Differential impact of type of killing on posttraumatic stress disorder symptoms in U.S. Army soldiers deployed to Afghanistan.

Over the past 20 years, U.S. military conflicts in Iraq and Afghanistan have been marked by high rates of combat and wartime killings. Research on Vietnam-era service members suggests that the type of killing (i.e., killing a combatant vs. noncombatant) is an important predictor of later mental health problems, including posttraumatic stress disorder (PTSD). The present study aimed to update these findings by exploring the impact of type of killing on PTSD symptoms using a sample of postdeployment active duty U.S. Army personnel (N = 875). Using multiple regression analysis, we found that the act of killing a noncombatant was significantly associated with PTSD symptoms, B = 7.50, p < .001, whereas killing a combatant was not, B = -0.85, p = .360. This remained significant after controlling for demographic variables, depressive symptoms, and general combat experiences. These findings support the need for thoughtful postdeployment screenings and targeted clinical interventions.

Prototyping Apps for the Management of Sleep, Fatigue, and Behavioral Health in Austere Far-Forward Environments: Development Study.

BACKGROUND: Military service inherently includes frequent periods of high-stress training, operational tempo, and sustained deployments to austere far-forward environments. These occupational requirements can contribute to acute and chronic sleep disruption, fatigue, and behavioral health challenges related to acute and chronic stress and disruption of team dynamics. To date, there is no centralized mobile health platform that supports self- and supervised detection, monitoring, and management of sleep and behavioral health issues in garrison and during and after deployments. OBJECTIVE: The objective of this study was to adapt a clinical decision support platform for use outside clinical settings, in garrison, and during field exercises by medics and soldiers to monitor and manage sleep and behavioral health in operational settings. METHODS: To adapt an existing clinical decision support digital health platform, we first gathered system, content, and context-related requirements for a sleep and behavioral health management system from experts. Sleep and behavioral health assessments were then adapted for prospective digital data capture. Evidence-based and operationally relevant educational and interventional modules were formatted for digital delivery. These modules addressed the management and mitigation of sleep, circadian challenges, fatigue, stress responses, and team communication. Connectivity protocols were adapted to accommodate the absence of cellular or Wi-Fi access in deployed settings. The resulting apps were then tested in garrison and during 2 separate field exercises. RESULTS: Based on identified requirements, 2 Android smartphone apps were adapted for self-monitoring and management for soldiers (Soldier app) and team supervision and intervention by medics (Medic app). A total of 246 soldiers, including 28 medics, received training on how to use the apps. Both apps function as expected under conditions of limited connectivity during field exercises. Areas for future technology enhancement were also identified. CONCLUSIONS: We demonstrated the feasibility of adapting a clinical decision support platform into Android smartphone-based apps to collect, save, and synthesize sleep and behavioral health data, as well as share data using adaptive data transfer protocols when Wi-Fi or cellular data are unavailable. The AIRE (Autonomous Connectivity Independent System for Remote Environments) prototype offers a novel self-management and supervised tool to augment capabilities for prospective monitoring, detection, and intervention for emerging sleep, fatigue, and behavioral health issues that are common in military and nonmilitary high-tempo occupations (eg, submarines, long-haul flights, space stations, and oil rigs) where medical expertise is limited.

Associations of health care staff burnout with negative health and organizational outcomes in the U.S. military health system.

RATIONALE: Burnout is a personal and occupational phenomenon that has been associated with negative physical and psychological outcomes in medical staff. Additionally, there are implications for healthcare organizations, as those staff who are burned out are more likely to have lower productivity or leave the organization. As with the Covid-19 pandemic, future national emergencies and potentially large-scale conflicts will require similar and likely even larger scale responses from the U.S. Military Health System, thus it is important to understand burnout in this population so that the readiness of the staff and the military can remain at a high level. OBJECTIVE: This assessment was designed to examine levels of burnout among United States Military Health System (MHS) staff working at Army installations and the factors that influence the development of burnout. METHODS: Anonymous data was collected from 13,558 active-duty U.S. Soldiers and civilian MHS employees. Burnout was measured using the Copenhagen Burnout Inventory and the Mini-Z. RESULTS: Results showed nearly half of staff who responded (48%) reported being burned out, an increase since last measured in 2019 (31%). Factors related to increased burnout included concerns about work/life balance and workload, low job satisfaction and feeling disconnected from others. Burnout was associated with increases in adverse physical and behavioral health (BH) outcomes. CONCLUSIONS: Results indicate that burnout is a common problem across MHS Army staff and is related to significant adverse health consequences for the individual and reduced retention of staff for the organization. These findings highlight the need to address burnout through policies that standardize health care delivery policies and practices, providing support to leadership to promote a healthy workplace, and individual support to those who experience burnout.

