[Factors influencing patient competency and health care of service members of the German armed forces with deployment-related mental illness: A patient interview study]. / Einflussfaktoren auf die Patientenkompetenz und die Versorgung einsatzgeschädigter, psychisch erkrankter Soldat*innen der Bundeswehr: eine Interviewstudie mit Betroffenen.

BACKGROUND: The number of service members of the German armed forces suffering from deployment-related mental health problems is steadily rising. Preliminary studies have shown that less than 50 % seek professional help. There is little knowledge about the factors influencing the development of an adequate level of patient competence to cope with the complexity of the clinical picture and the care of people with operational disabilities in the interprofessional network. METHODS: The article presents data gathered by semi-structured, guided interviews from 14 affected individuals analyzing salient beliefs about the perceived factors influencing their patient competence and care through the interprofessional network of supporters inside and outside the German armed forces. Data evaluation was carried out by means of content-structuring, qualitative content analysis using the method of deductive-inductive category formation. FINDINGS: Based on the interviews conducted, we identified four groups of salient beliefs having an influence on patient competence: identify changes and limitations, recognize illness, redirect one's life, help shape one's life again, and four groups of salient beliefs having an influence on care: intangible / material support, medical supplies, psychosocial support, third-party support. All main topics could be assigned to three levels of influence (individual, individual-contextual, contextual) and stored with a total of 70 topics (codes). INTERPRETATION: The development of an effective "social structure" was named by those affected as an important influencing factor. Family members, comrades, superiors, and military GPs appear to have a significant impact on patient competence and care. The respondents' opinions about the importance of internal factors such as the soldier's self-image and fear of stigmatization are consistent with previous findings. Structural factors like supply procedures were mentioned as specific German armed forces phenomena.

Deployment-related quarantining-a risk or resilience factor for German military service members? A prospective analysis during the third-fifth waves of COVID-19.

Background: Mandatory deployment-related quarantining added further constraints on soldiers during the pandemic. Contrary to overwhelming research documenting an adverse impact of quarantining on mental health, no adverse short-term mental health effects of pre-deployment quarantining for German soldiers were identified. Therefore, we are interested in a potentially delayed onset, the impact of an additional post-deployment quarantine, and quarantine-associated risk and resilience factors predicting mental health post-deployment. Methods: In a prospective research design, 928 German soldiers enrolled in the study at the in-processing of pre-deployment quarantine between February 2021 and March 2022. Every German military service member undergoing pre-deployment quarantine could participate. The soldiers were between 18 and 64 years old; 87.5% identified as male and 12.5% as female. Self-reported mental health (Mini-SCL), perceived social support (FSozU-K22), and perceived unit cohesion were assessed three to five times: at the beginning and the end of pre-deployment quarantine (Nt1 = 928, Nt2 = 907), if still mandatory-at the beginning and the end of post-deployment quarantine (Nt3 = 143 and Nt4 = 132), and 3 months post-deployment, on average 7 to 8 months later than pre-deployment quarantine (Nt5 = 308). The analyzed quarantine-associated risk and resilience factors were informedness about COVID-19, infection risk, quarantine benefit, clarity of quarantine protocol, need for intimacy/bonding, norms, stigma, practicality, financial disadvantages, boredom, and health-promoting leadership. Results: Despite four different mental health trajectories identified, repeated measures ANOVAs revealed a significant improvement in mental health post-deployment (F[2,265] = 21.54, p < 0.001), a small decrease in social support (F[2,266] = 16.85, p < 0.001), and no significant changes in unit cohesion (F[2,264] = 0.482, p = 0.618) 3 months post-deployment. Using stepwise regression, 24% of variance in mental health symptomatology post-deployment is predicted pre-deployment by a clear quarantine protocol, unit cohesion, intimacy/bonding, and social support (F[4,263] = 22.23, p < 0.001). In total, 30% of mental health at the end of post-deployment quarantine is predicted by stigma and a clear quarantine protocol (F[2,99] = 22.22, p < 0.001). Conclusion: Although no overall adverse impact of quarantining on mental health was found, it is recommended to address perceived stigma and clearly communicate the quarantine protocol, and to further follow up on the perceived decrease in social support.

Randomized Controlled Trials to Treat Obesity in Military Populations: A Systematic Review and Meta-Analysis.

