Resilience enhancing programs in the U.S. military: An exploration of theory and applied practice.

U.S. service members are at an enhanced risk for developing mental disorders. To address these challenges, while promoting operational readiness and improving mental health outcomes, the Department of Defense directed each service component to develop and implement universal resilience enhancing programs. This paper provides a review of theoretical approaches conceptualizing resilience to trauma, including the theoretical foundations of programs currently in place. The resilience programs of U.S. Army, U.S. Air Force, U.S. Navy and U.S. Marine Corps are described, and available program effectiveness data are reviewed. Gaps between theory and practice are identified and an alternative method of assessing psychological readiness in Army units that is informed by resilience theory is offered as one way to address these gaps and scientific concerns. By comprehensively assessing the stressors affecting Soldiers at regular intervals, military leaders may be able to better identify and mitigate stressors in a systematic way that bolsters individual and unit psychological fitness. An enhanced psychological readiness metric stands to strengthen the validity of current resilience programs, bring clarity to the mechanisms of resilience, and provide a novel way for leaders to promote readiness in their units. Application of this metric within the infrastructure of existing reporting systems stands to improve mental health outcomes for Service Members, enhance the psychological readiness of the force, and reduce healthcare costs over time.

Coping self-efficacy mediates effects of posttraumatic distress on communal coping in parent-adolescence dyads after floods.

Social cognitive theory provides a framework of human agency during environmental challenges, with coping self-efficacy (CSE) as an important construct underlying adaptation. We examined two alternative models involving CSE as a mediator of the association between posttraumatic stress symptoms (PTSS) and communal coping among parent-youth dyads after severe floods using Bayesian dyadic multilevel modeling. The first model included PTSS as the independent variable and communal coping as the dependent variable (disaster distress model). The independent and dependent variables were replaced for each other in the second model (communal coping model). We used data from 485 parent-youth dyads who experienced floods between 2015 and 2016 in Texas, USA. Parents of children (69% women) aged 10-19 years old, and their oldest child (53% male; Mean age = 13.75) in that age range were recruited. We assessed PTSS, CSE, and communal coping for parents and youths. Results favored the disaster distress model over the communal coping model. In the disaster distress model, results demonstrated that CSE declines as PTSS increases, predicting decreased communal coping. This mediation effect of CSE is stronger for youths compared to parents, indicating that children's CSE is affected more by PTSS.

The Impact of Adjustment on Workplace Attitudes and Behaviors Among Health Care Workers During the COVID-19 Pandemic.

OBJECTIVE: We examined the impact of health care workers' (HCWs) adjustment to the COVID-19 pandemic on their work-related attitudes and behaviors. METHODS: HCWs ( n = 1468) participated in an observational longitudinal study in which they completed surveys of anxiety and occupational health between 2020 and 2021. RESULTS: Most HCWs reported anxiety that was consistently below the diagnostic threshold (68%) or fell below the threshold within a year (16%). Others reported consistently high (14%) or increasing (2%) anxiety, especially women, younger HCWs, those with a weakened immune system, and allied health professionals. Consistently high or increasing anxiety was associated with poorer job satisfaction, work engagement, perceived supervisor support, burnout, and turnover intentions. CONCLUSIONS: Resources to support HCWs may be focused on those who report consistently high or increasing anxiety to minimize the effects of crises and disasters on the workforce.

Self-compassion reduces posttraumatic stress symptom severity in hurricane survivors via perceived social support.

OBJECTIVE: Following disasters such as hurricanes, self-compassion (e.g., being understanding and showing care toward oneself) can be a valuable personal resource that facilitates social support and reduces posttraumatic symptoms. As a result of their increased connection to other people and interpersonal competence, self-compassionate people may perceive more social support following a traumatic event, which in turn reduces posttraumatic stress symptoms (PTSS). The present study is the first to utilize a longitudinal design and latent variable modeling to test this mediation hypothesis. METHOD: A three-wave longitudinal design was utilized to assess hurricane exposure, self-compassion, perceived social support, and PTSS in hurricane survivors at baseline (T1), 3-month (T2), and 6-month (T3) follow-up. Participants at T1 included 261 hurricane survivors (88.5% women) who were racially diverse and particularly vulnerable to loss of resources (53.2% with an income of less than $30,000). Participants were recruited using online, print, and face-to-face methods, and all survey responses were completed online. RESULTS: Participants reported high hurricane stressor exposure (M = 9.14 serious stressors out of a possible 24). Controlling for hurricane exposure, self-compassion at T1 predicted PTSS at T3, and this was mediated by perceived social support at T2. CONCLUSIONS: Following hurricane exposure, self-compassionate people experience less PTSS over time because they perceive their social support resources to be more robust. Implementation of self-compassion education and training following a disaster could improve perceived social support networks that provide an additional protective factor against PTSS. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Nonlinear Changes in Facial Affect and Posttraumatic Growth: Assessment of Ecological Momentary Assessment Video Data.

