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DESCRIPTION: The U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) worked together to revise the 2017 VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. This article summarizes the 2023 clinical practice guideline (CPG) and its development process, focusing on assessments and treatments for which evidence was sufficient to support a recommendation for or against. METHODS: Subject experts from both departments developed 12 key questions and reviewed the published literature after a systematic search using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) method. The evidence was then evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method. Recommendations were made after consensus was reached; they were based on quality and strength of evidence and informed by other factors, including feasibility and patient perspectives. Once the draft was peer reviewed by an external group of experts and their inputs were incorporated, the final document was completed. RECOMMENDATIONS: The revised CPG includes 34 recommendations in the following 5 topic areas: assessment and diagnosis, prevention, treatment, treatment of nightmares, and treatment of posttraumatic stress disorder (PTSD) with co-occurring conditions. Six recommendations on PTSD treatment were rated as strong. The CPG recommends use of specific manualized psychotherapies over pharmacotherapy; prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy; paroxetine, sertraline, or venlafaxine; and secure video teleconferencing to deliver recommended psychotherapy when that therapy has been validated for use with video teleconferencing or when other options are unavailable. The CPG also recommends against use of benzodiazepines, cannabis, or cannabis-derived products. Providers are encouraged to use this guideline to support evidence-based, patient-centered care and shared decision making to optimize individuals' health outcomes and quality of life.
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Transtornos de Estresse Pós-Traumáticos , Transtornos de Estresse Traumático Agudo , Humanos , Transtornos de Estresse Pós-Traumáticos/terapia , Estados Unidos , Transtornos de Estresse Traumático Agudo/terapia , United States Department of Veterans Affairs , United States Department of Defense , Psicoterapia , Terapia Cognitivo-ComportamentalRESUMO
[Figure: see text].
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COVID-19/psicologia , Pessoal de Saúde/psicologia , Ansiedade/psicologia , COVID-19/epidemiologia , Medo/psicologia , Pessoal de Saúde/educação , Humanos , Pandemias , SARS-CoV-2 , Transtornos de Estresse Pós-Traumáticos/prevenção & controle , Transtornos de Estresse Pós-Traumáticos/psicologiaAssuntos
COVID-19/psicologia , Saúde Mental , Papel do Médico , Humanos , Pandemias , Saúde Pública , Resiliência Psicológica , SARS-CoV-2Assuntos
Infecções por Coronavirus/psicologia , Medo , Serviços de Saúde Mental , Saúde Mental , Pneumonia Viral/psicologia , Comportamento Social , Estresse Psicológico , Betacoronavirus , COVID-19 , Emoções , Humanos , Japão , Transtornos Mentais , Pandemias , SARS-CoV-2 , Condições Sociais , Apoio Social , Incerteza , Populações VulneráveisRESUMO
INTRODUCTION: The National Guard (NG) served as a critical component of the USA's response to the Coronavirus Disease 2019 (COVID-19) pandemic, while concurrently managing their personal responses to the pandemic. Determining whether the activation of NG service members in response to the COVID-19 pandemic was associated with a greater psychological strain can identify NG's needs for mental health support. MATERIALS AND METHODS: We surveyed 3993 NG unit (NGU) service members (75% Army NG, 79% enlisted, 52% 30-49 years old, and 81% males) during the COVID-19 pandemic, with surveys administered between August and November 2020. Almost half (46%) of NGU service members reported being activated in response to COVID-19 (mean activation length = 18.6 weeks). Activated service members completed the survey approximately 2 to 3 months post-activation. Surveys assessed demographics, service-related characteristics, unit cohesion and positive leadership skills (leadership), and COVID-19 activation, and outcomes including probable post-traumatic stress disorder (PTSD), clinically significant anxiety and depression, and anger. Descriptive and logistic regression analyses were conducted. The study was approved by the Institutional Review Board of the Uniformed Services University of the Health Sciences in Bethesda, MD. RESULTS: In all, 9.7% met the criteria for probable PTSD, 7.6% reported clinically significant anxiety and depression, and 13.2% reported feeling angry/anger outbursts. Multivariate logistic regression analyses, adjusting for demographic and service-related characteristics, indicated that COVID-19 activation was not associated with a greater risk of PTSD, anxiety and depression, or anger. Regardless of activation status, NGU service members with low levels of unit cohesion and leadership were more likely to report PTSD and anger, and low levels of unit cohesion were associated with clinically significant anxiety and depression. CONCLUSIONS: COVID-19 activation did not increase the risk of mental health difficulties among NGU service members. However, low levels of unit cohesion were associated with the risk of PTSD, anxiety and depression, and anger, and low levels of leadership were associated with the risk of PTSD and anger. The results suggest a resilient psychological response to COVID-19 activation and the potential for strengthening all NG service members through enhancing unit cohesion and leadership support. Future research on specific activation exposures, including the type of work tasks in which service members are engaged, particularly those associated with high-stress work conditions, is needed to help better understand their activation experience and how it may influence post-activation responses.