In recent years, overweight and obesity have reached an alarmingly high incidence and prevalence worldwide; they have also been steadily increasing in military populations. Military personnel, as an occupational group, are often exposed to stressful and harmful environments that represent a risk factor for disordered eating, with major repercussions on both physical and mental health. This study aims to explore the effectiveness of weight loss interventions and assess the significance of current obesity treatments for these populations. Three online databases (PubMed, PsycInfo, and Web of Science) were screened to identify randomized controlled trials (RCTs) aiming to treat obesity in active-duty military personnel and veterans. Random-effects meta-analyses were conducted for body weight (BW) and body mass index (BMI) values, both longitudinally comparing treatment groups from pre-to-post intervention and cross-sectionally comparing the treatment group to controls at the end of the intervention. A total of 21 studies were included: 16 cross-sectional (BW: n = 15; BMI: n = 12) and 16 longitudinal (BW: n = 15; BMI: n = 12) studies were meta-analyzed, and 5 studies were narratively synthesized. A significant small overall BW and BMI reduction from baseline to post-intervention was observed (BW: g = -0.10; p = 0.015; BMI: g = -0.32; p < 0.001), together with a decreased BMI (g = -0.16; p = 0.001) and nominally lower BW (g = -0.08; p = 0.178) in the intervention group compared to controls at the post-intervention time-point. Despite limitations, such as the heterogeneity across the included interventions and the follow-up duration, our findings highlight how current weight loss interventions are effective in terms of BW and BMI reductions in military populations and how a comprehensive approach with multiple therapeutic goals should be taken during the intervention.

The impact of the pandemic on the perception of stress and danger, and the adjustment of psychiatric and general medical staff of German military hospitals.

Introduction: The COVID-19 pandemic changed not only the working conditions but also the private conditions we live in. Health care professionals especially were confronted with multiple stressors, e.g., the risk of infection, lack of staff, and high workloads. Methods: To estimate some of the pandemic-related impacts this anonymous personnel survey was conducted in two German military hospitals (Hamburg and Berlin). This study presents a comparative analysis of the hospital staff in general vs. the psychiatric personnel (N = 685) at two measurement time points (MTPs) in April 2021 (n = 399) and December 2021 (n = 286). The survey contains the German version of the Covid Stress Scale (CSS) to assess the perceived level of pandemic-related stress, the Patient Health Questionnaire (German Version: PHQ-D) to screen for three major mental disorders, and the adjustment disorder-New Module (ADNM) to estimate the problems of adaptation to change. Results: The results showed a process of adaptation over the two MTPs with significant stress reduction at MTP2 in the general staff. The psychiatric staff did not report significantly higher pandemic-related symptoms. Quite the contrary, not only did the CSS show significantly lower xenophobia, traumatic stress, and compulsive checking, but the PHQ also showed lower stress symptoms and somatic symptoms at both MTPs. Also, the ADNM scores delivered evidence for a more effective adaptation process in psychiatric personnel (e.g., depressive mood, avoidance, anxiety). Discussion: The presented results must be interpreted while taking the unique situations of German military clinics into account. The supply of protective material was sufficient and there was no dramatic shortage of psychiatric staff during the pandemic. The inpatients were quite often (40%) elective treatments for trauma-related disorders, which could be discontinued in the case of a COVID-19 infection. The results of this study showed good adaptative skills among the psychiatric staff in military hospitals, which could be interpreted as a sign of good resilience. This might have led to lower stress-related symptoms during the COVID-19 pandemic.

Mental health during the COVID-19 pandemic: Stress and strain profiles in the German population.

Clinical observations indicate that people frequently display stress-related behavior during the COVID-19 pandemic. Although numerous studies have been published concerning pandemic-related psychological distress, systematic data on the interrelationships between stress sensitivity, personality, and behavioral characteristics of people are still lacking. In the present cross-sectional online survey study, we applied a German version of the COVID Stress Scales (CSS) and standard psychological questionnaires to systematically identify the complex interplay between stress sensitivity, gender, and personality in the modulation of quality of life and mental health in the German population (N = 1774; age ≥ 16 years). A CSS-based cluster analysis revealed two clusters characterized by higher and lower stress levels. Study participants in each cluster differed significantly with respect to neuroticism, extraversion, agreeableness, quality of life, depression, and anxiety. Females were significantly overrepresented in the higher stress cluster, while there was an overrepresentation of males in the lower stress cluster. Neuroticism was identified as a risk factor and extraversion as a protective factor for enhanced pandemic-related stress responses. For the first time our data show a taxonomy of factors, which modulate pandemic-related stress sensitivity and warrant consideration as key indicators of quality of life and psychological distress during the COVID-19 pandemic. We suggest that our data may advise governmental regulation of pandemic-related public health measures, to optimize quality of life and psychological health in different groups of the population.