Posttraumatic Growth (PTG), characterized by newfound meaning, perspective, and purpose for trauma survivors, remains enigmatic in its nature. This state is thought to arise from the dynamic interplay of biopsychosocial factors; however, the nature of this interplay is unclear. This study aimed to investigate the intricate relationship between PTG and facial affect dynamics, shedding light on the complex interplay of biopsychosocial factors that underpin this transformative process. We conducted a comprehensive investigation involving 19 wildfire survivors who provided daily self-reported PTG ratings alongside smartphone videos analyzed using Automated Facial Affect Recognition (AFAR) software. Our findings revealed compelling evidence of self-organization within facial affect, as indicated by notably high mean R2 and shape parameter values (i.e., nonlinear indices indicative of structural integrity and flexibility). Further regression analyses unveiled a significant interaction between the degree of facial affect 'burstiness' and coping self-efficacy (CSE) on PTG. This interaction suggested that PTG development was a nuanced process intricately linked to the coherence of emotion patterns exhibited by individuals. These insights illuminate the multifaceted dynamics at play in the emergence of PTG and contribute to a broader understanding of its biopsychosocial foundations.

Random intercept cross-lagged relations among trauma coping self-Efficacy, trauma coping, and PTSD symptoms among rural hurricane survivors.

BACKGROUND AND OBJECTIVES: The trajectories of recovery and non-recovery following a disaster are well-documented, but the mechanisms of post-disaster adaptation remain poorly understood. Rooted in social cognitive theory and the transactional model of stress and coping, this study longitudinally investigated the reciprocal relations among coping self-efficacy (CSE), coping behaviors (approach and avoidant), and posttraumatic stress symptoms (PTSS) among highly exposed hurricane survivors. DESIGN: 261 Hurricane Florence survivors completed measures of hurricane-related CSE, coping behaviors, and hurricane-related PTSS across three timepoints, beginning 5-8.5 months after Hurricane Florence. METHOD: Random-intercept cross-lagged panel models investigated the relations among study variables. RESULTS: Reciprocal, cross-lagged relations were identified between higher CSE and approach coping from T2 to T3. The lagged relations between approach coping at T1 and T2 were significant, as well as between avoidant coping at T2 and T3. Significant cross-sectional relations were also present for CSE, coping behaviors, and PTSS at T3. CONCLUSIONS: Results provide partial support for the positive feedback loop involving CSE and approach coping, but not for the negative feedback loop involving avoidant coping. CSE may be an important mechanism in longer-term disaster recovery, in part by increasing use of approach coping.

Big ideas series: self-regulation shift theory: trauma, suicide, and violence.

BACKGROUND: Traumatic stress, suicide, and impulsive violence arguably are three of the most consequential problems facing societies today. Self-regulation shift theory is introduced to capture the underlying coping dynamics involved in these three grave challenges. OBJECTIVES: Self-regulation shift theory, based in a nonlinear dynamical systems framework, focuses on critical psychological self-regulation thresholds and the role of cognitive self-appraisals in human adaptation to help understand these three significant societal challenges. METHODS: This essay reviews existing evidence within the posttraumatic adaptation process utilizing SRST for understanding dynamic self-regulation. This is followed by integrating SRST within existing current theoretical models for suicidal behaviors and violent outbursts. CONCLUSIONS: The essay concludes with methodological suggestions for future research applying SRST and how this research offers important opportunities to develop early warning systems that promote hope when hope seems impossible.

The mediating role of coping self-efficacy on social support and PTSD symptom severity among injury survivors.

