Military: Theory to Practice" held at the New York Academy of Science on September 14, 2012. The conference covered the state of the science in identification of PTSD biomarkers, including, the definition of different classes of biomarkers pertaining to PTSD. The aim of the satellite conference was to bring together researchers who have been supported by the Department of Defense, Veterans Administration, National Institutes of Health, and other agencies around the world, who are interested in the identification of biomarkers for PTSD risk, diagnosis, symptom severity and treatment response, for a discussion of salient issues regarding biomarker development for PTSD, as well as special considerations for the use of biomarkers in the military.

Epidemiology and prevention of combat-related post-traumatic stress in OEF/OIF/OND service members.

This article summarizes information about the prevalence of post-traumatic stress disorder (PTSD) in military personnel and Veterans who have served in the Iraq and Afghanistan conflicts as well as the disorder's impact and efforts to prevent it in this population. We examine prevalence in light of epidemiologic methods and discuss associated outcomes, etiology, and factors affecting risk for PTSD. Prevention strategies are presented both in terms of individual-level interventions and operational strategies designed to mitigate the development of PTSD. Our findings indicate that while research into the prevalence and consequences of PTSD in the Iraq and Afghanistan cohort has been significant, relatively little is known about the effectiveness of approaches designed to prevent it.

Prevention and care of combat-related PTSD: directions for future explorations.

In the past decade, military personnel supporting the wars in Iraq and Afghanistan have faced multiple deployments and repeated traumatic stressors. Despite efforts to prevent post-traumatic stress disorder (PTSD) and other combat-related emotional difficulties, a significant number of military personnel experience psychological injuries during and following their deployments. Despite increased attention to prevention and treatment of these problems, it is clear that substantially more work is required to fully understand the emotional impact of combat and to better intervene to prevent potentially chronic problems. In the present article, the authors discuss possible avenues for future research and interventions (clinical and otherwise) to better prevent the development of combat-related PTSD. We discuss screening, assessment, education, and intervention for PTSD throughout the deployment cycle. In this discussion, we attend to both the needs of the current cohort of combat veterans and the potential advances that may mitigate the severity and chronicity of post-traumatic problems arising from future conflicts.

Evaluation of a third-location decompression program for Canadian Forces members returning from Afghanistan.

BACKGROUND: Service members returning from combat can experience difficulty adapting to home life. To help ease this transition, the Canadian Forces provides a Third-location Decompression (TLD) program in Cyprus to members returning from deployment to Afghanistan. METHODS: The 5-day program consists of individual free time, structured recreational activities, and educational programming. Its perceived value and impact were measured immediately afterward and 4 to 6 months later. RESULTS: Respondents overwhelmingly supported the TLD concept, with 95% agreeing that "some form of TLD is a good idea." Eighty-one percent of participants found the program valuable, and 83% recommended it for future deployments to Afghanistan. Perceived value persisted 4 to 6 months after return, and 74% felt that it helped to make reintegration easier for them. CONCLUSION: Canadian Forces members saw value in the TLD program, and most members believed that the program had its intended effect of making the reintegration process easier for them.

Soldiers' perceptions of resilience training and postdeployment adjustment: validation of a measure of resilience training content and training process.

Group randomized trials of a resilience training program (formerly Battlemind training) demonstrated effectiveness of the program in reducing postdeployment adjustment problems among military personnel. These results are promising, but program evaluation is a dynamic, multifaceted task, and many questions remain. This article is designed to address one component of resilience training program evaluation: soldiers' perceptions of the training. Specifically, a self-report measure assessing attitudes and satisfaction in domains theorized to be important to resilience training was developed. This measure was administered to 782 soldiers who participated in a 1-hr resilience training session at 4-months postdeployment. Several mental health outcomes (e.g., alcohol problems, posttraumatic stress symptoms, physical health symptoms, unit morale) were assessed before training and 6 months later. Structural validity, internal consistency, concurrent validity, and predictive validity of the measure were examined. Analyses identified two factors reflecting attitudes toward Training Content and Training Process. The factors demonstrated good internal consistency, and both correlated with overall training satisfaction and mental health-related attitudes. In addition, both factors predicted significant positive change in a set of mental health outcomes at 6-month follow-up. Implications for postdeployment resilience training are discussed.