Trauma-related but not PTSD-related increases in hair cortisol concentrations in military personnel.

Dysregulated hypothalamic-pituitary-adrenal (HPA) axis functioning has been associated with posttraumatic stress disorder (PTSD). The current literature is inconsistent regarding this association, possibly due to confounding influences. Hair cortisol concentrations (HCC) allow for retrospective assessment of cumulative HPA axis secretion over several weeks and are considered a trait-like marker of HPA axis activity. Three groups of active and former German Armed Forces service members, comprising PTSD patients (n = 19), healthy controls with deployment-related trauma exposure (n = 10), and non-deployed healthy controls (n = 10) provided samples for HCC analysis. We observed significantly higher HCC in the PTSD and the deployed compared to the non-deployed group. HCC was neither significantly correlated with perceived chronic stress, nor with PTSD severity within patients. The results suggest a differential impact of trauma exposure on HPA axis activity and highlight the notion of cumulative, retrospective cortisol secretion as a psychobiological indicator of trauma exposure. TRIAL REGISTRATION: Australian Clinical Trials Registry (ACTRN12616000956404).

Salivary Cortisol and Alpha-Amylase in Posttraumatic Stress Disorder and Their Potential Role in the Evaluation of Cognitive Behavioral Treatment Outcomes.

Alterations in HPA-axis and autonomic nervous system activity have been associated with posttraumatic stress disorder (PTSD) development and maintenance and are potentially associated with trauma-focused cognitive behavioral therapy (TF-CBT) outcomes. We examined the role of salivary cortisol (sCort) and alpha-amylase (sAA) in PTSD and TF-CBT outcomes in German Armed Forces service members (N = 100). Participants categorized as PTSD patients (n = 39), previously deployed healthy controls (n = 33), and nondeployed healthy controls (n = 28) provided diurnal profiles of sCort and sAA; PTSD patients provided samples before, immediately after, and 3 months after an internet-based TF-CBT intervention. No group differences emerged regarding total daily sCort and sAA output or daily slopes, ps = .224-.897, fs = 0.05-0.24. Participants with PTSD demonstrated a significantly attenuated sCort awakening response compared to deployed, p = .021, d = 0.59, but not nondeployed controls, p = .918, d = 0.08. Moreover, a significantly steeper sAA awakening response emerged in PTSD patients, p = .034, d = 0.67, and deployed controls, p = .014, d = 0.80, compared to nondeployed controls. From pretreatment to posttreatment (n = 21) and posttreatment to follow-up (n = 14), stable sCort, ps = .282-.628, fs = 0.34-0.49, and sAA concentrations, ps = .068-.758, fs = 0.24-1.13 paralleled a nonsignificant treatment effect. Both PTSD and trauma exposure were associated with alterations in awakening responses, but further investigation is needed to determine whether the observed correspondence remains when PTSD symptoms significantly decline.

Suicidal behavior in German military service members: An analysis of attempted- and completed suicides between 2010 and 2016.