BACKGROUND: Social support confers a protective effect against elevated PTSD symptomatology following injury. However, little is known about the mechanisms through which social support conveys this protective mental health effect in injury survivors. Coping self-efficacy is linked to both social support and PTSD symptomatology but has not been examined. OBJECTIVE: To test coping self-efficacy as a mechanism for the relationship between social support and PTSD symptom severity among injury survivors. METHOD AND DESIGN: Participants consisted of 61 injury survivors (62.3% male, 72.1% White) admitted to a Level-1 Trauma Center. Social support was assessed at 2-weeks post-injury; coping self-efficacy at 6-weeks post-injury; and PTSD symptom severity at 3-months post-injury. RESULTS: A statistically significant indirect effect was found for the social support - coping self-efficacy - PTSD symptomatology pathway, providing evidence of mediation even after controlling for age, sex, race, and education (B = -0.51, SE = 0.18, CI = -0.92, -0.20). CONCLUSIONS: Social support may exert an effect on PTSD symptom severity post-injury through its connection with coping self-efficacy. Coping self-efficacy represents an important intervention target following injury for those survivors with lower social support who are at risk for elevated PTSD symptom severity levels.

Moral injury and psychosocial functioning in health care workers during the COVID-19 pandemic.

Studies of moral injury among nonmilitary samples are scarce despite repeated calls to examine the prevalence and outcomes of moral injury among civilian frontline workers. The purpose of this study was to describe the prevalence of moral injury and to examine its association with psychosocial functioning among health care workers during the COVID-19 pandemic. We surveyed health care workers (N = 480), assessing exposure to potentially morally injurious events (PMIEs) and psychosocial functioning. Data were analyzed using latent class analysis (LCA) to explore patterns of PMIE exposure (i.e., classes) and corresponding psychosocial functioning. The minimal exposure class, who denied PMIE exposure, accounted for 22% of health care workers. The moral injury-other class included those who had witnessed PMIEs for which others were responsible and felt betrayed (26%). The moral injury-self class comprised those who felt they transgressed their own values in addition to witnessing others' transgressions and feeling betrayed (11%). The betrayal-only class included those who felt betrayed by government and community members but otherwise denied PMIE exposure (41%). Those assigned to the moral injury-self class were the most impaired on a psychosocial functioning composite, followed by those assigned to the moral injury-other and betrayal-only classes, and finally the minimal exposure class. Moral injury is prevalent and impairing for health care workers, which establishes a need for interventions with health care workers in organized care settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Not how often but when: Self-efficacy to control cannabis use and PTSS.

OBJECTIVE: Cannabis use is prevalent with trauma survivors. Yet, the effects of cannabis use on posttraumatic stress symptoms (PTSS) have been equivocal with some studies showing a positive association and some showing a negative association. Integrating the self-medication hypothesis and social cognitive theory (SCT), the present study aimed to elucidate differential outcomes by considering frequency of cannabis use and self-efficacy to control cannabis use in different contexts (i.e., social facilitation, opportunistic, and emotional relief) in relation to PTSS. METHOD: Undergraduate students (N = 314) who endorsed lifetime trauma exposure and past-month cannabis use completed self-report measures assessing cannabis use behaviors, self-efficacy to control use, and PTSS. RESULTS: Parallel mediation revealed that initially, greater frequency of cannabis use was associated with PTSS severity (ß = .16, SE = .09, p = .004). With the inclusion of emotional relief self-efficacy, opportunistic self-efficacy, and social facilitation self-efficacy to control cannabis use as parallel mediators, frequency of cannabis use no longer predicted PTSS severity. There was also a significant indirect effect of emotional relief self-efficacy to control cannabis use on frequency of use and PTSS (95% CI [.14, .31]). CONCLUSIONS: Self-efficacy to control cannabis use during moments of emotional distress could serve a critical role in the relationship between cannabis use and PTSS. These results may inform clinical intervention and provide survivors with a better understanding of how use impacts recovery. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Exposure to potentially morally injurious events and mental health outcomes among frontline workers affected by the coronavirus pandemic.

OBJECTIVE: The current studies explored associations between exposure to potentially morally injurious events (PMIEs) and mental health outcomes among frontline workers affected by the coronavirus pandemic. METHOD: We administered online self-report surveys to emergency responders (N = 473) and hospital personnel (N = 854) in the Rocky Mountain region of the United States between April and June of 2020. Surveys assessed frequency and intensity of exposure to PMIEs alongside psychological and functional outcomes. RESULTS: Between 20% and 30% of frontline workers reported exposure to PMIEs of at least moderate frequency and intensity. Exposure to more intense PMIEs was associated with greater psychological symptoms (i.e., stress, depression, and anxiety) and functional impairment (i.e., professional burnout), especially among emergency responders who reported frequent exposure but also hospital workers who reported few exposures. CONCLUSION: Efforts to facilitate and maintain the well-being of the public health workforce should specifically address critical incidents encountered by frontline workers that have embedded moral and ethical challenges. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Engagement, Predictors, and Outcomes of a Trauma Recovery Digital Mental Health Intervention: Longitudinal Study.

