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.

Perceptions of High-Risk Situations for Sexual Assault: Gender Differences in the U.S. Air Force.

This study explored U.S. Air Force service members' perceptions of high-risk situations for sexual assault victimization. Qualitative data were collected from 52 active duty Airmen, including sexual assault survivors and general population officers and enlisted personnel. Participants were recruited through posted flyers, base-wide e-mail messages, and referrals from the Sexual Assault Response Coordinator's office. Content analysis was used to summarize participants' opinions and experiences. High-risk situations for all Airmen included excessive alcohol use, specific physical settings, and situations associated with work assignments. High-risk situations identified frequently by male and female sexual assault survivors and female (but not male) general population Airmen included power imbalance; isolation in the workplace and social settings; and youth, inexperience, and unfamiliarity with the military environment. Female Airmen identified workplaces with a predominance of men or being one of very few women in a group as a high-risk situation for sexual assault victimization. And female sexual assault survivors identified implicit but unwarranted trust between Airmen as a high-risk situation. This study provides new insight into gender differences in high-risk situations for sexual assault victimization, and the data can help policymakers better prevent sexual assault by appropriately tailoring and timing sexual assault risk reduction training.

Posttraumatic Stress Disorder in U.S. Military Primary Care: Trajectories and Predictors of One-Year Prognosis.

We examined the longitudinal course of primary care patients in the active duty Army with posttraumatic stress disorder (PTSD) and identified prognostic indicators of PTSD severity. Data were drawn from a 6-site randomized trial of collaborative primary care for PTSD and dpression in the military. Subjects were 474 soldiers with PTSD (scores ≥ 50 on the PTSD Checklist -Civilian Version). Four assessments were completed at U.S. Army installations: baseline, and follow-ups at 3 months (92.8% response rate [RR]), 6 months (90.1% RR), and 12 months (87.1% RR). Combat exposure and 7 validated indicators of baseline clinical status (alcohol misuse, depression, pain, somatic symptoms, low mental health functioning, low physical health functioning, mild traumatic brain injury) were used to predict PTSD symptom severity on the Posttraumatic Diagnostic Scale (Cronbach's α = .87, .92, .95, .95, at assessments 1-4, respectively). Growth mixture modeling identified 2 PTSD symptom trajectories: subjects reporting persistent symptoms (Persisters, 81.9%, n = 388), and subjects reporting improved symptoms (Improvers 18.1%, n = 86). Logistic regression modeling examined baseline predictors of symptom trajectories, adjusting for demographics, installation, and treatment condition. Subjects who reported moderate combat exposure, adjusted odds ratio (OR) = 0.44, 95% CI [0.20, 0.98], or who reported high exposure, OR = 0.39, 95% CI [0.17, 0.87], were less likely to be Improvers. Other baseline clinical problems were not related to symptom trajectories. Findings suggested that most military primary care patients with PTSD experience persistent symptoms, highlighting the importance of improving the effectiveness of their care. Most indicators of clinical status offered little prognostic information beyond the brief assessment of combat exposure.

Centrally Assisted Collaborative Telecare for Posttraumatic Stress Disorder and Depression Among Military Personnel Attending Primary Care: A Randomized Clinical Trial.

IMPORTANCE: It is often difficult for members of the US military to access high-quality care for posttraumatic stress disorder (PTSD) and depression. OBJECTIVE: To determine effectiveness of a centrally assisted collaborative telecare (CACT) intervention for PTSD and depression in military primary care. DESIGN, SETTING, AND PARTICIPANTS: The STEPS-UP study (Stepped Enhancement of PTSD Services Using Primary Care) is a randomized trial comparing CACT with usual integrated mental health care for PTSD or depression. Patients, mostly men in their 20s, were enrolled from 18 primary care clinics at 6 military installations from February 2012 to August 2013 with 12-month follow-up completed in October 2014. INTERVENTIONS: Randomization was to CACT (n = 332) or usual care (n = 334). The CACT patients received 12 months of stepped psychosocial and pharmacologic treatment with nurse telecare management of caseloads, symptoms, and treatment. MAIN OUTCOMES AND MEASURES: Primary outcomes were severity scores on the PTSD Diagnostic Scale (PDS; scored 0-51) and Symptom Checklist depression items (SCL-20; scored 0-4). Secondary outcomes were somatic symptoms, pain severity, health-related function, and mental health service use. RESULTS: Of 666 patients, 81% were male and the mean (SD) age was 31.1 (7.7) years. The CACT and usual care patients had similar baseline mean (SD) PDS PTSD (29.4 [9.4] vs 28.9 [8.9]) and SCL-20 depression (2.1 [0.6] vs 2.0 [0.7]) scores. Compared with usual care, CACT patients reported significantly greater mean (SE) 12-month decrease in PDS PTSD scores (-6.07 [0.68] vs -3.54 [0.72]) and SCL-20 depression scores -0.56 [0.05] vs -0.31 [0.05]). In the CACT group, significantly more participants had 50% improvement at 12 months compared with usual care for both PTSD (73 [25%] vs 49 [17%]; relative risk, 1.6 [95% CI, 1.1-2.4]) and depression (86 [30%] vs 59 [21%]; relative risk, 1.7 [95% CI, 1.1-2.4]), with a number needed to treat for a 50% improvement of 12.5 (95% CI, 6.9-71.9) and 11.1 (95% CI, 6.2-50.5), respectively. The CACT patients had significant improvements in somatic symptoms (difference between mean 12-month Patient Health Questionnaire 15 changes, -1.37 [95% CI, -2.26 to -0.47]) and mental health-related functioning (difference between mean 12-month Short Form-12 Mental Component Summary changes, 3.17 [95% CI, 0.91 to 5.42]), as well as increases in telephone health contacts and appropriate medication use. CONCLUSIONS AND RELEVANCE: Central assistance for collaborative telecare with stepped psychosocial management modestly improved outcomes of PTSD and depression among military personnel attending primary care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01492348.