Studies identified service members of the United States (US) Armed Forces as a high-risk group for suicide. A significant increase in the suicide rate in the US Armed Forces was found in recent years. To date, there is no military suicide statistic available for the German Armed Forces. This study examined attempted and completed suicides in active service members of the German Armed Forces between 2010 and 2016 retrospectively, on the basis of archived personal and medical records in the central archives of the Medical Service of German Armed Forces. The primary goal was to establish a suicide-statistic for the German Armed Forces and to calculate and compare the suicides rates with the German population. Secondary every case's data was analysed the groups of attempted and completed suicides were compared. 262 attempted suicides and 148 completed suicides were included in this study (N = 410). The suicide rates of the German Armed Forces peaked over the years 2014-2015 with a suicide rate of 15-16/100.000 active military service members and exceeded the civilian suicide rate in Germany of around 12/100.000 people during those years, although no general trend could be determined. These service members were mostly young men (attempted suicide 81.7%, completed suicide 99.3%), at the age of 17 - <35 years old (87% attempted suicide, 68,3% completed suicide), and were employed less than 6 years in the German Armed Forces (attempted suicide 72.9%, completed suicide 46.3%). Service members with attempted suicides belonged mostly to the military North Atlantic Treaty Organization (NATO)-rank-group for other ranks (lowermost military professionals) OR-1 -OR-4 (48.1%) or to the rank-group OR-6 -OR-9 in the group of completed suicides (34.5%). Only in about one third of cases a psychiatric diagnosis could be found in the records. Most frequent diagnoses were neurotic, stress-related and somatoform disorders (International Classification of Diseases Tenth Revision^ICD-10: F4) in 46.8%, and affective disorders (ICD-10: F3) in 43.3% of all cases. In the majority of cases there were signs for potential stressors in the private sector (attempted suicide 90.6%, completed suicide 82.6%). No typical risk factors which would enable a specific prevention could be identified in this analysis. Therefore, should preventive strategies be aiming at a multi-level intervention program.

Associations between oxytocin and vasopressin concentrations, traumatic event exposure and posttraumatic stress disorder symptoms: group comparisons, correlations, and courses during an internet-based cognitive-behavioural treatment.

Background: Posttraumatic stress disorder (PTSD) is characterized by impairments in extinction learning and social behaviour, which are targeted by trauma-focused cognitive behavioural treatment (TF-CBT). The biological underpinnings of TF-CBT can be better understood by adding biomarkers to the clinical evaluation of interventions. Due to their involvement in social functioning and fear processing, oxytocin and arginine vasopressin might be informative biomarkers for TF-CBT, but to date, this has never been tested. Objective: To differentiate the impact of traumatic event exposure and PTSD symptoms on blood oxytocin and vasopressin concentrations. Further, to describe courses of PTSD symptoms, oxytocin and vasopressin during an internet-based TF-CBT and explore interactions between these parameters. Method: We compared oxytocin and vasopressin between three groups of active and former male service members of the German Armed Forces (n = 100): PTSD patients (n = 39), deployed healthy controls who experienced a deployment-related traumatic event (n = 33) and non-deployed healthy controls who never experienced a traumatic event (n = 28). PTSD patients underwent a 5-week internet-based TF-CBT. We correlated PTSD symptoms with oxytocin and vasopressin before treatment onset. Further, we analysed courses of PTSD symptoms, oxytocin and vasopressin from pre- to post-treatment and 3 months follow-up, as well as interactions between the three parameters. Results: Oxytocin and vasopressin did not differ between the groups and were unrelated to PTSD symptoms. PTSD symptoms were highly stable over time, whereas the endocrine parameters were not, and they also did not change in mean. Oxytocin and vasopressin were not associated with PTSD symptoms longitudinally. Conclusions: Mainly due to their insufficient intraindividual stability, single measurements of endogenous oxytocin and vasopressin concentrations are not informative biomarkers for TF-CBT. We discuss how the stability of these biomarkers might be increased and how they could be better related to the specific impairments targeted by TF-CBT.

Antecedentes: El trastorno de estrés postraumático (TEPT) se caracteriza por deficiencias en el aprendizaje de extinción y el comportamiento social, que son el objetivo del tratamiento cognitivo conductual centrado en el trauma (TF-CBT). Los fundamentos biológicos de TF-CBT se pueden entender mejor agregando biomarcadores a la evaluación clínica de las intervenciones. Debido a su participación en el funcionamiento social y el procesamiento del miedo, la oxitocina y la arginina vasopresina podrían ser biomarcadores informativos para la TF-CBT, pero hasta la fecha, esto nunca se ha probado.Objetivo: Diferenciar el impacto de la exposición a un evento traumático y los síntomas del TEPT en las concentraciones de oxitocina y vasopresina en la sangre. Además, para describir la evolución de los síntomas del TEPT, la oxitocina y la vasopresina durante una TF-CBT basada en Internet y explorar las interacciones entre estos parámetros.Método: Comparamos la oxitocina y la vasopresina entre tres grupos de militares activos y ex militares de las Fuerzas Armadas Alemanas (n = 100): pacientes con TEPT (n = 39), controles sanos desplegados que experimentaron un evento traumático relacionado con el despliegue (n = 33) y controles sanos no desplegados que nunca experimentaron un evento traumático (n = 28). Los pacientes con TEPT se sometieron a una TF-CBT basada en Internet durante 5 semanas. Correlacionamos los síntomas del TEPT con la oxitocina y la vasopresina antes del inicio del tratamiento. Además, analizamos la evolución de los síntomas del TEPT, la oxitocina y la vasopresina antes y después del tratamiento y el seguimiento de 3 meses, así como las interacciones entre los tres parámetros.Resultados: La oxitocina y la vasopresina no difirieron entre los grupos y no se relacionaron con los síntomas del TEPT. Los síntomas del TEPT fueron muy estables en el tiempo, mientras que los parámetros endocrinos no lo fueron, y tampoco cambiaron en la media. La oxitocina y la vasopresina no se asociaron con los síntomas del TEPT de forma longitudinal.Conclusiones: Principalmente debido a su estabilidad intraindividual insuficiente, las mediciones únicas de las concentraciones de oxitocina y vasopresina endógenas no son biomarcadores informativos para TF-CBT. Discutimos cómo podría aumentarse la estabilidad de estos biomarcadores y cómo podrían relacionarse mejor con las deficiencias específicas a las que se dirige TF-CBT.

