Pre-deployment programmes for building resilience in military and frontline emergency service personnel.

BACKGROUND: Military personnel and frontline emergency workers may be exposed to events that have the potential to precipitate negative mental health outcomes such as depression, symptoms of post-traumatic stress and even post-traumatic stress disorder (PTSD). Programmes have been designed to build psychological resilience before staff are deployed into the field. This review presents a synthesis of the literature on these "pre-deployment resilience-building programmes". OBJECTIVES: The objective of this review was to assess the effectiveness of programmes that seek to build resilience to potentially traumatic events among military and frontline emergency service personnel prior to their deployment. These resilience programmes were compared to other interventions, treatment as usual or no intervention. SEARCH METHODS: Studies were identified through searches of electronic databases including Ovid MEDLINE, Embase, PsycINFO, Web of Science and Google Scholar. The initial search took place in January 2019, with an updated search completed at the end of September 2020. SELECTION CRITERIA: Only studies that used a randomised controlled trial (RCT)/cluster-RCT methodology were included. The programmes being evaluated must have sought to build resilience prior to exposure to trauma. Study participants must have been 18 years or older and be military personnel or frontline emergency workers. DATA COLLECTION AND ANALYSIS: Studies that met the inclusion criteria were assembled. Data extracted included methods, participants' details, intervention details, comparator details, and information on outcomes. The primary outcomes of interest were resilience, symptoms of post-traumatic stress and PTSD. Secondary outcomes of interest included acute stress disorder, depression, social support, coping skills, emotional flexibility, self-efficacy, social functioning, subjective levels of aggression, quality of sleep, quality of life and stress. Assessment of risk of bias was also completed. A total of 28 studies were included in a narrative synthesis of results. MAIN RESULTS: All 28 included studies compared an experimental resilience building intervention versus a control or no intervention. There was a wide range of therapeutic modalities used, including cognitive behavioural therapy (CBT) informed programmes, biofeedback based programmes, stress-management programmes, mindfulness and relaxation programmes, neuropsychological-based programmes, and psychoeducational-informed programmes. The main outcomes are specified here, secondary outcomes such as depression, social support, coping skills, self-efficacy, subjective levels of aggression and stress are reported in text. No studies reported on the following pre-specified outcomes; acute stress disorder, emotional flexibility, social functioning, quality of sleep and quality of life. Resilience Eight studies reported resilience as an outcome. We narratively synthesised the data from these studies and our findings show that five of these interventions had success in building resilience in their respective samples. Two of the studies that reported significant results utilised a CBT approach to build resilience, while the other three successful programmes were mindfulness-based interventions. Symptoms of post-traumatic stress Our narrative synthesis of results included eight studies. Two of the eight studies produced significant reductions in symptoms of post traumatic stress compared to controls. These interventions used neuropsychological and biofeedback intervention models respectively. PTSD caseness Four studies reported PTSD caseness as an outcome. Our narrative synthesis of results suggests that evidence is mixed as to the effectiveness of these interventions in reducing clinical diagnosis of PTSD. One study of a neuropsychology-orientated Attention Bias Modification Training (AMBT) programme had success in reducing both symptoms of post-traumatic stress and numbers of participants receiving a diagnosis of PTSD. A stress-management programme reported that, when baseline differences in rates of pre-deployment mental health issues were controlled for, participants in the control condition were at 6.9 times the risk of a diagnosis of PTSD when compared to the intervention group. Given the diversity of intervention designs and theoretical orientations used (which included stress-management, neuropsychological and psychoeducational programmes), a definitive statement on the efficacy of pre-deployment programmes at reducing symptoms of post-traumatic stress and PTSD cannot be confidently offered. AUTHORS' CONCLUSIONS: While a number of evaluations of relevant programmes have been published, the quality of these evaluations limits our ability to determine if resilience-building programmes 'work' in terms of preventing negative outcomes such as depression, symptoms of post-traumatic stress and diagnoses of PTSD. Based on our findings we recommend that future research should: a) report pre-/post-means and standard deviation scores for scales used within respective studies, b) take the form of large, RCTs with protocols published in advance, and c) seek to measure defined psychological facets such as resilience, PTSD and stress, and measure these concepts using established psychometric tools. This will provide more certainty in future assessments of the evidence base. From a clinical implications point of view, overall there is mixed evidence that the interventions included in this review are effective at safe guarding military personnel or frontline emergency workers from experiencing negative mental health outcomes, including PTSD, following exposure to potentially traumatic events. Based on this, practitioners seeking to build resilience in their personnel need to be aware of the limitations of the evidence base. Practitioners should have modest expectations in relation to the efficacy of resilience-building programmes as a prophylactic approach to employment-related critical incident traumas.