Help-Seeking Behaviors Among Active-Duty Military Personnel: Utilization of Chaplains and Other Mental Health Service Providers.

Military chaplains not only conduct religious services, but also provide counseling and spiritual support to military service members, operating as liaisons between soldiers and mental health professionals. In this study, active-duty soldiers (N = 889) reported help-seeking behaviors and mental health. Using logistic regressions, we describe the issues for which soldiers reported seeking help, then outline the characteristics of those who are most likely to seek help from a chaplain. Of the soldiers who sought help from a chaplain within the previous year, 29.9% reported high levels of combat exposure, 50.8% screened positive for depression, 39.1% had probable PTSD, and 26.6% screened positive for generalized anxiety disorder. The participant's unit firing on the enemy, personally firing on the enemy, and seeing dead bodies or human remains predicted seeing a chaplain. Future research should examine ways to engage soldiers who have had more combat experiences with the chaplain community to address spiritual issues.

Collaborating across the Departments of Veterans Affairs and Defense to integrate mental health and chaplaincy services.

BACKGROUND: Recognizing that clergy and spiritual care providers are a key part of mental health care systems, the Department of Veterans Affairs (VA) and Department of Defense (DoD) jointly examined chaplains' current and potential roles in caring for veterans and service members with mental health needs. OBJECTIVE: Our aim was to evaluate the intersection of chaplain and mental health care practices in VA and DoD in order to determine if improvement is needed, and if so, to develop actionable recommendations as indicated by evaluation findings. DESIGN: A 38-member multidisciplinary task group partnered with researchers in designing, implementing, and interpreting a mixed methods study that included: 1) a quantitative survey of VA and DoD chaplains; and 2) qualitative interviews with mental health providers and chaplains. PARTICIPANTS: Quantitative: the survey included all full-time VA chaplains and all active duty military chaplains (n = 2,163 completed of 3,464 invited; 62 % response rate). Qualitative: a total of 291 interviews were conducted with mental health providers and chaplains during site visits to 33 VA and DoD facilities. MAIN MEASURES: Quantitative: the online survey assessed intersections between chaplaincy and mental health care and took an average of 37 min to complete. Qualitative: the interviews assessed current integration of mental health and chaplain services and took an average of 1 h to complete. KEY RESULTS: When included on interdisciplinary mental health care teams, chaplains feel understood and valued (82.8-100 % of chaplains indicated this, depending on the team). However, findings from the survey and site visits suggest that integration of services is often lacking and can be improved. CONCLUSIONS: Closely coordinating with a multidisciplinary task group in conducting a mixed method evaluation of chaplain-mental health integration in VA and DoD helped to ensure that researchers assessed relevant domains and that findings could be rapidly translated into actionable recommendations.

Implementing collaborative primary care for depression and posttraumatic stress disorder: design and sample for a randomized trial in the U.S. military health system.

BACKGROUND: War-related trauma, posttraumatic stress disorder (PTSD), depression and suicide are common in US military members. Often, those affected do not seek treatment due to stigma and barriers to care. When care is sought, it often fails to meet quality standards. A randomized trial is assessing whether collaborative primary care improves quality and outcomes of PTSD and depression care in the US military health system. OBJECTIVE: The aim of this study is to describe the design and sample for a randomized effectiveness trial of collaborative care for PTSD and depression in military members attending primary care. METHODS: The STEPS-UP Trial (STepped Enhancement of PTSD Services Using Primary Care) is a 6 installation (18 clinic) randomized effectiveness trial in the US military health system. Study rationale, design, enrollment and sample characteristics are summarized. FINDINGS: Military members attending primary care with suspected PTSD, depression or both were referred to care management and recruited for the trial (2592), and 1041 gave permission to contact for research participation. Of those, 666 (64%) met eligibility criteria, completed baseline assessments, and were randomized to 12 months of usual collaborative primary care versus STEPS-UP collaborative care. Implementation was locally managed for usual collaborative care and centrally managed for STEPS-UP. Research reassessments occurred at 3-, 6-, and 12-months. Baseline characteristics were similar across the two intervention groups. CONCLUSIONS: STEPS-UP will be the first large scale randomized effectiveness trial completed in the US military health system, assessing how an implementation model affects collaborative care impact on mental health outcomes. It promises lessons for health system change.