Adherence and Psychosocial Well-Being During Pandemic-Associated Pre-deployment Quarantine.

Background: With the purpose of preventing SARS-Cov-2 traveling with the troops, pre-deployment and post-deployment quarantine are mandatory for the German military. This study investigates which factors could be addressed in order to facilitate adherence and mental health during isolation. Method: Six hundred three soldiers completed questionnaires at the beginning and at the end of pre-deployment quarantine: Mini-SCL (BSI), Perceived Social Support (FSozU-K22), Unit Cohesion, Military Quarantine Adherence Questionnaire (MQAQ), and quarantine-associated factors including informedness about Covid-19, perceived individual risk, benefit of quarantine, clarity of quarantine protocol, need of intimacy, social norms, stigma, practicality of the quarantine, financial disadvantages, boredom, and health promoting leadership. Results: Using stepwise regression analyses, up to 57% of the quarantine adherence was explained by social norms, boredom, perceived benefit/effectiveness of the quarantine, clear communication of the quarantine protocol and perceived risk of an infection, with social norms explaining 43%. In respect to mental health (Mini-SCL) at the beginning of quarantine, only 15% is explained by being in a partnership, (un)fulfilled need for bonding/intimacy, perceived unit cohesion, and perceived social support. Up to 20 % of the variance in mental health at the end of quarantine is explained by accumulated days of isolation before pre-deployment quarantine, age, clear communication of the quarantine protocol, perceived social support, fulfilled need for bonding/intimacy and perceived stigma. Mental health and quarantine adherence did correlate significantly, but to a slight extent. No differences between the beginning and the end of pre-deployment quarantine were found for the overall group in respect to mental health, quarantine adherence, perceived social support and perceived unit cohesion, while their trajectories differed for different subgroups including age, gender, rank, and accumulated days of quarantine: With increasing accumulated days of isolation prior to pre-deployment quarantine, mental health declined over the course of quarantine, though to a small degree. Conclusion: Findings suggest that addressing the norms of fellow soldiers and dependents alike could contribute to quarantine adherence in pre-deployment quarantine. Ongoing research should examine long-term effects on mental health, including these of accumulated days of quarantine, also taking into account post-deployment quarantine.

Psychometric properties of the German version of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) in clinical routine settings: study design and protocol of a multitrait-multimethod study.

