A bidirectional examination of mental health symptoms and perceptions of leader support: Which comes first?

Leader support for psychological health (LSPH) has been identified as an important factor in the prediction of mental health symptoms among warfighters. Although research has examined the relationship between LSPH and mental health symptoms, the extent to which this relationship is bidirectional has been underexplored. Consequently, the present study examined the longitudinal relationships between perceived LSPH and mental health symptoms (depression and PTSD) among military personnel over a 5-month period. We found that perceived LSPH at Time 1 (T1) was associated with fewer mental health symptoms at Time 2 (T2); however, mental health symptoms at T1 were also associated with lower perceptions of LSPH at T2. The results differed slightly based on the type of symptoms experienced, but the relationships between perceived LSPH and symptoms did not vary based on whether soldiers had been exposed to combat. However, it is important to note that the overall sample had low combat experience. Despite this, these findings may suggest that the assumption that leader support can enhance soldier mental health may fail to consider that the symptoms themselves may also affect how leaders are perceived. Therefore, organizations such as the military should consider both directions to optimally understand the relationship between leaders and subordinate mental health.

Limitations of benefit finding as a coping mechanism for combat-related PTSD symptoms.

Benefit finding has been identified as a buffer of the combat exposure-PTSD symptom link in soldiers. However, benefit finding may have a limited buffering capacity on the combat-PTSD symptom link over the course of a soldier's post-deployment recovery period. In the present study, soldiers returning from Operation Iraqi Freedom (OIF) were surveyed at two different time periods post-deployment: Time 1 was 4 months post-deployment (n = 1,510), and Time 2 was at 9 months post-deployment (n = 783). The surveys assessed benefit finding, PTSD symptoms, and combat exposure. Benefit finding was a successful buffer of the cross-sectional relationship between combat exposure and PTSD reexperiencing symptoms at Time 1, but not at Time 2. In addition, the benefit finding by combat interaction at time 1 revealed that greater benefit finding was associated with higher symptoms under high combat exposure at Time 2 after controlling for PTSD arousal symptoms at Time 1. The results of the present study indicate that benefit finding may have a buffering capacity in the immediate months following a combat deployment, but also indicates that more time than is allotted during the post-deployment adjustment period is needed to enable recovery from PTSD. Theoretical implications are discussed.

Job Demands and Resources among Healthcare Professionals during Virus Pandemics: A Review and Examination of Fluctuations in Mental Health Strain during COVID-19.

The present article examines how job demands and resources are related to indices of strain among healthcare professionals during virus pandemics. The article also presents the results of a study examining the relationships between COVID-19 demands (e.g., lack of personal protective equipment, concerns about infecting family members), resources (meaningful work, social support), and mental health strain within a sample of emergency medicine personnel over six consecutive weeks. COVID-19-related demands and hours worked were hypothesized to be positively related to mental health strain, whereas meaningful work and social support were hypothesized to be negatively related to mental health strain. Hours worked the prior week were hypothesized to exacerbate the positive relationships between COVID-19 demands and mental health strain, whereas the resources of meaningful work and social support were expected to buffer the relationships. Multilevel models controlling for mental health strain the prior week revealed that COVID-19 demands, along with hours worked, were each related to higher mental health strain during the week. Hours worked magnified the within-person relationship between personal COVID-19 demands and mental health strain. In contrast to the hypotheses, social support and meaningful work were not related to mental health strain. Discussion focuses on the implications of the findings for healthcare professionals.

Determinants of mental and physical health treatment-seeking among military personnel.

BACKGROUND: Although research has documented factors influencing whether military personnel seek treatment for mental health problems, less research has focused on determinants of treatment-seeking for physical health problems. AIMS: To explicitly compare the barriers and facilitators of treatment-seeking for mental and physical health problems. METHOD: US soldiers (n = 2048) completed a survey with measures of barriers and facilitators of treatment-seeking for mental and physical health problems as well as measures of somatic symptoms and mental health. RESULTS: The top barrier for both mental and physical health treatment-seeking was a preference for handling problems oneself. The top facilitators for both symptom types were related to treatment improving quality of life. Differential endorsement of barriers occurred for treatment of mental versus physical health symptoms. In contrast, facilitators were endorsed more for physical than for mental health treatment. While there were few gender differences, officers reported more barriers and facilitators than did enlisted personnel. Screening positive for mental or physical health problems was associated with greater endorsement of both barriers and facilitators for physical and mental health treatment, respectively. CONCLUSIONS: The leading barriers and facilitators for seeking treatment for mental health and physical problems are relatively similar, suggesting that health education should consider decision-making in seeking both mental and physical healthcare. Interventions should be tailored to reduce barriers for officers and improve facilitators for junior enlisted personnel, and address barriers and facilitators for service members screening positive for a mental or physical health problem.

