Order effects in PTSD network analysis: important implications for diagnostic conceptualization, treatment refinement, and research.

BACKGROUND: For decades confirmatory factor analysis (CFA) has been the preeminent method to study the underlying structure of posttraumatic stress disorder (PTSD); however, methodological limitations of CFA have led to the emergence of other analytic approaches. In particular, network analysis has become a gold standard to investigate the structure and relationships between PTSD symptoms. A key methodological limitation, however, which has significant clinical implications, is the lack of data on the potential impact of item order effects on the conclusions reached through network analyses. METHODS: The current study, involving a large sample (N = 5055) of active duty army soldiers following deployment to Iraq, assessed the vulnerability of network analyses and prevalence rate to item order effects. This was done by comparing symptom networks of the DSM-IV PTSD checklist items to these same items distributed in random order. Half of the participants rated their symptoms on traditionally ordered items and half the participants rated the same items, but in random order and interspersed between items from other validated scales. Differences in prevalence rate and network composition were examined. RESULTS: The prevalence rate differed between the ordered and random item samples. Network analyses using the ordered survey closely replicated the conclusions reached in the existing network analyses literature. However, in the random item survey, network composition differed considerably. CONCLUSION: Order effects appear to have a significant impact on conclusions reached from PTSD network analysis. Prevalence rates were also impacted by order effects. These findings have important diagnostic and clinical treatment implications.

The Impact of Just and Unjust War Events on Mental Health Need and Utilization within U.S. Service Members.

Background: Soldiers are resilient to just war events, such as killing enemy combatants and life-threatening experiences, but these same soldiers appear to struggle with unjust war events, such as killing a noncombatant or being unable to help civilian women and children in need. This study is the first to examine how just and unjust war experiences are associated with clinical health service outcomes. Methods: Two samples of soldiers in different stages of readjustment from deployment were drawn from a longitudinal, survey-based study of a US Army brigade. Measures included items related to combat events, mental health utilization, perceived mental health need, PTSD, depression, and functional impairment. Results: After controlling for other kinds of combat events, just war events (i.e., life-threatening events and killing enemy combatants) predicted outcomes in soldiers who are less than three months post-deployment, but only predicted 2 of 26 outcomes in soldiers one year post deployment. In contrast, unjust war events were found to be robust predictors of short-term and long-term outcomes related to mental health need and utilization, even after controlling for exposure to other combat events. Conclusions: The results extend previous longitudinal research that suggests that exposure to unjust war events carry a heavier long-term mental health burden than other types of events. Additionally, Soldiers exposed to unjust war events had an unmet need for care one year post deployment that was not directly tied to PTSD or depression. The results question the emphasis on life-threat within mental health pathogenesis models.

Brief behavioral treatment for insomnia: Treatment schedule and training feasibility in the military.

Insomnia is a threat to the well-being and combat readiness of military service members. Brief Behavioral Treatment for Insomnia (BBTI) is effective in treating insomnia, but the treatment schedule is difficult to implement in the Military Health System due to shorter appointment windows than what is offered in civilian settings. In the present study, 23 behavioral health providers were trained in a version of BBTI adapted for use within the Military Health System. Training was conducted remotely via a 2-day webinar, followed by 12 weekly telephone consultations with a trainer. Surveys were conducted before and after the 2-day webinar, and after the consultation period. Training led to increases in target knowledge scores and self-rated confidence in administering BBTI. All providers reported implementing the treatment with multiple patients during the 12-week period, and all providers reported that the intervention was more effective than their usual treatment method. All behavioral health providers also reported that they were likely to use BBTI in the future when treating patients with insomnia, and that they would advertise their BBTI skills to primary care providers to encourage insomnia referrals. Although conducted with a small sample size, the current study gives provisional support for (a) feasibility of implementing the adapted version of BBTI within the Military Health System and (b) feasibility of training the adapted BBTI to behavioral health providers via remote learning methodology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Physical Injuries, Treatment-Seeking, and Perceived Barriers to Treatment in U.S. Army Drill Sergeants.