INTRODUCTION: The aim of this study is to investigate the diagnostic accuracy, psychometric properties and clinical utility of the German version of the Clinician-Administered Post-Traumatic Stress Disorder (PTSD) Scale for Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) (CAPS-5) in routine clinical settings. METHODS AND ANALYSIS: This study is a non-interventional, multitrait-multimethod design, multicentre study that will be carried out at German civil and military inpatient and outpatient clinics. A total sample size of n=219 participants who have experienced at least one traumatic event according to criteria as defined in the DSM-5 will be recruited. For the investigation of the diagnostic accuracy and clinical utility of the CAPS-5, participants will be categorised into one of three groups, depending on their traumatic experiences and post-traumatic symptomatology: (1) monotraumatisation with PTSD; (2) multiple traumatisation with PTSD and (3) traumatisation without PTSD. Interviews will be conducted face to face by interviewers in routine clinical settings. All participants will also be asked to complete a comprehensive set of questionnaires in order to investigate different facets of construct validity and clinical utility. First, differences between all three groups in CAPS-5 sum and subscale scores will be investigated. Test-retest reliability and inter-rater reliability will be determined. Internal consistency will be calculated using structural equation modeling (SEM) based internal consistency coefficients. Construct validity will be measured with Spearman's rank correlation analyses and multivariate analyses of variance with Holm-Bonferroni corrected post hoc analysis of variances. In order to test diagnostic accuracy, receiver operating characteristics and sensitivity and specificity analyses will be conducted. The model structure of the German CAPS-5 will be analysed using confirmatory factor analyses. ETHICS AND DISSEMINATION: The study received ethical approval by the Ethics Committees of the Faculty of Psychology at the Ruhr-Universität Bochum (reference numbers: 331 and 358). The results of the study will be presented nationally and internationally at scientific conferences and will be published in scientific journals. TRIAL REGISTRATION NUMBER: DRKS00015325.

Evaluation of an internet-based intervention for service members of the German armed forces with deployment-related posttraumatic stress symptoms.

BACKGROUND: The present study was designed to evaluate the efficacy of a therapist-guided internet-based cognitive-behavioral therapy (iCBT) intervention for service members of the German Armed Forces with posttraumatic stress disorder (PTSD). The iCBT was adapted from Interapy, a trauma-focused evidence-based treatment based on prolonged exposure and cognitive restructuring. It lasted for 5 weeks and included 10 writing assignments (twice a week). The program included a reminder function if assignments were overdue, but no multimedia elements. Therapeutic written feedback was provided asynchronously within one working day. METHODS: Male active and former military service members were recruited from the German Armed Forces. Diagnoses were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Mini-International Neuropsychiatric Interview. Psychopathology was assessed at pre-treatment, post-treatment, and 3-month follow-up. Severity of PTSD was the primary outcome and anxiety was the secondary outcome. Participants were randomly allocated to a treatment group that received iCBT immediately or to a waitlist group that received iCBT after 6 weeks. Due to the overall small sample size (n = 37), the two groups were collapsed for the statistical analyses. Change during the intervention period was investigated using latent-change score models. RESULTS: Improvements in the CAPS-5 were small and not statistically significant. For anxiety, small significant improvements were observed from pre- to follow-up assessment. The dropout rate was 32.3%. CONCLUSIONS: The low treatment utilization and the high dropout rate are in line with previous findings on treatment of service members. The interpretation of the current null results for the efficacy of iCBT is limited due to the small sample size, however for military samples effect estimates were also smaller in other recent studies. Our results demonstrate the need to identify factors influencing treatment engagement and efficacy in veterans. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN12616000956404.

[Intervention programs for psychological stress in children of military personnel in the USA - Results of a systematic literature review with regard to transferability to Germany]. / Interventionsprogramme bei psychischen Belastungen von Kindern von Militärangehörigen in den USA.

Intervention programs for psychological stress in children of military personnel in the USA - Results of a systematic literature review with regard to transferability to Germany Abstract. Military personnel who have been deployed in war zones or other unstable regions are at an increased risk to develop mental health disorders, including posttraumatic stress disorder. Likewise, their children are at high risk to develop mental health problems as well as emotional and behavioral difficulties. Most research on prevalence of mental health problems as well as on interventions within this group was conducted in the USA. In Germany, no systematic intervention for children of military members focusing on their experiences of deployment exist. The systematic literature review aimed to analyze existing intervention programs in the USA, in particular for children of military members regarding evidence, type and addressed target group (parents, children, both). Compared to the social welfare and health care systems in the USA, the German systems are different. Hence, a second aim was to examine the transferability of these programs to the specific needs of children of German military members (Bundeswehr). 27 intervention programs could be included in the review. Programs, directly or indirectly, are addressing the needs of children of a deployed parent. They are usually focusing on the "emotional cycle of deployment" (phase of preparation of deployment, separation phase of deployment and the return of the deployed parent). The programs mainly focused on parenting skills, family reactions to stress, coping strategies of families, and the feeling of coherence within the family. Only 20 % of the interventions could be assigned to the type of indicated prevention. Nine interventions have shown positive effects (either in RCT or non-experimental designs). Several elements of the programs are transferable to the German situation of children of military members. In particular, contents which address the specific situation of families with a military member are desperately needed in Germany. Transferability is limited by the non-comparability of health care and social welfare systems in the USA and in Germany.