LINKS Training and Unit Support for Mental Health: a Group-randomized Effectiveness Trial.

The LINKS curriculum, adapted from Britt et al. (2018a), was designed to improve unit climate, knowledge, and attitudes about mental health treatment seeking in military personnel. The present study extends this research by examining implementation options, comparing the effectiveness of LINKS to an active control condition with training delivered by non-experts and comparing modules that varied in training length. Eight Army platoons were randomly assigned to one of four conditions: (1) 1-h Active Control, (2) 2-h Active Control, (3) 1-h LINKS, or (4) 2-h LINKS. Two platoons were assigned to each condition. Surveys were administered at pre-training (T1), post-training (T2), and 3 months later (T3). Eighty-four participants completed all study phases. Regardless of training content, participants receiving the 2-h modules reported greater training acceptability than those receiving the 1-h modules. At T3, participants in the LINKS conditions reported more mental health knowledge than participants in the Active Control conditions. Sustained effects were also observed on a number of treatment barriers and facilitators, with the LINKS conditions generally leading to better outcomes. At T3, 2-h LINKS condition participants reported receiving more mental health treatment relative to the other conditions. Findings suggest that LINKS can be effectively delivered by non-expert trainers, is a viable intervention for targeting mental health treatment-seeking, and is optimally packaged in a 2-h module. The training might benefit from additional leadership training efforts.

Common mental disorders among US army aviation personnel: Prevalence and return to duty.

OBJECTIVES: Assess the prevalence of US Army aviation personnel with common mental disorders, the percentage that return to duty following mental health treatment, and predictors of return to duty. METHODS: Examined the prevalence over a 5-year period. The percentage of personnel who were granted a waiver to return to flying duty following treatment was also determined. RESULTS: The results revealed a 5-year prevalence of 0.036 (95% CI = 0.034-0.038) for personnel experiencing one or more of the mental disorders (N = 1,155). Prevalence was highest for adjustment disorders and for nonpilot participants. Overall, personnel were granted a waiver 55.3% of the time and suspended or disqualified 44.7% of the time. Waivers were more likely to be granted for an adjustment disorder and for pilots. CONCLUSIONS: Discussion focuses on the importance of aviation personnel receiving mental health treatment when problems are not severe to maximize the likelihood of returning to duty.

Coping Strategies as Moderators of the Association Between Combat Exposure and Posttraumatic Stress Disorder Symptoms.

The present research examined selected coping strategies as moderators of the relationship between combat exposure and posttraumatic stress disorder (PTSD) symptoms among service members who were deployed to Iraq (N = 2,023) and Afghanistan (N = 1,023). A three-factor model of coping was confirmed for both military operations: positive emotion-focused, self-blame, and prayer/spirituality. Positive emotion-focused coping was inversely associated with PTSD symptoms (r = -.14) and buffered service members from the negative effects of combat exposure in both Iraq (r2 = .01) and Afghanistan (r2 = .02). Self-blame coping was positively associated with PTSD symptoms in both samples (Iraq, r = .36; Afghanistan, r = .29) but only magnified the relationship between combat exposure and PTSD symptoms among service members in Iraq (r2 = .01) . These findings were replicated when controlling for unit cohesion and symptoms of depression. Prayer/spirituality coping was not significantly associated with PTSD symptoms, regardless of combat exposure. Discussion focuses on how specific positive emotion-focused coping strategies may be helpful for military personnel in combat operations given the uncontrollable and chaotic nature of the environment. Implications include providing training for deploying personnel that covers the use of these positive emotion-focused coping strategies and the potential problems with self-blame. Such training may also be suitable for other high-risk occupations in which employees face uncontrollable situations.

Longitudinal determinants of mental health treatment-seeking by US soldiers.