BACKGROUND: Worldwide, exposure to potentially traumatic events is extremely common, and many individuals develop posttraumatic stress disorder (PTSD) along with other disorders. Unfortunately, considerable barriers to treatment exist. A promising approach to overcoming treatment barriers is a digital mental health intervention (DMHI). However, engagement with DMHIs is a concern, and theoretically based research in this area is sparse and often inconclusive. OBJECTIVE: The focus of this study is on the complex issue of DMHI engagement. On the basis of the social cognitive theory framework, the conceptualization of engagement and a theoretically based model of predictors and outcomes were investigated using a DMHI for trauma recovery. METHODS: A 6-week longitudinal study with a national sample of survivors of trauma was conducted to measure engagement, predictors of engagement, and mediational pathways to symptom reduction while using a trauma recovery DMHI (time 1: N=915; time 2: N=350; time 3: N=168; and time 4: N=101). RESULTS: Confirmatory factor analysis of the engagement latent constructs of duration, frequency, interest, attention, and affect produced an acceptable model fit (χ22=8.3; P=.02; comparative fit index 0.973; root mean square error of approximation 0.059; 90% CI 0.022-0.103). Using the latent construct, the longitudinal theoretical model demonstrated adequate model fit (comparative fit index 0.929; root mean square error of approximation 0.052; 90% CI 0.040-0.064), indicating that engagement self-efficacy (ß=.35; P<.001) and outcome expectations (ß=.37; P<.001) were significant predictors of engagement (R2=39%). The overall indirect effect between engagement and PTSD symptom reduction was significant (ß=-.065; P<.001; 90% CI -0.071 to -0.058). This relationship was serially mediated by both skill activation self-efficacy (ß=.80; P<.001) and trauma coping self-efficacy (ß=.40; P<.001), which predicted a reduction in PTSD symptoms (ß=-.20; P=.02). CONCLUSIONS: The results of this study may provide a solid foundation for formalizing the nascent science of engagement. Engagement conceptualization comprised general measures of attention, interest, affect, and use that could be applied to other applications. The longitudinal research model supported 2 theoretically based predictors of engagement: engagement self-efficacy and outcome expectancies. A total of 2 task-specific self-efficacies-skill activation and trauma coping-proved to be significant mediators between engagement and symptom reduction. Taken together, this model can be applied to other DMHIs to understand engagement, as well as predictors and mechanisms of action. Ultimately, this could help improve the design and development of engaging and effective trauma recovery DMHIs.

Trauma Coping Self-Efficacy Mediates Associations Between Adult Attachment and Posttraumatic Stress Symptoms.

Attachment orientations reflect individuals' expectations for interpersonal relationships and influence emotion regulation strategies and coping. Previous research has documented that anxious and avoidant attachment orientations have deleterious effects on the trauma recovery process leaving these survivors vulnerable to posttraumatic stress disorder (PTSD) symptoms. However, avoidant attachment may be more complicated. Prior work has also found those high in avoidant attachment but also low in anxious attachment (i.e., dismissing) may not experience such vulnerabilities. Further, avoidant attachment individuals often report higher self-efficacy than their anxiously attached counterparts. The present study examined trauma coping self-efficacy (CSE-T) as a previously unexamined mechanism of action between adult attachment and PTSD symptoms. Structural equation modeling results showed that anxious attachment was associated with lower CSE-T and greater PTSD symptoms six weeks later. Further, a significant indirect effect of anxious attachment on PTSD symptoms through CSE-T was found. Contrary to hypotheses, avoidant attachment also exhibited an indirect effect on PTSD symptoms through CSE-T, such that avoidant attachment was associated with lower CSE-T, which in turn, was associated with greater PTSD symptoms. Also contrary to hypotheses, the interaction between anxious and avoidant attachment was not significantly associated with either CSE-T or PTSD symptoms. Results suggest that both anxious and avoidant attachment orientations contribute to poor self-regulation following trauma, as they undermine perceptions of trauma coping self-efficacy.