Development of Training to Prepare Army Medics to Address Behavioral Health Needs of Soldiers in Far-Forward Environments Utilizing Mobile App Technology.

INTRODUCTION: Multi-domain operational combat environments will likely restrict key components of current behavioral health (BH) service delivery models. Combat teams in far-forward outposts or extended missions may need to rely on their own internal assets to manage combat and operational stress reactions for extended periods of time. As such, combat medics are expected to take on additional responsibilities as providers of BH support for isolated teams. As they receive limited BH training, medics require additional training to sufficiently respond to combat and operational stress reactions in their assigned teams. This study provided combat medics with a BH training and a mobile application-based support tool that would assist them in identifying and responding to BH concerns in their soldiers. The current analysis examines pre- to post-training changes in attitudes related to utilizing BH skills. MATERIALS AND METHODS: We created a brief training aimed to increase medics' ability and confidence regarding managing BH issues. Its development was part of a study on the feasibility of the Soldier and Medic Autonomous Connectivity Independent System for Remote Environments (AIRE) apps (NOCTEM, LLC), a digital system designed for far-forward BH and sleep monitoring and management. Participants were combat medics from two Army combat brigades preparing for a training rotation through a combat training center (CTC). A total of 16 medics consented to participation with nine medics available at the follow-up after the field exercise. Medics were surveyed before the training and after their return from the CTC. RESULTS: In pre-training surveys, most medics indicated it was within their scope to assess for stress/anxiety, suicidal risk, stress reaction, and sleep problems; assist soldiers with optimizing work performance; and provide interventions for BH concerns and sleep problems. Less than half believed it was within their scope to assess and address team communication issues or provide intervention for stress reactions. After the CTC rotation, more medics endorsed that it was in their scope to provide interventions for acute stress reactions to traumatic events. Before the CTC rotation, at most 60% of the group felt at least moderately confident in utilizing the BH skills of discussing problems, assessing for concerns, and providing interventions. After CTC, the confidence levels for each skill increased or remained the same for most medics. Intervention skills had the highest proportion of medics (66%) reporting increased confidence in using the skills. CONCLUSIONS: A larger proportion of medics believed it was within their scope of work and felt confident in assessing BH problems, and a smaller proportion believed it is within their scope of work and felt confident in applying interventions. The training increased most medics' confidence to administer interventions for BH and team communication issues. Similar training programs can help medics serve as support for a wide variety of circumstances when the brigade's mental health teams are inaccessible. Additionally, the Medic AIRE app expanded the ability to evaluate and provide interventions without extensive training in treatment modalities or BH conditions. This concept shows promise for providing medics with actionable tools when training time is limited such as during preparation for extended deployments.

Calibrating the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) for detecting alcohol-related problems among Canadian, UK and US soldiers: cross-sectional pre-deployment and post-deployment survey results.

OBJECTIVES: Excessive alcohol use can bring about adverse health and work-related consequences in civilian and military populations. Screening for excessive drinking can help identify individuals at risk for alcohol-related problems who may require clinical interventions. The brief validated measures of alcohol use such as the Alcohol Use Disorders Identification Test (AUDIT), or abbreviated AUDIT-Consumption (AUDIT-C), are often included in military deployment screening and epidemiologic surveys, but appropriate cut-points must be used to effectively identify individuals at risk. Although the conventional AUDIT-C cut-points ≥4 for men and ≥3 for women are commonly used, recent validation studies of veterans and civilians recommend higher cut-points to minimise misclassification and overestimation of alcohol-related problems. This study aims to ascertain optimal AUDIT-C cut-points for detecting alcohol-related problems among serving Canadian, UK and US soldiers. DESIGN: Cross-sectional pre/post-deployment survey data were used. SETTINGS: Comprised Army locations in Canada and UK, and selected US Army units. PARTICIPANTS: Included soldiers in each of the above-mentioned settings. OUTCOME MEASURES: Soldiers' AUDIT scores for hazardous and harmful alcohol use or high levels of alcohol problems served as a benchmark against which optimal sex-specific AUDIT-C cut-points were assessed. RESULTS: Across the three-nation samples, AUDIT-C cut-points of ≥6/7 for men and ≥5/6 for women performed well in detecting hazardous and harmful alcohol use and provided comparable prevalence estimates to AUDIT scores ≥8 for men and ≥7 for women. The AUDIT-C cut-point ≥8/9 for both men and women performed fair-to-good when benchmarked against AUDIT ≥16, although inflated AUDIT-C-derived prevalence estimates and low positive predictive values were observed. CONCLUSION: This multi-national study provides valuable information regarding appropriate AUDIT-C cut-points for detecting hazardous and harmful alcohol use, and high levels of alcohol problems among soldiers. Such information can be useful for population surveillance, pre-deployment/post-deployment screening of military personnel, and clinical practice.