BACKGROUND: Studies with members of the armed forces have found a gap between reports of mental health symptoms and treatment-seeking. AIMS: To assess the impact of attitudes on treatment-seeking behaviours in soldiers returning from a combat deployment. METHOD: A sample of 529 US soldiers were surveyed 4 months (time 1) and 12 months (time 2) post-deployment. Mental health symptoms and treatment-seeking attitudes were assessed at time 1; reported mental healthcare visits were assessed at time 2. RESULTS: Factor analysis of the total time 1 sample revealed four attitude factors: professional concerns, practical barriers, preference for self-management and positive attitudes about treatment. For the subset of 160 soldiers reporting a mental health problem at time 1, and controlling for mental health symptom severity, self-management inversely predicted treatment-seeking; positive attitudes were positively related. CONCLUSIONS: Results demonstrate the importance of broadening the conceptualisation of barriers and facilitators of mental healthcare beyond stigma. Techniques and delivery models emphasising self-care may help increase soldiers' interest in using mental health services.

Barriers and Facilitators of Mental Health Treatment-Seeking in U.S. Active Duty Soldiers With Sexual Assault Histories.

Despite significant mental health needs among sexual assault (SA) victims in the military, little is known about treatment-seeking patterns or factors associated with service use. This study examined service use behavior, barriers, and facilitators of mental health treatment-seeking in an active duty sample of 927 U.S. Army soldiers with mental health problems. SA victims (n = 113) did not differ from non-victims on barriers or facilitators after adjusting for demographic and mental health variables, with stigma rated as the largest barrier. Most SA victims (87.6%) had sought informal support and 59.3% had sought formal treatment. One third of treatment-seekers had dropped out of treatment. Multivariate logistic regression analyses identified several correlates of treatment-seeking among SA victims: Black race (OR = 7.57), SA during the military (OR = 4.34), positive treatment beliefs (OR = 2.22), social support for treatment (OR = 2.14), self-reliance (OR = 0.47), and stigma towards treatment seekers (OR = 0.43). Mental health symptoms were not associated with treatment seeking. Findings suggested that treatment-facilitating interventions should focus on improving recognition of mental health symptoms, altering perceptions related to self-reliance, and reducing stigma. Interventions should also enlist support for treatment-seeking from unit members, leaders, and significant others.

Impediments to mental health treatment as predictors of mental health symptoms following combat.

This longitudinal study examined whether impediments to mental health treatment would predict changes in mental health symptoms (posttraumatic stress disorder [PTSD] and depression) in the months following soldiers returning from combat. Three-hundred ten combat veterans completed measures of impediments to treatment and measures of PTSD and depression symptoms at 2, 3, and 4 months following a 15-month combat deployment. Structural equation modeling revealed that greater impediments (a latent variable indexed by stigma, practical barriers, and negative treatment attitudes) at 2 months predicted increased PTSD and depression symptoms from 2-3 months (ß = .14) and greater impediments at 3 months predicted increased symptoms from 3-4 months (ß = .26). In contrast, evidence was not obtained for the opposite causal direction of symptoms predicting higher levels of impediments at the different periods. Possible mechanisms for the predictive effects of impediments are discussed.

Perceived Work Demands and Emergency Department Crowding as Predictors of Objective Stress Among Emergency Physicians: A Shift-Level Approach.

OBJECTIVE: To understand shift-level determinants of emergency physician (EP) burnout, relationships were tested between EP shift demands, stress, and fatigue. METHOD: EP ( n = 16) were assessed over 114 shifts that occurred before and during the COVID-19 pandemic. Salivary cortisol (an indicator of stress) and self-reported fatigue were collected prior to and following each shift. An objective crowding score (National Emergency Department Overcrowding Scale) per shift was calculated. Shift demands were assessed at the end of each shift. RESULTS: Multilevel models revealed that shift demands, National Emergency Department Overcrowding Scale, and the pandemic were related to higher levels of end-of-shift cortisol, but not fatigue. Cortisol levels were higher for shifts with a higher number of demands, greater crowding, and during the pandemic. CONCLUSIONS: Shift demands predicted objective indicators of stress, but not self-reported fatigue. Interventions are needed to decrease stress and shift demands to reduce EP burnout.

Morale as a moderator of the combat exposure-PTSD symptom relationship.

We examined morale as a moderator of the relationship between combat exposure and posttraumatic stress disorder (PTSD) symptoms in a longitudinal study of U.S. soldiers who had participated in a deployment to Iraq. Soldiers (N = 636) completed assessments at 4 (Time 1) and 10 (Time 2) months following their combat deployment. Combat exposure (both breadth and perceived stressfulness), morale, and PTSD symptoms were assessed at Time 1, and PTSD symptoms were assessed again at Time 2. Results of multivariate multiple regressions revealed that morale at Time 1 interacted with both the breadth and stressfulness of combat exposure to predict PTSD symptoms at both Time 1 and Time 2, even when partialling out the effect of unit support. The slope of the given combat exposure and PTSD symptoms relationship was weaker when reports of morale were higher (with the effect size of the interaction ranging from .01 to .04). The results suggest that morale may buffer soldiers from the negative consequences of combat stressors.