Social cognitive mechanisms in healthcare worker resilience across time during the pandemic.

PURPOSE: Healthcare workers are at increased risk for mental health problems during disasters such as the COVID-19 pandemic. Identifying resilience mechanisms can inform development of interventions for this population. The current study examined pathways that may support healthcare worker resilience, specifically testing enabling (social support enabled self-efficacy) and cultivation (self-efficacy cultivating support) models. METHODS: Healthcare workers (N = 828) in the Rocky Mountain West completed self-report measures at four time points (once per month from April to July of 2020). We estimated structural equation models to explore the potential mediating effects that received social support and coping self-efficacy had (at time 2 and time 3) between traumatic stress symptom severity (at time 1 and time 4). Models included covariates gender, age, minority status, and time lagged co-variations between the proposed mediators (social support and coping self-efficacy). RESULTS: The full model fit the data well, CFI = .993, SRMR = .027, RMSEA = .036 [90% CIs (0.013, 0.057)]. Tests of sequential mediation supported enabling model dynamics. Specifically, the effects of time 1 traumatic stress severity were mediated through received social support at time 2 and time 3 coping self-efficacy, in sequential order to reduce time 4 traumatic stress severity. CONCLUSIONS: Findings show the importance of received social support and coping self-efficacy in mitigating psychopathology risk. Interventions can support mental health by focusing on social resource engagement that facilitates coping empowerment, which may decrease risk for mental health job-related problems among frontline healthcare workers exposed to highly stressful events.

Mental health risks differentially associated with immunocompromised status among healthcare workers and family members at the pandemic outset.

The mental health of healthcare workers (HCWs) is critical to their long-term well-being and future disaster preparedness. Goal 1 of this study was to identify rates of mental health problems experienced by HCWs. Goal 2 was to test a model of risk stemming from pandemic-related stressors and vulnerability factors. This cross-sectional study included HCWs (N â€‹= â€‹2,246 [1,573 clinical providers; 673 non-clinical staff]) in the Rocky Mountain West who voluntarily completed an online survey in April/May 2020. Respondents completed measures for traumatic stress symptoms, depression, anxiety, alcohol use, and sleep. Logistic regressions stratified by professional role (clinical versus non-clinical) were specified to predict clinical screening cutoff (positive/negative) as a function of five pandemic-related stressors (immunocompromised self; immunocompromised household member; care provision to infected patients; clinical management role; positive cases). Results showed that more than half of HCWs surveyed (52.5%) screened positive (above cutoff) for traumatic stress, depression, or anxiety, with ~20% reporting problematic alcohol use, and variable insufficient sleep from ~10% off shift to ~50% on shift. Clinical employees with an immunocompromised household member had increased odds of screening positive for a mental health problem. Non-clinical HCWs who were immunocompromised were at elevated risk for screening positive a mental health problem. Being female, minority status, and younger increased odds for mental health problems. Implications include alleviating a portion of the mental health burden of HCWs involved in response to the SARS-CoV-2 pandemic by considering policies to protect immunocompromised HCWs and their families (e.g., vaccine priorities, telework options).

The power of appraisals in predicting PTSD symptom improvement following cognitive rehabilitation: A randomized clinical trial.

BACKGROUND: Patients with PTSD often voice concern over their perceived change in cognitive functioning. However, these negative appraisals do not always align with objective neuropsychological performance, yet are strongly predictive of PTSD symptom severity and self-reported functional impairment. METHODS: The present study involves a secondary analysis examining the role of appraisals of a subsample of 81 adults with full or subthreshold PTSD on treatment outcomes in a randomized controlled trial investigating the effectiveness of a cognitive rehabilitation treatment, Strategic Memory and Reasoning Training (n = 38), compared to a psychoeducation control arm, the Brain Health Workshop (n = 43). Neither condition addressed PTSD symptoms, focusing instead on cognitive skills training and psychoeducation about the brain. RESULTS: Intent-to-treat models showed statistically significant improvements for both groups on composite scores of executive functioning and memory. Additionally, both groups experienced clinically significant reductions in PTSD symptoms (assessed via the Clinician-Administered PTSD Interview) and the SMART group showed fewer negative appraisals about cognitive functioning following training. Change in appraisals of cognitive functioning was associated with change in PTSD as well as change in quality of life, with no differential associations based on group status. In contrast, neurocognitive test score changes were not associated with change in symptoms or functional outcomes. LIMITATIONS: We did not collect data on other appraisals (e.g., self-efficacy), which could have further elucidated pathways of change. CONCLUSIONS: Our findings suggest that interventions that do not directly target PTSD symptoms can lead to PTSD symptom change via change in appraisals of functioning.