Suicide Behavior Results From the U.S. Army's Suicide Prevention Leadership Tool Study: The Behavioral Health Readiness and Suicide Risk Reduction Review (R4).

INTRODUCTION: The U.S. Army developed a new tool called the Behavioral Health Readiness and Suicide Risk Reduction Review (R4) for suicide prevention. A 12-month evaluation study with the primary objective of testing the hypothesis (H1) that Army units receiving R4 would demonstrate improved outcomes in suicidal-behavior measures following the intervention, relative to control, was then conducted. The results of analyses to answer H1 are herein presented. MATERIALS AND METHODS: The R4 intervention (R4-tools/instructions/orientation) evaluation study, Institutional Review Board approved and conducted in May 2019-June 2020, drew samples from two U.S. Army divisions and employed a repeated measurement in pre-/post-quasi-experimental design, including a nonequivalent, but comparable, business-as-usual control. Intervention effectiveness was evaluated using self-report responses to suicide-related measures (Suicide Behaviors Questionnaire-Revised/total-suicide behaviors/ideations/plans/attempts/non-suicidal self-injuries) at 6-/12-month intervals. Analyses examined baseline to follow-up linked and cross-sectional cohorts, incidence/prevalence, and intervention higher-/lower-use R4 subanalyses. RESULTS: Both divisions demonstrated favorable in-study reductions in total-suicide burden, with relatively equivalent trends for total-suicide behaviors, total-suicide risk (Suicide Behaviors Questionnaire-Revised), suicidal ideations, and non-suicidal self-injuries. Although both demonstrated reductions in suicide plans, the control showed a more robust trend. Neither division demonstrated a significant reduction in suicide attempts, but subgroup analyses showed a significant reduction in pre-coronavirus disease 2019-attempt incidence among those with higher-use R4 relative to control. CONCLUSIONS: There is no evidence of harm associated with the R4 intervention. R4 effectiveness as a function of R4 itself requires confirmatory study. R4 is judged an improvement (no evidence of harm + weak evidence of effectiveness) over the status quo (no safety data or effectiveness studies) with regard to tool-based decision-making support for suicide prevention in the U.S. Army.

Behavioral Health Provider Attitudes Toward Behavioral Health Profiles in the U.S. Army.

INTRODUCTION: U.S. Army healthcare providers' use of profiles to document and communicate behavioral health (BH) condition limitations to commanders is vital to understanding both the individual soldier's BH readiness for missions and, as an aggregate, the unit's overall BH readiness status. Quantitative work exploring the link between soldier attitudes toward BH profiles and treatment utilization found that profiles may actually promote increases in treatment-seeking behavior in those receiving conventional BH services. BH provider attitudes on the subject, however, have not been quantitatively explored. Using data from the recently described Behavioral Health Readiness and Decision-Making Instrument (B-REDI) study, the current inquiry addresses this by examining BH providers' pre-/post-B-REDI attitudes toward BH profiles, including therapeutic alliance, to better understand how BH profiles may impact BH treatment. METHODS: This study was approved by the WRAIR Institutional Review Board and is part of the larger B-REDI study. BH providers (n = 307) across five installations supporting active duty U.S. Army Divisions completed surveys longitudinally across three time points from September 2018 to March 2019. The survey specific to this study included five items, developed by WRAIR, assessing BH provider attitudes toward BH profiles. Of the providers who completed the survey, 250 (81%) consented to participate in the study and 149 (60%) completed the 3-month follow-up survey. RESULTS: Over 80% of BH providers expressed agreement with each of three items assessing rationale for issuing BH profiles in both the pre- and post B-REDI period. Specifically, most providers agreed that profiles facilitate commander support to the soldier, afford soldiers resources for recovery, and give commanders increased understanding of soldier health for mission planning. Twenty-six percent of BH providers agreed, 46% were neutral, and 28% disagreed on whether profile impact on the soldier was positive or not in the pre-B-REDI period, but there was a significant positive trend relative to baseline in the post B-REDI period. The vast majority of providers (≥94%) did not endorse agreement that BH profiles negatively impact therapeutic alliance in either the pre- or post-B-REDI period. CONCLUSIONS: Assuming that therapeutic alliance and perceptions of BH profile impact on soldiers are useful proxy measures of how treatment utilization may be affected by profiling, this inquiry fails to establish any meaningful negative association between them. This may provide some additional reassurance to BH providers and policymakers that efforts to improve readiness decision-making, such as B-REDI, and increased profiling in conventional military BH settings may not negatively impact treatment utilization rates.