Chaplaincy and mental health in the department of Veterans affairs and department of defense.

Chaplains play important roles in caring for Veterans and Service members with mental health problems. As part of the Department of Veterans Affairs (VA) and Department of Defense (DoD) Integrated Mental Health Strategy, we used a sequential approach to examining intersections between chaplaincy and mental health by gathering and building upon: 1) input from key subject matter experts; 2) quantitative data from the VA / DoD Chaplain Survey (N = 2,163; response rate of 75% in VA and 60% in DoD); and 3) qualitative data from site visits to 33 VA and DoD facilities. Findings indicate that chaplains are extensively involved in caring for individuals with mental health problems, yet integration between mental health and chaplaincy is frequently limited due to difficulties between the disciplines in establishing familiarity and trust. We present recommendations for improving integration of services, and we suggest key domains for future research.

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.

Prevalence of perceived stress and mental health indicators among reserve-component and active-duty military personnel.

OBJECTIVES: We examined stress levels and other indicators of mental health in reservists and active-duty military personnel by deployment status. METHODS: We used data from the Department of Defense Health-Related Behaviors surveys, which collect comprehensive, population-based data for reserve and active-duty forces. Data were collected from 18 ,342 reservists and 16, 146 active-duty personnel. RESULTS: Overall, with adjustment for sociodemographic and service differences, reservists reported similar or less work and family stress, depression, and anxiety symptoms than did active-duty personnel. However, reservists who had been deployed reported higher rates of suicidal ideation and attempts than did active-duty personnel who had been deployed and higher rates of post-traumatic stress disorder symptomatology than did any active-duty personnel and reservists who had not been deployed. The highest rates of suicidal ideation and attempts were among reservists who had served in theaters other than Iraq and Afghanistan. CONCLUSIONS: Our results suggest that deployment has a greater impact on reservists than on active-duty members, thus highlighting the urgent need for services addressing reservists' unique postdeployment mental health issues. Also, deployment to any theater, not only Iraq or Afghanistan, represents unique threats to all service members' mental well-being.

Socio-cultural factors that foster use and abuse of alcohol among a sample of enlisted personnel at four Navy and Marine Corps installations.

Rates of heavy drinking are consistently higher among U.S. military personnel than among civilians, particularly among young male personnel. In addressing drinking in the military, more information is needed on contextual factors influencing drinking to better understand the conditions that lead to or facilitate drinking. Results from 15 focus groups conducted with enlisted personnel at 2 Navy and 2 Marine Corps installations as part of formative research for an alcohol abuse prevention trial are reported in this article. The study explored the "drinking climate" of each installation in terms of shared attitudes and recognized norms regarding alcohol use and installation personnel's general understanding of policies concerning alcohol consumption. Analysis revealed several contextual factors that add to our understanding of drinking behaviors.

Substance use and mental health trends among U.S. military active duty personnel: key findings from the 2008 DoD Health Behavior Survey.

OBJECTIVE: Examine substance use and mental health issues among U.S. military personnel. METHODS: Data were from the 2008 (and before) population-based Department of Defense Health Related Behavior Surveys. The sample size for the 2008 survey was 28,546 (70.6% response rate). RESULTS: Analyses examined substance use, stress, depression, post-traumatic stress disorder (PTSD), suicidal ideation and attempts, deployment, and job satisfaction. Trends show reductions in tobacco use and illicit drug use, but increases in prescription drug misuse, heavy alcohol use, stress, PTSD, and suicidal attempts. Deployment exacerbated some of these behavior changes. Despite the demanding lifestyle, job satisfaction was high. CONCLUSIONS: The military has shown progress in decreasing cigarette smoking and illicit drug use. Additional emphasis should be placed on understanding increases in prescription drug misuse, heavy alcohol use, PTSD, and suicide attempts, and on planning additional effective interventions and prevention programs. Challenges remain in understanding and addressing military mental health needs.

An evaluation of a sexual assault prevention and advocacy program for U.S. Navy personnel.

To address the needs of Navy personnel (and dependents), the Navy implemented the Sexual Assault Victim Intervention (SAVI) program. The SAVI program has two components, namely, a presentation/training component and an advocacy component. The presentation/training component involves education designed to increase awareness and prevention of sexual victimization, delivered to all military and civilian personnel through presentations, and training of SAVI advocates. The advocacy component provides victims with professionally trained advocates who provide information and emotional support and help guide victims through various medical, legal, and investigative processes. Data are presented on (1) satisfaction with program quality, (2) how well the SAVI program met its primary objectives (e.g., helps program users cope with sexual trauma), (3) how well the SAVI program met its primary program objectives or reasons for being (e.g., helps service members concentrate on their jobs), and (4) program effects on mission-related outcomes (i.e., quality of life, readiness, and intended retention).