Social engagement, self-efficacy, and posttraumatic stress symptoms across 6 months of psychotherapy.

OBJECTIVE: The current study was conducted in a naturalistic treatment setting to examine whether and how perceptions about social engagement, trauma coping self-efficacy, and posttraumatic stress symptoms (PTS) influence one another across 6 months of psychotherapy for trauma survivors. METHOD: The sample included 183 clients who reported exposure to traumatic events and significant PTS (PCL-5 ≥ 33). Participants (Mage = 37.8, 53.6% female) completed surveys at intake, 3 months, and 6 months into treatment. A cross-lagged panel analysis was used to test the relationships among perceived social engagement, coping self-efficacy, and PTS across three assessment points. RESULTS: PTS at 3-months was a mediator in the relationship between intake perceived social engagement and 6-month coping self-efficacy and between intake perceived social engagement and 6-month perceived social engagement. CONCLUSIONS: PTS several months into treatment may serve as a mechanism between intake perceived social engagement and functional outcomes such as coping self-efficacy.

The Indirect Effect of Coping Self-Efficacy on the Relation Between Sexual Violence and PTSD Symptoms.

One in five women experience rape and one in four experience unwanted sexual contact, incurring significant risk of negative psychological outcomes such as posttraumatic stress disorder (PTSD). Given this heightened risk, it is imperative to examine factors that can inhibit the development of PTSD symptoms in response to sexual violence in women. Perceived coping self-efficacy (CSE) is a cognitive appraisal ability utilized to regulate internal and external stressors that arise from traumatic events and is crucial for effective adaptation after traumas such as sexual violence. This study investigated CSE as a potential protective factor against trauma-related psychopathology in female rape survivors. In this study, 518 female undergraduate students (M age = 22.71 years, SD = 8.33 years; 82.4% Caucasian) completed self-report measures of nonconsensual sexual experiences, CSE, and PTSD symptom severity. Of those, 375 women (M age = 22.89 years, SD = 6.91 years; 83.7% Caucasian) reported at least one incident of a nonconsensual sexual experience. We hypothesized that CSE would indirectly affect the relationship between sexual violence and PTSD symptom severity, such that CSE would be protective against PTSD symptoms. In line with our hypothesis, there was evidence of a significant indirect effect, 95% confidence interval (CI) = [0.18, 0.44]. This evidence suggests that CSE may be an important protective factor given women's increased risk of developing PTSD symptoms following sexual violence. Furthermore, this finding suggests that programs targeting the development of CSE may prevent or lessen risk of PTSD symptoms following sexual violence.

Pandemic-related mental health risk among front line personnel.

The mental health of frontline workers is critical to a community's ability to manage crises and disasters. This study assessed risks for mental health problems (traumatic stress, depression, anxiety, alcohol use, insomnia) in association with pandemic-related stressors in a sample of emergency and hospital personnel (N = 571). Respondents completed self-report surveys online from April 1st to May 7th, 2020 in the Rocky Mountain region of the United States. Results showed that roughly fifteen to thirty percent of respondents screened positive for each disorder. Odds of screening positive were similar between groups for probable acute traumatic stress, depressive disorder, anxiety disorder, and alcohol use disorder; emergency personnel reported significantly higher rates of insufficient sleep than healthcare workers. Logistic regressions showed that respondents who reported having an immunocompromised condition had higher odds of acute traumatic stress, anxiety, and depression. Having an immunocompromised household member was associated with higher odds of insufficient sleep and anxiety. Being in a direct care provision role was associated with higher odds of screening positive for risky alcohol use. Being in a management role over direct care providers was associated with higher odds of screening positive for anxiety, risky alcohol use, and insufficient sleep. There was an inverse relationship between number of positive COVID-19 cases and anxiety, such that as positive cases went up, anxiety decreased. Overall, the mental health risks that we observed early in the COVID-19 pandemic are elevated above previous viral outbreaks (SARS) and comparable to rates shown in disasters (9/11 attacks; Hurricane Katrina).