Far Forward Behavioral Health Service Delivery in Future Combat Environments: A Qualitative Needs Assessment.

INTRODUCTION: It is expected that future multi-domain operational (MDO) combat environments will be characterized by limited capabilities for immediate combat stress control support services for soldiers or immediate evacuation from theater. The operational requirements of the future battlefield make it unlikely that current models for behavioral health (BH) treatment could be implemented without significant adjustments. We conducted a qualitative study with Special Forces medics and operators and soldiers who had deployed to austere conditions in small groups in an effort to inform construction of a BH service delivery model for an MDO environment. The objectives of this study were (1) characterizing stressors and BH issues that were encountered and (2) describing mitigation strategies and resources that were useful or needed in these types of deployments. MATERIALS AND METHODS: Six focus groups were conducted at three army installations with 23 active duty soldiers, including three groups of medics using a semi-structured interview guide focused on stressors they encountered during deployments to austere conditions, and the impact of those stressors on mission and focus. Focus group recordings were transcribed, imported into NVivo software (version 12), and independently coded by two researchers. An analysis was then conducted to develop themes across participants. The study was reviewed by the Walter Reed Army Institute of Research Human Subjects Protection Board. RESULTS: Behavioral health concerns were commonly cited as a stressor in far forward environments. Other common stressors included ineffective or inexperienced leaders, as well as poor team dynamics (e.g., communication and cohesion). Four primary strategies were mentioned as mitigations for deployment stressors: leadership, morale, resilience training, and strength of the team. When asked about resources or training that would have helped with these types of deployments, participants frequently mentioned the availability of BH providers and development of new and realistic BH skills trainings for non-providers and leaders. CONCLUSIONS: Current models for treating BH problems need to be adapted for the future MDO environments in which soldiers will be expected to deploy. Understanding what issues need to be addressed in these environments and how they can best be delivered is an important first step. This study is the first to use qualitative results from those who have already deployed to such environments to describe the stressors and BH issues that were most commonly encountered, the mitigation strategies used, and the resources that were useful or needed.

Results of the Behavioral Health Readiness Evaluation and Decision-Making Instrument Study.

INTRODUCTION: Recent reports have demonstrated behavioral health (BH) system and individual provider challenges to BH readiness success. These pose a risk to winning on the battlefield and present a significant safety issue for the Army. One of the most promising areas for achieving better BH readiness results lies in improving readiness decision-making support for BH providers. The Walter Reed Army Institute of Research (WRAIR) has taken the lead in addressing this challenge by developing and empirically testing such tools. The results of the Behavioral Health Readiness Evaluation and Decision-Making Instrument (B-REDI) field study are herein described. METHODS: The B-REDI study received WRAIR Institutional Review Board approval, and BH providers across five U.S. Army Forces Command installations completed surveys from September 2018 to March 2019. The B-REDI tools/training were disseminated to 307 providers through random clinic assignments. Of these, 250 (81%) providers consented to participate and 149 (60%) completed both initial and 3-month follow-up surveys. Survey items included a wide range of satisfaction, utilization, and proficiency-level outcome measures. Analyses included examinations of descriptive statistics, McNemar's tests pre-/post-B-REDI exposure, Z-tests with subgroup populations, and chi-square tests with demographic comparisons. RESULTS: The B-REDI resulted in broad, statistically significant improvements across the measured range of provider proficiency-level outcomes. Net gains in each domain ranged from 16.5% to 22.9% for knowledge/awareness (P = .000), from 11.1% to 15.8% for personal confidence (P = .001-.000), and from 6.2% to 15.1% for decision-making/documentation (P = .035-.002) 3 months following B-REDI initiation, and only one (knowledge) failed to maintain a statistically significant improvement in all of its subcategories. The B-REDI also received high favorability ratings (79%-97% positive) across a wide array of end-user satisfaction measures. CONCLUSIONS: The B-REDI directly addresses several critical Army BH readiness challenges by providing tangible decision-making support solutions for BH providers. Providers reported high degrees of end-user B-REDI satisfaction and significant improvements in all measured provider proficiency-level domains. By effectively addressing the readiness decision-making challenges Army BH providers encounter, B-REDI provides the Army BH health care system with a successful blueprint to set the conditions necessary for providers to make more accurate and timely readiness determinations. This may ultimately reduce safety and mission failure risks enterprise-wide, and policymakers should consider formalizing and integrating the B-REDI model into current Army BH practice.

Methodology of the U.S. Army's Suicide Prevention Leadership Tool Study: The Behavioral Health Readiness and Suicide Risk Reduction Review (R4).