Daily expression of workaholism and family outcomes: The buffering and magnifying effects of economic resources.

Workaholism is increasingly recognized as a potential threat to occupational health. Although most research has conceptualized workaholism as a trait, some research suggests that it may also fluctuate from day to day. Moreover, the effects of the dynamic properties of workaholism on work and family outcomes may be contingent on one's economic situation. Therefore, the aim of the present study was to test the interactive effect of workday workaholism and economic resources on nightly work-family conflict and family engagement. Using experience sampling methodology, we demonstrated that workaholism fluctuates from one day to the next and has detrimental short-term effects on work-family conflict. Additionally, our findings indicated that the interaction between workday workaholism and perceived income adequacy predicted both nighty work-family conflict and family engagement. While the association between workday workaholism and work-family conflict was stronger for those who experienced low income adequacy, the relationship between workaholism and family engagement was stronger for those who exhibited high income adequacy. Similarly, job security buffered the effect of workaholism on work-family conflict. We discuss the theoretical and practice implications of this study as well as recommend future research directions.

Objective assessment of sleep and fatigue risk in emergency medicine physicians.

OBJECTIVES: Fatigue is a state of physical and mental exhaustion in which people feel exhausted or drained of energy. Shift workers are highly vulnerable to fatigue, and this is especially true of emergency physicians (EPs). Shift scheduling (shift hours, frequency/length of breaks, time of shift, and number of hours off between shifts) can affect levels of fatigue in EPs. When EPs are fatigued, they experience decrements in cognition, resulting in an increased risk of errors. This study assessed the state of fatigue in EPs in the emergency department of a large, urban hospital using objective measures (sleep metrics and shift scheduling) over multiple months. METHODS: Seventeen EPs, nine females, wore wrist-activity monitors called ReadiBands for 2 months. The ReadiBand is an objective actigraphy measure that communicates with a smartphone application to quantify sleep metrics and predict future fatigue. RESULTS: Throughout the 3083 on-shift hours of data, analyses revealed that EPs have poor sleep quality (mean ± SD 7.71 ± 1.84/10) and sleep quantity (mean ± SD 6.77 ± 1.66 h), with sleep efficiency within "normal" ranges (mean ± SD 87.26 ± 9.00). Participants spent 725 h (23.52%) on shifts with fatigue scores indicative of significant impairment (equivalent to BAC of .08%). In addition, results indicated that shift type (day, evening, night) was significantly associated with fatigue score, where night shifts were associated with higher fatigue scores. CONCLUSIONS: Fatigue is an issue for many EPs. The present study addressed the percentage of time EPs are in a fatigued state when on shift over an extended duration of time. More research is needed to examine system-level interventions for reducing fatigue in EPs.

Shift Happens: Emergency Physician Perspectives on Fatigue and Shift Work.

Research has shown that shiftworkers experience poor sleep and high levels of fatigue. Although considerable research has been performed on fatigue within many shift-work occupations, very little has been done with emergency physicians (EPs). This qualitative study was conducted with the goal of gaining insight into EPs' perceptions of fatigue at work. Twenty EPs from an academic medical center participated in virtual interviews, with nine open-ended questions asked in a semi-structured interview format. Twelve common topics with four main themes emerged from the interviews. Three of these common themes included sources of fatigue (including both work- and home-related sources), consequences of fatigue (including impacts on individuals and performance), and prevention and mitigation strategies to cope with fatigue. The fourth main theme was the belief in the inevitability of fatigue due to high cognitive load, emotionally taxing work experiences, work unpredictability, and the 24/7 shift-work nature of emergency medicine. EPs' experiences with fatigue are consistent with but extend those of other types of shiftworkers. Our findings suggest that EPs tend to incorporate the inevitability of fatigue at work into their identity as EPs and experience a sense of learned helplessness as a result, suggesting areas for future interventions.

"I Don't Want to Go to Work": A Mixed-Methods Analysis of Healthcare Worker Experiences from the Front- and Side-Lines of COVID-19.

