Insufficient Sleep and Behavioral Health in the Military: A 5-Country Perspective.

PURPOSE OF REVIEW: The goal of this paper was to highlight the degree to which sleep, behavioral health, and leader involvement were interrelated using data from militaries in five English-speaking countries: Australia, Canada, New Zealand, the UK, and the United States. RECENT FINDINGS: Many service members reported sleeping fewer than the recommended 7 h/night: 34.9%, 67.2%, and 77.2% of respondents from New Zealand, Canada, and the United States, respectively. Countries reporting shorter sleep duration also reported fewer insomnia-related difficulties, likely reflecting higher sleep pressure from chronic sleep loss. Across all countries, sleep problems were positively correlated with behavioral health symptoms. Importantly, leader promotion of healthy sleep was positively correlated with more sleep and negatively correlated with sleep problems and behavioral health symptoms. Insufficient sleep in the military is ubiquitous, with serious implications for the behavioral health and functioning of service members. Leaders should attend to these risks and examine ways to promote healthy sleep in service members.

Longitudinal measurement invariance and growth curve modeling of psychological resilience across the deployment cycle.

The concept of resilience is embedded within military culture and professional identity. To date, temporal changes in individuals' perceptions of their own resilience have not been systematically assessed in highstakes occupational contexts, like the military. The current study examined change in selfreported resilience over time by: (1) examining the longitudinal measurement invariance of the Brief Resilience Scale (BRS); (2) assessing the longitudinal pattern of resilience across a combat deployment cycle; and (3) examining predictors of postdeployment resilience and change in resilience scores across time. U.S. Army soldiers assigned to a combat brigade completed a survey at four time points over the course of a deployment cycle: (a) prior to deployment to Afghanistan; (b) during deployment; (c) immediately following return to home station; and (d) approximately 2-3 months thereafter. The longitudinal measurement invariance of the BRS was established. Growth curve modeling indicated that, on average, self-reported resilience decreased across the deployment cycle, but there was considerable individual variation in the rate of change. Of note, loneliness, as measured during deployment, predicted the rate of change in self-reported resilience over time. Results have implications for the longitudinal analysis of resilience and for the development of interventions with military personnel.

Impact of the COVID-19 pandemic on army families: Household finances, familial experiences, and soldiers' behavioral health.

The Coronavirus Disease 2019 (COVID-19) pandemic has significantly impacted employment and finances, childcare, and behavioral health across the United States. The Behavioral Health Advisory Team assessed the pandemic's impact on the behavioral health of U.S. Army soldiers and their families. Over 20,000 soldiers at three large installation groups headquartered in the northwestern continental U.S., Republic of Korea, and Germany participated in the cross-sectional survey. Multivariable logistic regression models indicated that key demographics (gender, rank), severity of household financial impact, changes in work situation due to childcare issues, and family members' difficulty coping (both self and spouse/partner and/or child) were independently and consistently associated with greater odds of screening positive for probable clinical depression and generalized anxiety, respectively. These findings highlight how Army families were impacted similarly by the pandemic as their civilian counterparts. Army leadership may action these findings with targeted support for soldiers and their families to ensure they are utilizing supportive services available to them, and that military services continually evolve to meet soldier and family needs during times of crisis and beyond.

Acute Stress Reaction in Combat: Emerging Evidence and Peer-Based Interventions.

PURPOSE OF REVIEW: This paper highlights the topic of combat-related acute stress reactions (ASRs) in service members. Specifically, we contrast ASRs with related psychiatric conditions, report the estimated prevalence of ASRs for soldiers deployed to combat, and discuss how team members can effectively respond to these reactions. RECENT FINDINGS: Although not regarded as a clinical disorder, ASRs can have a significant impact on high-risk occupations like the military in which impaired functioning can imperil team members and others. Based on self-report, 17.2% of soldiers who have deployed to combat report having experienced a possible ASR. To our knowledge, this is the first such prevalence estimate. The prevalence of ASRs underscores the need for improved prevention, management, and recovery strategies. Peer-based intervention protocols such as iCOVER may provide a useful starting point to address ASRs in team members.

Problematic Anger in the Military: Focusing on the Forgotten Emotion.

PURPOSE OF REVIEW: Problematic anger is common in veteran and military populations, yet understudied relative to other mental health difficulties. However, in recent years, more clinical and research attention has been turned to problematic anger. This paper highlights important new findings in the epidemiology, course, and neurobiology of anger, the associations of anger with other mental health problems and risk, and next steps for research and practice. RECENT FINDINGS: In longitudinal research, findings show that problematic anger changes over the life course of military members and veterans, and that deployment increases the likelihood of problematic levels of anger. Problematic anger is related to a range of mental health issues, most perniciously aggression and suicidality. Promising new assessment and treatment approaches are emerging, including innovations that leverage digital technology. Key areas of research include advancing assessment of problematic anger to identify patterns of heterogeneity, as well as advancing the evidence base for anger treatments. Recommended progress in clinical practice include conducting routine assessment of problematic anger in veteran and military populations, developing prevention and early intervention for at risk individuals, and optimizing the timing of interventions throughout the military lifecycle.

Management of Acute Stress Reactions in the Military: A Stepped Care Approach.