PROTOCOL: Mental disorder, psychological problems and terrorist behaviour: A systematic review.

This is the protocol for a Campbell systematic review. The objectives are as follows: the first objective of the review (Objective 1-Prevalence) is to present a synthesis of the reported prevalence rates of mental health difficulties in terrorist samples. Where sufficient data is available, the synthesis will be sensitive to the heterogeneity of the terrorism phenomenon by exploring the rates of mental health difficulties for different forms of terrorism and for different terrorist roles (e.g., bombing, logistics, finance, etc.). The second objective (Objective 2-Temporality) will synthesise the extent to which mental health difficulties pre-date involvement in terrorism within prevalence studies. Finally, the third objective (Objective 3-Risk) aims to further establish temporality by examining the extent to which the presence of mental disorder is associated with terrorist involvement by comparing terrorist and non-terrorist samples.

Mental disorder, psychological problems and terrorist behaviour: A systematic review and meta-analysis.

Background: The link between mental health difficulties and terrorist behaviour has been the subject of debate for the last 50 years. Studies that report prevalence rates of mental health difficulties in terrorist samples or compare rates for those involved and not involved in terrorism, can inform this debate and the work of those responsible for countering violent extremism. Objectives: To synthesise the prevalence rates of mental health difficulties in terrorist samples (Objective 1-Prevalence) and prevalence of mental health disorders pre-dating involvement in terrorism (Objective 2-Temporality). The review also synthesises the extent to which mental health difficulties are associated with terrorist involvement compared to non-terrorist samples (Objective 3-Risk Factor). Search Methods: Searches were conducted between April and June 2022, capturing research until December 2021. We contacted expert networks, hand-searched specialist journals, harvested records from published reviews, and examined references lists for included papers to identify additional studies. Selection Criteria: Studies needed to empirically examine mental health difficulties and terrorism. To be included under Objective 1 (Prevalence) and Objective 2 (Temporality), studies had to adopt cross-sectional, cohort, or case-control design and report prevalence rates of mental health difficulties in terrorist samples, with studies under Objective 2 also needing to report prevalence of difficulties before detection or involvement in terrorism. For Objective 3 (Risk Factor) studies where there was variability in terrorist behaviour (involved vs. not involved) were included. Data Collection and Analysis: Captured records were screened in DisillterSR by two authors. Risk of bias was assessed using Joanna Briggs Institute checklists, and random-effects meta-analysis conducted in Comprehensive Meta-Analysis software. Results: Fifty-six papers reporting on 73 different terrorist samples (i.e., studies) (n = 13,648) were identified. All were eligible for Objective 1. Of the 73 studies, 10 were eligible for Objective 2 (Temporality) and nine were eligible for Objective 3 (Risk Factor). For Objective 1, the life-time prevalence rate of diagnosed mental disorder in terrorist samples (k = 18) was 17.4% [95% confidence interval (CI) = 11.1%-26.3%]. When collapsing all studies reporting psychological problems, disorder, and suspected disorder into one meta-analyses (k = 37), the pooled prevalence rate was 25.5% (95% CI = 20.2%-31.6%). When isolating studies reporting data for any mental health difficulty that emerged before either engagement in terrorism or detection for terrorist offences (Objective 2: Temporality), the life-time prevalence rate was 27.8% (95% CI = 20.9%-35.9%). For Objective 3 (Risk Factor), it was not appropriate to calculate a pooled effect size due the differences in comparison samples. Odds ratios for these studies ranged from 0.68 (95% CI = 0.38-1.22) to 3.13 (95% CI = 1.87-5.23). All studies were assessed as having high-risk of bias which, in part, reflects challenges conducting terrorism research. Author's Conclusions: This review does not support the assertion that terrorist samples are characterised by higher rates of mental health difficulties than would be expected in the general population. Findings have implications for future research in terms of design and reporting. There are also implications for practice with regards the inclusion of mental health difficulties as indicators of risk.