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COVID-19 , Transtornos de Estresse Pós-Traumáticos , Masculino , Humanos , Adulto , Pessoa de Meia-Idade , Feminino , COVID-19/epidemiologia , Pandemias , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos de Estresse Pós-Traumáticos/psicologia , Ansiedade/epidemiologia , Transtornos de Ansiedade/epidemiologia , Depressão/epidemiologia , Depressão/psicologiaRESUMO
OBJECTIVE: Attachment style and social support networks (SSN) are associated with suicide ideation (SI) and suicide attempt (SA). How these two factors interact is important to understanding the mechanisms of risk for suicidal behaviors and identifying interventions. METHOD: Using the Army Study to Assess Risk and Resilience in Servicemembers New Soldier Study (N = 38,507 soldiers), we examined how three attachment styles (preoccupied, fearful, and secure) and SSN (smaller vs larger) were associated with lifetime SI, SA, and SA among soldiers with SI. The interaction of each attachment style by SSN was examined. RESULTS: All three attachment styles were associated with SI and SA in the total sample (for SA: preoccupied OR = 2.82, fearful OR = 2.84, and secure OR = 0.76). Preoccupied and fearful attachment were associated with SA among suicide ideators. Smaller SSN was associated with a higher risk for all three outcomes (range of ORs = 1.23-1.52). The association of SSN with SI and with SA among suicide ideators was significantly modified by the presence or absence of preoccupied attachment style. Among soldiers without preoccupied attachment, larger SSN was associated with lower risk of SI. Among suicide ideators with preoccupied attachment, a larger SSN was associated with lower risk of SA. CONCLUSION: This study highlights the need for increased understanding of the role of attachment style and social networks in suicide risk, in particular preoccupied attachment among soldiers with SI. A critical next step is to explore these relationships prospectively to guide intervention development.