INTRODUCTION: Drill sergeants work under mentally and physically challenging conditions. The current study examined self-reported rates of physical injuries in drill sergeants; rates of treatment-seeking for injuries; perceived barriers toward treatment-seeking; and associated demographic and environmental factors. MATERIALS AND METHODS: Drill sergeants from across all Army basic training locations completed self-report surveys from September to November of 2018. In total, 726 drill sergeants were included in analyses. Drill sergeants indicated whether they had acquired an injury during their time in the drill sergeant role and whether they had sought treatment for all such injuries. Furthermore, drill sergeants rated their agreement with a number of possible perceived barriers to treatment-seeking for physical injuries. Regression models examining each phenomenon included hours of sleep obtained per day; general- and health-specific leadership behaviors of the company command teams; unit cohesion; time as a drill sergeant; duty location; gender; military operational specialty; years in the military; previous combat deployments; and route of assignment. The study was approved by the Walter Reed Army Institute of Research Institutional Review Board. RESULTS: In total, 38% of respondents reported acquiring an injury during their time as drill sergeants. Of those who had acquired an injury, 61% reported seeking medical help for all injuries acquired. Injuries were more likely in females (49%) than in males (34%) and less likely in drill sergeants reporting at least 6 hours of sleep (27%) versus those reporting 5 hours (40%) and 4 hours or less (43%). Reported comparisons were significant after controlling for demographic and environmental variables in regression models. The most strongly endorsed perceived barriers to treatment-seeking were "Seeking help would place too much burden on the other drill sergeants" (69%) and "Seeking help would interfere with my ability to train the recruits" (60%). Both of these perceived barriers were significantly associated with reduced treatment-seeking in injured drill sergeants, after controlling for demographic and environmental variables. CONCLUSIONS: This study is the first to examine injury occurrence, treatment-seeking, and perceived barriers to treatment-seeking in U.S. Army drill sergeants. Building on previous studies that showed the negative effects of sleep deprivation on the safety and behavioral health of drill sergeants, the current study gives further evidence of the negative effects of such sleep deprivation, this time in the domain of physical injuries. The results suggest that pursuing strategies that allow for healthier sleep duration may contribute to injury reduction.

US Army Drill Sergeants: Stressors, Behavioral Health, and Mitigating Factors.

INTRODUCTION: The role of the drill sergeant is one of the most challenging within the US Army, involving unusually long hours and little time off, for a minimum of 2 years. The current study sought to examine the behavioral health of this population and identify risk factors that might be addressed by policy changes. MATERIALS AND METHODS: In total, 856 drill sergeants across all Army basic training sites completed surveys from September to November of 2018. Drill sergeants identified factors that had caused stress or worry during their assignment. Rates were measured for behavioral health outcomes including depression, insomnia, anxiety, burnout, functional impairment, alcohol misuse, aggression, and low morale. Potential risk and resilience factors included time as a drill sergeant, sleep, route of assignment, general leadership, health-promoting leadership, and drill sergeant camaraderie. The study was approved by the Walter Reed Army Institute of Research Institutional Review Board. RESULTS: The most commonly experienced stressors were finding time to exercise, lack of sleep, and long work hours. Percentages of drill sergeants meeting behavioral health screening criteria were 19% for depression, 27% for moderate-to-severe insomnia, 14% for generalized anxiety disorder, 48% for high burnout, 32% for functional impairment, 35% for moderate alcohol misuse, 32% for off-duty aggression, and 25% for low morale. Rates for most outcomes were associated with time spent as a drill sergeant, with behavioral health issues peaking during 13-18 months. Poorer outcomes were also associated with fewer hours of sleep and initial unhappiness regarding involuntary assignment to the role of drill sergeant, while better outcomes were associated with higher ratings of general leadership, health-promoting leadership, and drill sergeant camaraderie. CONCLUSIONS: This study is the first to examine behavioral health and morale of drill sergeants and to identify risk and resilience factors. Suggestions for policy changes include increasing the number of drill sergeants to decrease workload and allow sufficient time for recovery and sleep.

Methodology of the U.S. Army's Suicide Prevention Leadership Tool Study: The Behavioral Health Readiness and Suicide Risk Reduction Review (R4).

INTRODUCTION: The Secretary of the U.S. Army issued two directives in late 2017 to directly combat the problem of suicide in the U.S. Army. The first was to develop an Army tool to assist commanders and first-line leaders in preventing suicide and improving behavioral health (BH) outcomes, which has been previously published as the BH Readiness and Risk Reduction Review (R4). The second was to conduct an evaluation study of the tool with Army units in the field. This study is the first to empirically examine the Army's tool-based methods for identifying and caring for the health and welfare of soldiers at risk for suicide, and this article outlines the methodology employed to study the effectiveness of the R4 tools and accomplish the Secretary's second directive. METHODS: The Walter Reed Army Institute of Research Institutional Review Board approved the R4 study. The study employed a repeated measurements in pre/post quasi-experimental design, including a nonequivalent but comparable business-as-usual control group. The R4 intervention consisted of the R4 tools, accompanying instructions, and an orientation. Samples were drawn from two geographically separated U.S. Army divisions in the continental United States, each composed of four comparable brigades. Study implementation consisted of three phases and three data collections over the course of 12 months. Soldiers completed anonymous survey instruments to assess a range of health factors, behaviors, characteristics, tool-related decision-making processes, and the frequency, type, and quality of interactions between soldiers and leaders. RESULTS: The R4 study commenced on May 6, 2019, and concluded on June 4, 2020. Sample size goals were achieved for both the divisions at all three data collection time points. CONCLUSIONS: The methodology of the R4 study is critical for the U.S. Army from both a precedential and an outcome-based standpoint. Despite the use of many previous tools and programs for suicide prevention, this is the first time the Army has been able to empirically test the effectiveness of tool-supported decision-making among Army units in a rigorous fashion. The methodology of such a test is a critical marker for future interventional inquiries on the subject of suicide in the Army, and the results will allow for more informed decision-making by leaders when approaching these ongoing challenges.

