Biofeedback-Assisted Resilience Training for Traumatic and Operational Stress: Preliminary Analysis of a Self-Delivered Digital Health Methodology.

BACKGROUND: Psychological resilience is critical to minimize the health effects of traumatic events. Trauma may induce a chronic state of hyperarousal, resulting in problems such as anxiety, insomnia, or posttraumatic stress disorder. Mind-body practices, such as relaxation breathing and mindfulness meditation, help to reduce arousal and may reduce the likelihood of such psychological distress. To better understand resilience-building practices, we are conducting the Biofeedback-Assisted Resilience Training (BART) study to evaluate whether the practice of slow, paced breathing with or without heart rate variability biofeedback can be effectively learned via a smartphone app to enhance psychological resilience. OBJECTIVE: Our objective was to conduct a limited, interim review of user interactions and study data on use of the BART resilience training app and demonstrate analyses of real-time sensor-streaming data. METHODS: We developed the BART app to provide paced breathing resilience training, with or without heart rate variability biofeedback, via a self-managed 6-week protocol. The app receives streaming data from a Bluetooth-linked heart rate sensor and displays heart rate variability biofeedback to indicate movement between calmer and stressful states. To evaluate the app, a population of military personnel, veterans, and civilian first responders used the app for 6 weeks of resilience training. We analyzed app usage and heart rate variability measures during rest, cognitive stress, and paced breathing. Currently released for the BART research study, the BART app is being used to collect self-reported survey and heart rate sensor data for comparative evaluation of paced breathing relaxation training with and without heart rate variability biofeedback. RESULTS: To date, we have analyzed the results of 328 participants who began using the BART app for 6 weeks of stress relaxation training via a self-managed protocol. Of these, 207 (63.1%) followed the app-directed procedures and completed the training regimen. Our review of adherence to protocol and app-calculated heart rate variability measures indicated that the BART app acquired high-quality data for evaluating self-managed stress relaxation training programs. CONCLUSIONS: The BART app acquired high-quality data for studying changes in psychophysiological stress according to mind-body activity states, including conditions of rest, cognitive stress, and slow, paced breathing.

PHIT for Duty, a Mobile Application for Stress Reduction, Sleep Improvement, and Alcohol Moderation.

Post-traumatic stress and other problems often occur after combat, deployment, and other military operations. Because techniques such as mindfulness meditation show efficacy in improving mental health, our team developed a mobile application (app) for individuals in the armed forces with subclinical psychological problems as secondary prevention of more significant disease. Based on the Personal Health Intervention Toolkit (PHIT), a mobile app framework for personalized health intervention studies, PHIT for Duty integrates mindfulness-based relaxation, behavioral education in sleep quality and alcohol use, and psychometric and psychophysiological data capture. We evaluated PHIT for Duty in usability and health assessment studies to establish app quality for use in health research. Participants (N = 31) rated usability on a 1 (very hard) to 5 (very easy) scale and also completed the System Usability Scale (SUS) questionnaire (N = 9). Results were (mean ± SD) overall (4.5 ± 0.6), self-report instruments (4.5 ± 0.7), pulse sensor (3.7 ± 1.2), sleep monitor (4.4 ± 0.7), sleep monitor comfort (3.7 ± 1.1), and wrist actigraphy comfort (2.7 ± 0.9). The average SUS score was 85 ± 12, indicating a rank of 95%. A comparison of PHIT-based assessments to traditional paper forms demonstrated a high overall correlation (r = 0.87). These evaluations of usability, health assessment accuracy, physiological sensing, system acceptability, and overall functionality have shown positive results and affirmation for using the PHIT framework and PHIT for Duty application in mobile health research.

Toward Preventing Post-Traumatic Stress Disorder: Development and Testing of a Pilot Predeployment Stress Inoculation Training Program.

The objective of this pilot study was to design, develop, and evaluate a predeployment stress inoculation training (PRESIT) preventive intervention to enable deploying personnel to cope better with combat-related stressors and mitigate the negative effects of trauma exposure. The PRESIT program consisted of three predeployment training modules: (1) educational materials on combat and operational stress control, (2) coping skills training involving focused and relaxation breathing exercises with biofeedback, and (3) exposure to a video multimedia stressor environment to practice knowledge and skills learned in the first two modules. Heart rate variability assessed the degree to which a subset of participants learned the coping skills. With a cluster randomized design, data from 351 Marines randomized into PRESIT and control groups were collected at predeployment and from 259 of these who responded to surveys on return from deployment. Findings showed that the PRESIT group reduced their physiological arousal through increased respiratory sinus arrhythmia during and after breathing training relative to controls. Logistic regression, corrected for clustering at the platoon level, examined group effects on post-traumatic stress disorder (PTSD) as measured by the Post-traumatic Stress Checklist after controlling for relevant covariates. Results showed that PRESIT protected against PTSD among Marines without baseline mental health problems. Although limited by a small number of participants who screened positive for PTSD, this study supports the benefits of PRESIT as a potential preventive strategy in the U.S. military personnel.

Relaxation training assisted by heart rate variability biofeedback: Implication for a military predeployment stress inoculation protocol.

Decreased heart rate variability (HRV) is associated with posttraumatic stress disorder (PTSD) and depression symptoms, but PTSD's effects on the autonomic stress response and the potential influence of HRV biofeedback in stress relaxation training on improving PTSD symptoms are not well understood. The objective of this study was to examine the impact of a predeployment stress inoculation training (PRESTINT) protocol on physiologic measures of HRV in a large sample of the military population randomly assigned to experimental HRV biofeedback-assisted relaxation training versus a control condition. PRESTINT altered the parasympathetic regulation of cardiac activity, with experimental subjects exhibiting greater HRV, that is, less arousal, during a posttraining combat simulation designed to heighten arousal. Autonomic reactivity was also found to be related to PTSD and self-reported use of mental health services. Future PRESTINT training could be appropriate for efficiently teaching self-help skills to reduce the psychological harm following trauma exposure by increasing the capacity for parasympathetically modulated reactions to stress and providing a coping tool (i.e., relaxation method) for use following a stressful situation.

Influence of spirituality on depression, posttraumatic stress disorder, and suicidality in active duty military personnel.

Understanding the role of spirituality as a potential coping mechanism for military personnel is important given growing concern about the mental health issues of personnel returning from war. This study seeks to determine the extent to which spirituality is associated with selected mental health problems among active duty military personnel and whether it moderates the relationship between combat exposure/deployment and (a) depression, (b) posttraumatic stress disorder (PTSD), and (c) suicidality in active duty military personnel. Data were drawn from the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Over 24,000 randomly selected active duty personnel worldwide completed an anonymous self-report questionnaire. High spirituality had a significant protective effect only for depression symptoms. Medium, as opposed to high or low, levels of spirituality buffered each of the mental health outcomes to some degree. Medium and low spirituality levels predicted depression symptoms but only among those with moderate combat exposure. Medium spirituality levels also predicted PTSD symptoms among those with moderate levels of combat exposure and predicted self-reported suicidal ideation/attempt among those never deployed. These results point to the complex relationship between spirituality and mental health, particularly among military personnel and the need for further research.