Parental military deployment as risk factor for children's mental health: a meta-analytical review.

There is evidence that military service increases the risk of psychosocial burden for not only service members but also their spouses and children. This meta-analysis aimed to systematically assess the association between military deployment of (at least one) parent and impact on children's mental health. For this meta-analytic review, publications were systematically searched and assessed for eligibility based on predefined inclusion criteria (studies between 2001 until 2017 involving children with at least one parent working in military services). Measurements were determined by total problem scores of the children as well as symptoms of anxiety/depression, hyperactivity/inattention, and aggressive behavior. Meta-analyses aggregated the effect sizes in random-effect models and were calculated separately for the relation between parental deployment and civilian/normative data and for the relation between parental deployment and non-deployment. Age of the children was used as moderator variable to explore any potential source of heterogeneity between studies. Parental military deployment was associated with problems in children and adolescents compared to civilian/normative samples. Significant effect sizes reached from small to moderate values; the largest effect sizes were found for overall problems and specifically for anxious/depressive symptoms and aggressive behavior. Within the military group, children of deployed parents showed more problem behavior than children of non-deployed parents, but effect sizes were small. Age of the children had no moderating effect. The results emphasize that children of military members, especially with a deployed parent, should be assessed for emotional and behavioral problems.

German research perspectives on suicidality and the rationale for future multinational suicide prevention projects among military service personnel.

As a result of scientific publications indicating that the last two decades have seen an increase in the number of suicides in the US Armed Forces, the topic of suicide in the military of other countries, such as Germany, has also received a lot of attention in media and science alike. Risk factors for suicidal behaviour and suicide were identified in several research projects in the US, Canada, the UK, and Germany. Until now, German suicide research among military service personnel has mainly focused on epidemiological aspects of suicides and suicidality, individual risk factors, sub-groups at risk for suicide, suicides and deployment abroad, and associations of suicide and suicide attempts with acute mental disorders. The key findings are summarized in this review article. Efforts should be made to develop and evaluate risk group-focused and occupation-focused prevention and intervention programs. Future multinational studies should address potential differences between risk groups for fatal and non-fatal suicidal behaviour.

[Mental Health Stigma: An Influencing Factor in Healthcare Utilization by Veterans of the German Armed Forces]. / "Treffer im Kopf" ­ Stigma psychischer Erkrankungen als Einflussfaktor auf die Inanspruchnahme von Hilfsangeboten durch VeteranInnen der Bundeswehr.

THEORETICAL BACKGROUND AND OBJECTIVE OF THE STUDY: Mental illness stigma is a barrier to healthcare utilization. This study is the first to research the connection between mental illness stigma and the use of healthcare by veterans of the German Armed Forces. An overview of perceived stigma components in this sample is provided that should help understand how these factors influence healthcare utilization. METHODS: 43 interviews with veterans of the German Armed Forces were conducted. The resulting data were analyzed in several coding steps. It was investigated whether the stigma experience of veterans of the German Armed Forces could be well illustrated by the theory-based stigmatization model of Link and Phelan. A set of hypotheses on stigma and healthcare utilization based on the data were developed. RESULTS: All stigma components according to the model of Link and Phelan were found in the sample. Internalized stigma, perceived public stigmatization, vocational disadvantage and social exclusion as well as feared misunderstanding of the military past in the civilian sector were reported as main stigma-relevant barriers to the use of healthcare. CONCLUSIONS: Recommendations for interventions are given to decrease mental illness stigma in this specific group of former soldiers.

Challenges for Research into Military Investigations.

In cases of suspected violations of rules, regulations or the law by armed forces personnel, investigations are invariably mandatory. Military investigations differ from well-researched civilian criminal investigations. Differing from civilian police detectives, most military investigators - as disciplinary supervisors and military police personnel - have a number of tasks to accomplish, which include leading in combat and ensuring military readiness. Military investigations can lead to substantive negative or positive consequences for military readiness, including mental health, unit cohesion and subjective legal certainty. This impact on unit cohesion and mental health is influenced by any prior history of distress or trauma; military investigations are often preceded by contravention of internal disciplinary acts, complaints and traumatic events. This study explores factors in the differing military and legal systems of Germany and the United Kingdom (UK) that might help military personnel to successfully conduct investigations while ensuring deployment readiness and maintaining human rights.