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INTRODUCTION: The National Guard (NG) served as a critical component of the U.S. response to the coronavirus disease 2019 pandemic. Understanding the impact of types of pandemic-related disaster work on mental health responses can aid in sustaining NG service members' health and preparation for subsequent activations and future pandemics. MATERIALS AND METHODS: We surveyed 1,363 NG unit (NGU) service members (88% Army; 80% enlisted; 32% 30 to 39 years old; 84% male) following activation in response to the pandemic. Surveys were administered between August and December 2020, which was approximately 2 to 3 months post-activation. Surveys assessed overall activation stress, participation in different types of disaster work, probable post-traumatic stress disorder (PTSD), anxiety and depression, and anger. A disaster work stress scale assessed different types of disaster work during activation and associated stress levels. For each individual, we calculated an overall work task stress (WTS) scaled score, with a maximum score of 100. Logistic regression analyses were conducted to examine the relationship of high-stress disaster work tasks to post-activation PTSD, anxiety and depression, and anger, adjusting for socio-demographic and service-related variables. The study was approved by the Institutional Review Board of the Uniformed Services University (USU) in Bethesda, MD. RESULTS: Among NGU service members, 12.7% (n = 172) described their activation as very/extremely stressful. The work tasks with the highest scaled scores were as follows: (1) Patient transportation (WTS scaled score = 100); (2) working with the dead (WTS = 82.2); and (3) working with families of coronavirus disease 2019 patients (WTS = 72.7). For each individual's work tasks, we identified the work task associated with the highest WTS score. The top one-third of WTS scores were classified as the high-stress group. Approximately 9% of participants (n = 111) had probable PTSD, 6.7% (n = 85) had clinically significant anxiety and depression, and 12.3% (n = 156) had high anger. Multivariable logistic regression analyses, adjusting for covariates, found that NGU service members exposed to the highest level of disaster WTS were more likely to report PTSD (odds ratio [OR] = 1.48 [95% confidence interval [CI] = 1.13-1.94], χ2 = 7.98), anxiety and depression (OR = 1.91 [95% CI = 1.17-3.13]; χ2 = 6.67), and anger (OR = 1.63 [95% CI = 1.13-2.37]; χ2 = 6.66) post-activation. CONCLUSIONS: Identifying work tasks associated with high levels of stress can help detect individuals at risk for adverse mental health responses post-exposure. Distinguishing features of high-stress work conditions can be generalized to other types of work conditions and disaster response and are important targets for planning and preventive efforts.
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The National Guard (NG) served as a critical component of the US COVID-19 response while concurrently managing personal COVID-19 responses. Understanding pandemic-related concerns, sleep difficulties, increased substance use, and stress management strategies can promote readiness for subsequent disasters. We surveyed 3221 NG service members (75% Army; 79% enlisted; 52% 30-49 years; 81% male) during COVID-19 (August-November 2020). Almost half were activated in response to COVID-19 (mean = 18.6 weeks) and completed the survey 2-3 months post-activation. Service members indicated great concern about family health (39%), the indefinite nature of the pandemic (35%), and their financial situation (23%). Over one-third reported changes in usual sleep amount, 33% described poor sleep quality, and 21% had trouble falling/staying asleep. Increased substance use was reported by 30%, including increased alcohol (13.5%), tobacco (9%), and caffeine/energy drinks (20.1%) consumption. Chi-square analyses and analyses of variance found those who activated reported more increased tobacco and caffeine/energy drink use versus non-activated, with no sleep difficulties nor alcohol use differences. Helpful stress management strategies included spending time outdoors (53%), exercising (48%), talking to family/friends (38%), and having a daily routine (38%). Specific health-, financial-, and job-related stressors were associated with COVID-19. Incorporating stress management in planning/preventive efforts promotes resilience during disasters.
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COVID-19 , Distúrbios do Início e da Manutenção do Sono , Transtornos Relacionados ao Uso de Substâncias , Humanos , Masculino , Feminino , Pandemias , Cafeína , COVID-19/epidemiologia , Adaptação Psicológica , Transtornos Relacionados ao Uso de Substâncias/epidemiologiaRESUMO
The COVID-19 pandemic exerted an extraordinary impact on public mental health to an extent not yet fully understood. Risk perception shaped psychological and behavioral responses, including experiences of distress, psychiatric disorders, and engagement in pandemic-related health behaviors. COVID-19 created unique aspects of evolving risk with various communities disproportionately impacted. The unique nature and duration of the pandemic required public-private partnerships that leveraged and adapted promising practices to promote essential elements that foster well-being after disasters. Early findings are reviewed, and further research will inform on best practices for protecting public mental health during future pandemics.