INTRODUCTION: The Secretary of the U.S. Army issued two directives in late 2017 to directly combat the problem of suicide in the U.S. Army. The first was to develop an Army tool to assist commanders and first-line leaders in preventing suicide and improving behavioral health (BH) outcomes, which has been previously published as the BH Readiness and Risk Reduction Review (R4). The second was to conduct an evaluation study of the tool with Army units in the field. This study is the first to empirically examine the Army's tool-based methods for identifying and caring for the health and welfare of soldiers at risk for suicide, and this article outlines the methodology employed to study the effectiveness of the R4 tools and accomplish the Secretary's second directive. METHODS: The Walter Reed Army Institute of Research Institutional Review Board approved the R4 study. The study employed a repeated measurements in pre/post quasi-experimental design, including a nonequivalent but comparable business-as-usual control group. The R4 intervention consisted of the R4 tools, accompanying instructions, and an orientation. Samples were drawn from two geographically separated U.S. Army divisions in the continental United States, each composed of four comparable brigades. Study implementation consisted of three phases and three data collections over the course of 12 months. Soldiers completed anonymous survey instruments to assess a range of health factors, behaviors, characteristics, tool-related decision-making processes, and the frequency, type, and quality of interactions between soldiers and leaders. RESULTS: The R4 study commenced on May 6, 2019, and concluded on June 4, 2020. Sample size goals were achieved for both the divisions at all three data collection time points. CONCLUSIONS: The methodology of the R4 study is critical for the U.S. Army from both a precedential and an outcome-based standpoint. Despite the use of many previous tools and programs for suicide prevention, this is the first time the Army has been able to empirically test the effectiveness of tool-supported decision-making among Army units in a rigorous fashion. The methodology of such a test is a critical marker for future interventional inquiries on the subject of suicide in the Army, and the results will allow for more informed decision-making by leaders when approaching these ongoing challenges.

Risk of Secondary Traumatic Stress in Treating Traumatized Military Populations: Results from the PTSD Clinicians Exchange.

INTRODUCTION: This study examined risk factors for secondary traumatic stress (STS) in behavioral health clinicians and whether access to the Post-Traumatic Stress Disorder (PTSD) Clinicians Exchange website mitigated STS risk. METHODS: A diverse sample of clinicians (N = 605) treating traumatized military populations in Department of Veterans Affairs (VA), Department of Defense, and community practice settings were randomized to a newsletter-only control group or the exchange group. The exchange website included resources for treating PTSD and promoting clinician well-being. Online surveys were administered at 0-, 6-, and 12-months postrandomization. Regression analyses were used to examine the link among risk factors, exchange access, and STS. RESULTS: Baseline clinician demographics, experience, total caseload, appeal of evidence-based practices (EBPs), and likelihood of adopting EBPs if required were not linked with STS at the 12-month assessment period. Providing care at the VA, more burnout, less compassion satisfaction, greater trauma caseload, less openness to new EBPs, and greater divergence from EBP procedures were linked with greater STS. Only burnout and divergence were associated with STS after accounting for other significant STS risk factors. Exchange and control group clinicians reported similar STS levels after accounting for burnout and divergence. CONCLUSIONS: Given that burnout was linked with STS, future intervention may use techniques targeting burnout and STS (eg, emotion regulation strategies). Research exploring the link between divergence from EBPs and STS may inform EBP dissemination efforts and STS interventions. Finally, results highlight the need for research optimizing STS intervention efficacy among clinicians treating military populations.

Mental Health Service Utilization and Perceived Barriers to Receiving Care in Deployed Soldiers.

INTRODUCTION: Scant research has examined mental health treatment utilization and barriers to care in deployed U.S. soldiers. This study aims to assess mental health treatment utilization in deployed soldiers, including providers used and barriers to care. MATERIALS AND METHODS: U.S. Army soldiers (n = 2,412) in a combat environment were surveyed on psychiatric symptoms, mental health help received, sources of care, and perceived barriers to care by Mental Health Advisory teams from 2009 to 2013. RESULTS: Of the 25% of soldiers at mental health risk, 37% received mental health help, with 18% receiving help from a provider. Nonprovider sources of care were utilized significantly more frequently than providers. Soldiers at mental health risk reported significantly greater anticipated career-related stigma, organizational barriers to care, self-reliance views, and negative attitudes toward care, yet these constructs did not differ between who did or did not receive help. Soldiers who received help from providers exclusively reported significantly more anticipated career-related stigma and fewer organizational barriers to care than those that received no help. Soldiers who spent no time living outside the forward operating base and soldiers with six or more types of combat exposures were more likely to receive help. CONCLUSIONS: Prevalence of common psychopathology and receipt of care in a combat environment was similar to previous reports from postdeployment settings. Nonprovider sources of care were more frequently utilized as compared to an in-Garrison report. Findings suggest important differences exist in sources of help and barriers to care in deployed vs. postdeployment environments. The hypothesized barriers to care did not preclude receiving any help, however, less than one-half of soldiers at mental health risk received help. Thus, future research should identify factors that have the greatest influence on help seeking behavior in both deployed and Garrison settings.