During the COVID-19 pandemic, healthcare workers (HCW) were categorized as "essential" and "non-essential", creating a division where some were "locked-in" a system with little ability to prepare for or control the oncoming crisis. Others were "locked-out" regardless of whether their skills might be useful. The purpose of this study was to systematically gather data over the course of the COVID-19 pandemic from HCW through an interprofessional lens to examine experiences of locked-out HCW. This convergent parallel mixed-methods study captured perspectives representing nearly two dozen professions through a survey, administered via social media, and video blogs. Analysis included logistic regression models of differences in outcome measures by professional category and Rapid Identification of Themes from Audio recordings (RITA) of video blogs. We collected 1299 baseline responses from 15 April 2020 to 16 March 2021. Of those responses, 12.1% reported no signs of burnout, while 21.9% reported four or more signs. Qualitative analysis identified four themes: (1) professional identity, (2) intrinsic stressors, (3) extrinsic factors, and (4) coping strategies. There are some differences in the experiences of locked-in and locked-out HCW. This did not always lead to differing reports of moral distress and burnout, and both groups struggled to cope with the realities of the pandemic.

Benefit finding at war: a matter of time.

Benefit finding, described as one's ability to find benefits from stressful situations, has been hypothesized as a buffer against the negative effects of stress on mental health outcomes. Nonetheless, many have questioned the buffering potential of benefit finding in the face of prolonged and excessive stress such as is found in the combat environment. This study suggests that the length of a combat deployment and benefit finding may impact the relationship between combat exposure and posttraumatic stress disorder (PTSD) symptoms. Surveys were distributed to U.S. enlisted soldiers (n = 1,917), officers, and warrant officers (n = 163) of various combat and combat support units deployed to Iraq. A significant 3-way interaction (sr(2) = .004, p < .05) revealed that benefit finding buffered soldiers from increased PTSD symptoms under high levels of combat exposure early in the deployment, but not in later months. These results indicate that although benefit finding may be a useful coping approach during the early phases of deployment, prolonged exposure to stress may diminish a soldier's ability to use benefit finding as a method for coping.

Stigma of mental illness and service use in the military.

BACKGROUND: Many service members do not utilize the available services designed to assist them in coping with post-traumatic stress disorder and other mental health problems that emerge during active duty. AIMS: In the current paper, we discuss the possible role stigma plays in the underutilization of treatments in the military, and attempt to transfer a well-articulated framework for understanding stigma and stigma-change in civilian populations to the military context. METHODS: The literature was searched for papers reviewing negative beliefs about mental illness and fears of stigmatization and underutilization of treatments, especially as relevant to service members. RESULTS: We explain how public stigma, self stigma, and label avoidance may emerge as barriers to care seeking and service participation in soldiers, and propose approaches/strategies for change. We then discuss a number of recent applications of these approaches in both civilian and military initiatives. CONCLUSIONS: Stigma-change programs specifically created by/for the military that integrate components of education and direct contact with respected peers or veterans who have coped with mental health problems may have great utility at both the early stages of military training and later, when soldiers return from theatres of operation.

Chronicling moral distress among healthcare providers during the COVID-19 pandemic: A longitudinal analysis of mental health strain, burnout, and maladaptive coping behaviours.

The COVID-19 pandemic has presented many novel situations that have amplified the presence of moral distress in healthcare. With limited resources to protect themselves against the virus and strict safety regulations that alter the way they work, healthcare providers have felt forced to engage in work behaviours that conflicted with their professional and personal sense of right and wrong. Although many providers have experienced moral distress while being physically in the workplace, others suffered while at home. Some healthcare providers worked in facilities that were unable to open during the pandemic due to restrictions, which could contribute to a sense of powerlessness and guilt. The current study assessed whether the ability to see patients each week impacted the relationship between an employee's moral distress and their mental health strain, burnout, and maladaptive coping. A total of 378 healthcare providers responded to weekly surveys over the course of 7 months (April 2020-December 2020). Hierarchical linear modeling techniques were used to examine the study variables over time. Results showed that moral distress predicted an individual's mental health strain and burnout, even after controlling for the prior week. However, moral distress was not a significant predictor of maladaptive coping. Interestingly, there was not a significant difference between the average ratings of moral distress between those who were able, and those who were not able to see patients, meaning that both groups experienced symptoms of moral distress. However, cross-level moderation results indicated that the ability to see patients magnified the relationships between moral distress and mental health strain and burnout over time. Implications of the results and recommendations for how moral distress should be addressed among healthcare providers are discussed.