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COVID-19 , Transtornos Mentais , Humanos , Transtornos Mentais/epidemiologia , Transtornos Mentais/terapia , Saúde Mental , Pandemias , SARS-CoV-2RESUMO
Research on disaster behavioral health presents significant methodological challenges. Challenges are even more complex for research on mass violence events that involve military members, families, and communities, due to the cultural and logistical considerations of working with this population. The current article aims to inform and educate on this specialized area of research, by presenting a case study on the experience of designing and conducting disaster behavioral health research after a mass violence event in a military setting: the 2013 mass shooting at the Washington Navy Yard, in Washington, D.C. Using the case example, the authors explore methodological challenges and lessons learned from conducting research in this context, and provide guidance for future researchers.
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Desastres , Militares , Humanos , Instalações Militares , Washington , ViolênciaRESUMO
OBJECTIVE: In times of repeated disaster events, including natural disasters and pandemics, public health workers must recover rapidly to respond to subsequent events. Understanding predictors of time to recovery and developing predictive models of time to recovery can aid planning and management. METHODS: We examined 681 public health workers (21-72 y, M(standard deviation [SD]) = 48.25(10.15); 79% female) 1 mo before (T1) and 9 mo after (T2) the 2005 hurricane season. Demographics, trauma history, social support, time to recover from previous hurricane season, and predisaster work productivity were assessed at T1. T2 assessed previous disaster work, initial emotional response, and personal hurricane injury/damage. The primary outcome was time to recover from the most recent hurricane event. RESULTS: Multivariate analyses found that less support (T1; odds ratio [OR] = .74[95% confidence interval [CI] = .60-.92]), longer previous recovery time (T1; OR = 5.22[95%CI = 3.01-9.08]), lower predisaster work productivity (T1; OR = 1.98[95%CI = 1.08-3.61]), disaster-related personal injury/damage (T2; OR = 3.08[95%CI = 1.70-5.58]), and initial emotional response (T2; OR = 1.71[95%CI = 1.34-2.19]) were associated with longer recovery time (T2). CONCLUSIONS: Recovery time was adversely affected in disaster responders with a history of longer recovery time, personal injury/damage, lower work productivity following prior hurricanes, and initial emotional response, whereas responders with social support had shorter recovery time. Predictors of recovery time should be a focus for disaster preparedness planners.
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Tempestades Ciclônicas , Planejamento em Desastres , Desastres , Humanos , Feminino , Masculino , Saúde Pública , Pessoal de Saúde , Mão de Obra em SaúdeRESUMO
OBJECTIVE: Among U.S. Army soldiers suicide attempts (SAs) are a significant public health concern, particularly early in service. We examined the association of attachment style with SA and suicide ideation (SI) among U.S. Army soldiers. METHODS: We analyzed survey data from new soldiers who participated in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). The sample consists of 38,507 soldiers entering Basic Combat Training (BCT) between April 2011 and November 2012. Attachment style (secure, preoccupied, fearful, and dismissing) was assessed using items from the Relationship Questionnaire. Lifetime (pre-enlistment) SA and SI were assessed with a modified Columbia Suicide Severity Rating Scale. Logistic regression analyses examined associations of attachment style with lifetime SA, SI, and attempts among ideators, after adjusting for socio-demographic characteristics. RESULTS: The secure attachment style was associated with lower odds of SA (OR = 0.76, 95% CI = 0.63-0.92), whereas preoccupied (OR = 4.63, 95% CI = 3.83-5.61), fearful (OR = 4.08, 95% CI = 3.38-4.94), or dismissing (OR = 1.56, 95% CI = 1.24-1.96) attachment styles were associated with higher odds of SA. Similar results were found for SI. Importantly, both preoccupied (OR = 1.67, 95% CI = 1.37-2.04) and fearful (OR = 1.70, 95% CI = 1.38-2.08) attachment were associated with attempts among ideators. CONCLUSION: These findings highlight the clinical importance of attachment style in predicting suicidal behavior and as possible targets for intervention. A critical next step is for prospective research to examine whether attachment style predicts future suicidal behavior.