Randomized Controlled Trial of a Web-Based Intervention to Disseminate Clinical Practice Guidelines for Posttraumatic Stress Disorder: The PTSD Clinicians Exchange.

Delivery of best-practice care for posttraumatic stress disorder (PTSD) is a priority for clinicians working with active duty military personnel and veterans. The PTSD Clinicians Exchange, an Internet-based intervention, was designed to assist in disseminating clinically relevant information and resources that support delivery of key practices endorsed in the Veterans Administration (VA)-Department of Defense (DoD) Clinical Practice Guidelines (CPG) for the Management of Posttraumatic Stress. We conducted a randomized controlled trial to examine the effectiveness of the Clinicians Exchange intervention in increasing familiarity and perceived benefits of 26 CPG-related and emerging practices. The intervention consisted of ongoing access to an Internet resource featuring best-in-class resources for practices, self-management of burnout, and biweekly e-mail reminders highlighting selected practices. Mental health clinicians (N = 605) were recruited from three service sectors (VA, DoD, community); 32.7% of participants assigned to the Internet intervention accessed the site to view resources. Individuals who were offered the intervention increased their practice familiarity ratings significantly more than those assigned to a newsletter-only control condition, d = 0.27, p = .005. From baseline to 12-months, mean familiarity ratings of clinicians in the intervention group increased from 3.0 to 3.4 on scale of 1 (not at all) to 5 (extremely); mean ratings for the control group were 3.2 at both assessments. Clinicians generally viewed the CPG practices favorably, rating them as likely to benefit their clients. The results suggest that Internet-based resources may aid more comprehensive efforts to disseminate CPGs, but increasing clinician engagement will be important.

Understanding How Clinicians Use a New Web-based Tool for Disseminating Evidence-Based Practices for the Treatment of PTSD: The PTSD Clinicians Exchange.

INTRODUCTION: Web-based interventions hold great promise for the dissemination of best practices to clinicians, and investment in these resources has grown exponentially. Yet, little research exists to understand their impact on intended objectives. MATERIALS & METHODS: The Post-Traumatic Stress Disorder (PTSD) Clinicians Exchange is a website to support clinicians treating veterans and active duty military personnel with PTSD, evaluated in a randomized controlled trial (N = 605). This manuscript explores how a subset of clinicians, those who utilized the intervention (N = 148), engaged with it by examining detailed individual-level web analytics and qualitative feedback. Stanford University and New England Research Institutes Institutional Review Boards approved this study. RESULTS: Only 32.7% of clinicians randomized to the intervention ever accessed the website. The number of pages viewed was positively associated with changes from baseline to 12 months in familiarity (P = 0.03) and perceived benefit of practices (P = 0.02). Thus, engagement with the website did predict an improvement in practice familiarity and benefit outcomes despite low rates of use. CONCLUSIONS: This study demonstrates the importance of methodologically rigorous evaluations of participant engagement with web-based interventions. These approaches provide insight into who accesses these tools, when, how, and with what results, which can be translated into their strategic design, evaluation, and dissemination.

Efficacy of a Web-Based Tool in Reducing Burnout Among Behavioral Health Clinicians: Results From the PTSD Clinicians Exchange.

Objective: Burnout is widespread among behavioral health clinicians treating posttraumatic stress disorder (PTSD) among military populations. Intervention-based strategies have shown some benefit in addressing clinician burnout. One Web-based tool, the PTSD Clinicians Exchange, was designed to disseminate clinical best practices for the treatment of PTSD and facilitate self-care to mitigate burnout. This study sought to determine whether this tool could reduce burnout among clinicians treating military populations. Methods: A total of 605 behavioral health clinicians from the U.S. Department of Veterans Affairs, the Department of Defense, and the community were enrolled in a randomized controlled trial to test the effectiveness of the PTSD Clinicians Exchange. Clinicians were assessed on demographic characteristics, practice patterns, and organizational support with an online survey at baseline and at 6 and 12 months. Burnout, secondary traumatic stress (STS), and compassion satisfaction were measured with the Professional Quality of Life Scale. Results: At baseline, no differences were observed in mean±SD burnout scores for the intervention (19.9±5.1) and control groups (20.2±5.4). Participation in the Exchange had no effect on burnout score at 12 months; burnout scores remained stable across the study period. In a multivariable stepwise regression model, older age, lower burnout at baseline, and lower STS scores and higher compassion satisfaction scores at 12 months were significantly associated with lower burnout scores. Conclusions: The PTSD Clinicians Exchange did not mitigate burnout among clinicians, possibly because of the content provided, the dissemination mechanism, or participants' limited use of the Web site. These results can be used to inform and enhance future interventions.