Suicides between 2010 and 2014 in the German Armed Forces-Comparison of Suicide Registry Data and a German Armed Forces Survey.

BACKGROUND: The last 10 years have seen an increase in the number of suicides in the US Armed Forces. Accordingly, the topic of suicides in the German military has received a lot of attention in media and science alike. METHODS: This study retrospectively examined all suicides (N = 107) committed by active, nonretired German military personnel from 2010 to the end of 2014, analyzing archived medical records. In a second step, these data were compared to a representative German Armed Forces survey conducted in 2012 (N = 1,549). RESULTS: The following risk groups for suicide were identified: male (OR = 9.6), single (OR = 7.8), aged over 45 years (OR = 4.0), short period of service (<2 years; OR = 2.7), and low level of education (OR = 2.2). Surprisingly, military personnel with little experience in deployments abroad (<2 missions) showed double the risk (OR = 2.0) compared to those who had been deployed more than once. DISCUSSION: Multiple robustness checks show that being single, aged over 45 years, and having obtained a low level of education exhibit the most robust effects on suicide risk. CONCLUSION: Efforts should be made to develop and evaluate risk group-focused prevention programs. We conclude, that further studies should be initiated to show differences of risk groups between lethal and nonlethal suicidal behavior.

Work disability in soldiers with posttraumatic stress disorder, posttraumatic embitterment disorder, and not-event-related common mental disorders.

OBJECTIVE: Posttraumatic mental disorders may occur with different affect qualities. Best known is posttraumatic stress disorder (PTSD), a conditioned anxiety reaction with intrusions. Another event-related mental disorder is posttraumatic embitterment (PTED), characterized by affect of embitterment and thoughts of revenge, occurring after an event deeply hurting basic beliefs. Knowing about associated disability is important for treatment and sociomedical decisions. This is the first study to explore work-disability in patients with PTSD, PTED, and not-event-related common mental disorder (CMD). METHOD: In this observational study, 101 soldiers (85% men, 31 years, 50% experienced expedition abroad) with different mental disorders were investigated concerning common mental disorders (MINI) and accompanying work capacity impairment (Mini-ICF-APP). Interviews were conducted by a state-licensed psychotherapist with expertise in sociomedical description of (work) capacity impairment. Patients with PTSD, PTED, and other CMD were compared concerning their degrees and pattern of work capacity impairment. RESULTS: PTSD patients (n = 23) were more strongly impaired in mobility as compared to patients with other CMD (n = 64) or PTED. Patients with PTED (n = 14) were more impaired in interactional capacities (contacts with others, group integration) as compared to patients with other CMD or PTSD. CONCLUSIONS: PTSD patients need support to improve mobility in (work-relevant) traffic situations. Apart from this, they are not specifically more or less impaired than patients with other CMD. PTED patients should get attention concerning their interactional problems as these may disturb esprit de corps, which is an essential requirement for service in the armed forces. (PsycINFO Database Record

Attitudes towards disclosing a mental illness among German soldiers and their comrades.

Many soldiers with mental illness (SWMIs) struggle with the decision whether to disclose their condition in or outside the military. This study therefore explored views on (self-)labeling as 'mentally ill', experiences of discrimination and coping, risks and benefits of (non-)disclosure, service use, disclosure decisions and consequences of disclosing. Active-duty SWMIs as well as soldiers without mental illness (commanding officers; enlisted ranks) and military social workers participated in focus groups. Transcripts were analyzed using qualitative content analysis. SWMIs perceived negative stereotypes about their group (weakness, incompetence, blame, malingering) and saw stigma as a barrier to help-seeking. Being labeled 'mentally ill' was seen as harmful for one's career. Self-labeling led to poor self-esteem, greater need for help and feelings of weakness. Many SWMIs had experienced discrimination, such as gossip or inappropriate comments. Social isolation was a disadvantage of secrecy. Most SWMIs preferred selective disclosure and many did not disclose to their family. Military staff without mental illness expressed partly different views and described organizational challenges posed by SWMIs. Our findings suggest that disclosure decisions are personal and difficult and that stigma remains a barrier to re-integration and recovery of SWMIs in the military. Implications for interventions to support SWMIs are discussed.