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Militares , Tentativa de Suicídio , Humanos , Estados Unidos/epidemiologia , Estudos Prospectivos , Fatores de Risco , Ideação SuicidaRESUMO
OBJECTIVE: Community characteristics, such as collective efficacy, a measure of community strength, can affect behavioral responses following disasters. We measured collective efficacy 1 month before multiple hurricanes in 2005, and assessed its association to preparedness 9 months following the hurricane season. METHODS: Participants were 631 Florida Department of Health workers who responded to multiple hurricanes in 2004 and 2005. They completed questionnaires that were distributed electronically approximately 1 month before (6.2005-T1) and 9 months after (6.2006-T2) several storms over the 2005 hurricane season. Collective efficacy, preparedness behaviors, and socio-demographics were assessed at T1, and preparedness behaviors and hurricane-related characteristics (injury, community-related damage) were assessed at T2. Participant ages ranged from 21-72 (M(SD) = 48.50 (10.15)), and the majority were female (78%). RESULTS: In linear regression models, univariate analyses indicated that being older (B = 0.01, SE = 0.003, P < 0.001), White (B = 0.22, SE = 0.08, P < 0.01), and married (B = 0.05, SE = 0.02, p < 0.001) was associated with preparedness following the 2005 hurricanes. Multivariate analyses, adjusting for socio-demographics, preparedness (T1), and hurricane-related characteristics (T2), found that higher collective efficacy (T1) was associated with preparedness after the hurricanes (B = 0.10, SE = 0.03, P < 0.01; and B = 0.47, SE = 0.04, P < 0.001 respectively). CONCLUSION: Programs enhancing collective efficacy may be a significant part of prevention practices and promote preparedness efforts before disasters.
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Tempestades Ciclônicas , Desastres , Humanos , Feminino , Masculino , Estudos Longitudinais , Inquéritos e Questionários , FloridaRESUMO
OBJECTIVE: Suicide and suicide attempts among U.S. Army soldiers are a significant concern for public health. This study examined the association of parental suicide attempt prior to age 13 of the soldier with subsequent risk of pre-enlistment suicide attempt. METHOD: We conducted secondary analyses of survey data from new soldiers who participated in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) (N = 38,396). A series of logistic regression analyses were conducted. RESULTS: Of all new soldiers, 1.4% reported that they attempted suicide between age 13 and entering the Army, and 2.3% reported a parental suicide attempt prior to age 13. Parental suicide attempt was associated with increased odds of subsequent suicide attempt; however, this association was moderated by gender and was significant only among male soldiers. The association between parental suicide attempt and pre-enlistment suicide attempt among male soldiers was still significant after controlling for socio-demographic characteristics, soldier/parental psychopathology, and childhood adversities. CONCLUSIONS: These results highlight parental suicide attempt as a unique pre-enlistment risk factor for suicide attempt, especially among male new soldiers. Further studies are needed to separate the genetic and environmental contributions to intra-familial risk for suicidal behavior.
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Militares , Tentativa de Suicídio , Adolescente , Criança , Feminino , Humanos , Masculino , Pais , Fatores de Risco , Ideação Suicida , Estados UnidosRESUMO
COVID-19 is a unique disaster, which has placed extreme stress on Healthcare Workers (HCWs) and the systems in which they work. Eradicating the pandemic requires sustainment of the healthcare workforce through actions that mitigate stress, promote resilience, and enhance performance. A major barrier is the lack of organizational practices and procedures designed to sustain HCWs during prolonged crisis events, such as COVID-19. Adapting existing best practices from other high-risk occupations allows for a more rapid, efficient response to optimize workforce well-being and preserve healthcare organizational functioning. This paper discusses current and emerging literature on the unique impacts of COVID-19 on HCWs and provides actionable, evidence-informed recommendations for individuals, teams, and leaders to enhance sustainment of HCWs that is critical to the preservation of national and global health security.