Soldier Attitudes Toward Behavioral Health Profiles in the US Army.

INTRODUCTION: Behavioral health (BH) readiness is a critical component of U.S. Army personnel readiness. Medical providers issue BH profiles in order to communicate BH-related duty limitations to the commander and reflect BH force readiness on both micro/macro-levels. A recent report indicates BH profile underutilization may be significantly elevating U.S. Army safety and mission-failure risks, and a study of BH provider decision-making suggests some providers may be hesitant to use profiles due to concerns that soldiers' attitudes toward BH profiles may negatively impact treatment utilization. This potential link, however, has not been empirically examined. This study addresses this gap by assessing soldiers' attitudes towards BH profiles to better understand how BH profiles may impact treatment utilization and explore for any BH profile-related stigma effect. METHODS: Approved by the Walter Reed Army Institute of Research (WRAIR) Institutional Review Board as part of the Land Combat Study II, the survey specific to this study included eight WRAIR-developed items assessing soldier attitudes toward BH profiles. Soldiers (N = 1,043) from two active duty U.S. Army brigades completed cross-sectional, anonymous surveys in 2017-2018. Soldier self-reported BH care utilization was assessed and used to create sub-groups for analysis. RESULTS: A majority of soldiers indicated that being placed on a BH profile would make them as or more likely to seek (71%) and no more or less likely to drop out (84%) of BH care. Among soldiers who had received BH care, BH profiles were associated with more favorable treatment seeking attitudes among those inclined to access conventional BH services and less favorable treatment seeking and maintenance attitudes among those inclined to access BH services from sources incapable of issuing profiles. Negative attitudes towards BH profiles were significantly more prevalent when compared to physical injury profiles, except in the group who had received BH care from a source incapable of issuing a profile. No significant proportional differences were observed among soldiers toward the rationale for BH profiles. Almost all soldiers (95% or greater) preferred their BH condition not come to the commander's attention during pre-deployment screening (SRP), choosing either BH profile or crisis options instead. CONCLUSIONS: Results suggest soldiers who would be less likely to seek or more likely to drop out of BH care due to a BH profile may be those that are less likely to access conventional BH services in the first place. This may provide some preliminary reassurance to conventional providers that increased BH profiling practices may not be inversely proportional to the amount of BH care delivered and may encourage treatment-seeking behaviors among the population they serve. Soldiers seeking BH care from sources incapable of issuing a profile may be sensitive to a potential BH profile-related stigma effect (possibly more global profile-related effect in this group), which should be factored into policy outreach efforts. A BH profile represents a more palatable BH duty limitation disclosure option for many soldiers, and supports the merits of a disclosure process that is earlier than SRP for promoting risk mitigation and more honest appraisals of BH mission-readiness levels.

Military occupation as a moderator between combat exposure and posttraumatic stress disorder symptoms in US Army personnel.

Military occupational designations are standardized classifications that help define and convey a service member's expected duties and responsibilities. The present study examined how occupational designation was related to adverse combat-reactions, specifically posttraumatic stress disorder (PTSD). It was hypothesized that at comparable levels of combat, non-combat units would display greater symptomology than combat units. The study sample consisted of 785 combat-deployed, active-duty enlisted US Army personnel. Participants were administered self-report questionnaires, including the Combat Experiences Scale and PTSD Checklist for DSM-5. Occupation was coded using the three-branch system (i.e., Operations, Support, & Force Sustainment). Hierarchical multiple linear regression (MLR) was run to examine the effect of occupation, combat, and unit cohesion on PTSD symptoms. Operations units reported the highest frequency of combat exposure; however, Force Sustainment units displayed the highest PTSD symptoms. In MLR analysis, there was a significant interaction between Force Sustainment units and combat exposure (ß = 0.10, p = .019), that was not observed in Operations or Support units. These findings demonstrate that PTSD symptom intensity is not solely a function of combat exposure, and that non-combat units may react differently when exposed to elevated levels of combat.

Fidelity to Best Practices of Psychiatric Assessments in Army Behavioral Health Settings.