Sleep deprivation and hazardous unintended sleep in US army drill sergeants.

OBJECTIVES: Sleep deprivation is an occupational hazard for members of the armed forces, and has potential consequences not only for the sleep-deprived individuals, but also for the people around them. Perhaps the most consistently sleep-deprived population in the US Army are drill sergeants, who lead intense cycles of initial training for new soldiers. In the first systematic assessment of drill sergeants, the current study examined sleep deprivation and its relationship to falling asleep in two hazardous contexts: while driving, and while co-supervising recruit trainings. DESIGN: In total 856 drill sergeants across all Army basic training sites completed surveys. Sleep-related items measured sleep quantity, sleep problems, exhaustion, and stress due to lack of sleep. RESULTS: Drill sergeants reported working long hours (M = 14.74 hours, SD = 2.53), and being at work 6.42 (SD = 0.6) days per week, while obtaining low levels of sleep (75% reported five hours or less per night). Many (27%) met criteria for moderate or severe clinical insomnia. A substantial proportion (42%) reported having fallen asleep at the wheel at least once during their time as a drill sergeant. Further, the likelihood of this occurring was associated with obtaining low amounts of sleep and with meeting criteria for clinical insomnia. Similar rates of occurrence and associations with sleep issues were observed for falling asleep during recruit trainings. CONCLUSIONS: Results highlight the importance of ensuring drill sergeants acquire adequate sleep in order to reduce the risk of accidents involving this population and those in their care.

Prevalence of Bystander Intervention Opportunities and Behaviors Among U.S. Army Soldiers.

The bystander intervention model is one approach utilized to reduce risky behaviors within the U.S. Army; however, it is unclear how frequently soldiers experience opportunities to intervene and whether they already intervene in such situations. The present analysis aims to ascertain frequencies for opportunities to intervene and the rates at which soldiers intervene when presented with such opportunities. Soldiers ( N = 286) were asked whether they had witnessed particular risky behavior scenarios of interest to the Army (i.e., suicide-related behaviors, alcohol misuse, or sexual harassment/assault) during the previous 2 months and whether they had intervened in those scenarios. Prevalence rates within this sample were calculated to determine the frequency of such situations and subsequent interventions. Logistic regression was used to ascertain any differences in witnessing scenarios by demographic groups. Nearly half (46.8%) of the soldiers reported witnessing at least one scenario involving risky behaviors. Most soldiers who witnessed an event relating to suicide or alcohol misuse also reported consistently intervening (87.9% and 74.4%, respectively), whereas just half consistently intervened in response to scenarios relating to sexual harassment/assault (49.2%). Lower ranking soldiers were twice as likely as higher ranks to witness scenarios involving alcohol misuse (odds ratio = 2.18, 95% confidence interval [1.11, 4.26]) and sexual harassment/assault (odds ratio = 2.21, 95% confidence interval [1.05, 4.62]). These data indicate that soldiers regularly encounter opportunities to intervene in risky behaviors, and while a majority intervened in such scenarios, more training is warranted, particularly around sexual assault and harassment. This supports the notion that bystander intervention training is a worthwhile investment for the Army.

Hedonic and sensory characteristics of odors conditioned by pairing with tastants in humans.

Animals readily acquire positive odor-taste hedonic associations, but evidence for this in humans remains weak and was explored further. Retronasal pairing of odors with sucrose or salty stimuli (Experiment 1) increased the rated sweetness of sucrose-paired odors without altering liking, although changes in odor pleasantness correlated with sucrose liking. Experience of odors with sucrose or quinine by sweet likers (Experiment 2) found increased pleasantness and sweetness for sucrose-paired odors, whereas quinine-paired odors became less liked and more bitter. Odor-sucrose pairings in sweet likers and dislikers (Experiment 3) found increased sweetness in both groups but increased odor liking only in likers. These data suggest that evaluative and sensory learning are dissociable and that evaluative changes are sensitive to individual differences in sweet liking.