While civilian and military psychiatric clinical practice guidelines (CPGs) exist for psychiatric assessments, data are lacking on providers' adherence to these criteria. This study evaluated the use of psychiatric CPGs' assessment criteria by Army behavioral health providers (BHPs). In a weighted cross-sectional survey, 348 BHPs were evaluated on their assessment of a systematically selected patient on 15 total domains recommended by the Departments of Veterans Affairs and Defense CPGs for substance use disorders, posttraumatic stress disorder, and major depressive disorder. The proportion of BHPs providing high-quality assessment and the association between high-quality assessment and BHP and patient characteristics were examined. Using the weighted sample, 80% of BHPs provided a high-quality assessment. BHPs who saw ≥20 patients per week were significantly more likely to provide high-quality assessments compared with BHPs who saw <20 patients per week [odds ratio (OR)=1.72, 95% confidence interval (CI)=1.01-2.92]. Patients diagnosed with generalized anxiety disorder [adjusted OR (AOR)=0.42, 95% CI=0.18-0.96] or whose BHPs did not assess patients' current overall physical health (AOR=0.26, 95% CI=0.07-0.97) or lifetime duration of treatment for mental health (AOR=0.03, 95% CI=0.01-0.20) were less likely to receive high-quality assessments. A majority of Army BHPs are conducting high-quality assessments for the 3 most common mental disorders in military populations. If recommendations to increase fidelity to assessment could be implemented, more patients could receive optimized care.

Behavioral health of US military veterinary personnel deployed to Afghanistan.

OBJECTIVE To compare symptoms of compromised behavioral health (BH symptoms) and factors protecting against those symptoms (protective factors) in military veterinary and nonveterinary health-care personnel deployed to Afghanistan. DESIGN Cross-sectional survey. SAMPLE 237 deployed military health-care personnel (21 veterinary and 216 nonveterinary). PROCEDURES Surveys were administered to participants during combat deployment in Afghanistan in 2013 to collect information on BH symptoms and protective factors. Data were compared between veterinary and nonveterinary health-care personnel by use of regression models controlling for demographic characteristics and deployment experiences. Partial correlations were computed to assess relationships between protective factors and BH symptoms, controlling for personnel type. RESULTS Less than 15% of veterinary and nonveterinary health-care personnel were at risk for suicidal ideation, major depressive disorder, generalized anxiety disorder, and posttraumatic stress disorder. After adjusting for covariates, both personnel types had similar levels of depression, posttraumatic stress disorder, and anxiety symptoms; however, veterinary personnel reported more distressing secondary traumatic stress symptoms and a greater number of anger reactions. Self-care, team support, and perceived supportive leadership were inversely associated with BH symptoms regardless of personnel type. Veterinary personnel engaged in less self-care, provided less team care, and rated leadership behaviors less positively than nonveterinary health-care personnel. CONCLUSIONS AND CLINICAL RELEVANCE Compared with nonveterinary health-care personnel, deployed veterinary personnel were at greater risk of generalized anxiety disorder and reported more secondary traumatic stress and anger reactions, but were less likely to be engaged in and exposed to protective factors. Interventions designed to promote self-care and team support for veterinary personnel and their leaders may reduce the occupational risk of BH symptoms in deployment and perhaps other settings.

Secondary traumatic stress in deployed healthcare staff.

OBJECTIVE: Using a novel measure that integrated a range of symptoms, the present study established the degree to which deployed health care staff reported secondary traumatic stress (STS) symptoms. The present study also examined whether STS symptoms were associated with staff functioning, risk factors, and the delivery of psychotherapy techniques. METHOD: A cross-sectional survey was administered to 236 U.S. military health care staff deployed to Afghanistan. Linear and multiple regression analyses evaluated the relationship between STS, staff functioning, and risk factors in the combined sample of deployed staff, and the delivery of psychotherapy techniques in behavioral health staff. RESULTS: The majority of health care staff reported few STS symptoms. STS was negatively associated with job performance and family connectedness. Exposure to combat events, professional demands, and burnout were positively associated with STS; self-care and health-promoting leadership were inversely associated with STS. In behavioral health staff, providing trauma narrative techniques was positively associated with STS. CONCLUSIONS: Although the majority of health care staff reported low STS scores, STS was inversely associated with work and family functioning. The relationship between STS symptoms and risk mitigation strategies such as self-care and health-promoting leadership suggest possible avenues of future research. Research should explore the utility of an STS measure that integrates different types of symptoms and evaluate how these symptoms influence functioning in work, family, and other domains. In addition, considering that using trauma narratives is common to several psychotherapies for posttraumatic stress disorder, the link between STS and providing this technique warrants further investigation. (PsycINFO Database Record (c) 2018 APA, all rights reserved).