PURPOSE OF THE REVIEW: This review highlights knowledge gaps surrounding the development and use of interventions for Acute Stress Reactions (ASRs). First, we propose that a stepped care approach to intervention for ASR be developed and utilized in military operational environments. A stepped care approach would include detection and assessment, followed by behavioral intervention, and then medication intervention for ASRs. Second, we discuss potential strategies that can be taken for the development of safe and effective ASR medications. RECENT FINDINGS: ASRs commonly occur in operational environments, particularly in military populations. ASRs impact the safety and performance of individual service members and teams, but there are currently limited options for intervention. Efforts to improve ASR detection and assessment, and development and delivery of ASR interventions for implementation in operational environments, will be critical to maintaining the safety and performance of service members.

US soldiers and the role of leadership: COVID-19, mental health, and adherence to public health guidelines.

BACKGROUND: Previous studies have documented the impact of domain-specific leadership behaviors on targeted health outcomes in employees. The goal of the present study was to determine the association between specific leadership behaviors addressing COVID-19 and US soldiers' mental health and adherence to COVID-19 public health guidelines. METHODS: An electronic, anonymous survey was administered to US Army soldiers across three major commands (N = 7,829) from December 2020 to January 2021. The primary predictor of interest was soldiers' ratings of their immediate supervisors' behaviors related to COVID-19. The outcomes were soldiers' mental health (i.e., depression and generalized anxiety) and adherence to COVID-19 public health guidelines. Covariates were rank, gender, ratings of immediate supervisors' general leadership, level of COVID-19 concerns, and COVID-19 status (e.g., tested positive, became seriously ill). Logistic regressions were used to model the unique association of COVID-19 leadership behaviors with outcomes after adjusting for covariates. RESULTS: High levels of COVID-19 leadership behaviors were associated with lesser likelihood of soldiers' screening positive for depression (AOR = 0.46; 95% CI [0.39, 0.54]) and anxiety (AOR = 0.54; 95% CI [0.45, 0.64]), and greater likelihood of frequent adherence to preventive health guidelines (AORs = 1.58; 95% CI [1.39, 1.80] to 2.50; 95% CI [2.01, 3.11]). CONCLUSION: Higher levels of COVID-19 leadership behaviors may support soldiers' mental health and encourage their adherence to COVID-19 public health guidelines. Given the link between these leader behaviors and soldier adaptation to the pandemic over and above general leadership, training for supervisors should focus on targeting specific health-promoting behaviors. Results can inform leader training for the military and other high-risk occupations.

Health-Promoting Leadership During an Infectious Disease Outbreak: A Cross-Sectional Study of US Soldiers Deployed to Liberia.

ABSTRACT: Infectious disease outbreaks are uniquely stressful for essential employees. One way to support workers is for supervisors to engage in behaviors promoting employees' well-being and attitudes toward preventive medicine practices. We examined whether health-promoting leadership contributes to these outcomes in a population of active-duty soldiers (N = 173) deployed to provide nonmedical support in Liberia during the 2014 Ebola epidemic using data reported in Sipos, Kim, Thomas, and Adler (Mil Med 183[3-4]:e171-e178, 2018). Soldiers completed surveys assessing posttraumatic stress disorder (PTSD), depression, anxiety, sleep problems, burnout, morale, and attitudes and rated their leaders on health-promoting behaviors. Using mixed-effects logistic regression, health-promoting leadership focused on psychological health was associated with decreased odds of PTSD, depression, anxiety, and burnout, and increased odds of high morale and avoiding unnecessary risk. Health-promoting leadership focused on preventive medicine was associated with decreased odds of depression and anxiety, and increased odds of high morale, positive attitudes, and avoiding unnecessary risk. Findings suggest health-promoting leadership could be valuable for workers responding to epidemics.

Distinguishing the Effects of Life Threat, Killing Enemy Combatants, and Unjust War Events in U.S. Service Members.

Although previous studies have identified behavioral health risks associated with combat exposure, it is unclear which types of combat events are associated with these risks, particularly regarding contrasts among the risks associated with life-threatening experiences, killing combatants, and exposure to unjust war events, such as killing a noncombatant or being unable to help civilian women and children. In the present study, we examined surveys from 402 soldiers following deployment (i.e., baseline) and again 13 months later (i.e., Year 1). Regression analyses were conducted across a range of behavioral health (e.g., posttraumatic stress disorder, depression, suicide ideation, anxiety, somatic, insomnia, aggression) and benefit-finding measures, each controlling for two combat event categories while assessing the predictive utility of a third. The results suggested that life-threatening events were associated with poor behavioral health at baseline, relative risk (RR) = 10.00, but not at Year 1, RR = 2.67. At both baseline and Year 1, killing enemy combatants was not associated with behavioral health, RRs = 1.67-3.33, but was positively associated with benefit-finding, RRs = 26.67-40.00. Exposure to unjust war events was associated with a transdiagnostic pattern of behavioral health symptoms at baseline, RR = 40.00, and Year 1, RR = 23.33. Overall, the results suggest unjust war event exposure is particularly injurious, above and beyond exposure to other combat-related events. Future research can build on these findings to develop clearer descriptions of the combat events that might place service members at risk for moral injury and inform the development of assessment and treatment options.

Tired and angry: Sleep, mental health, and workplace relational aggression.

Workplace relational aggression incurs substantial costs to organizations in the form of reduced employee effectiveness and can exact a personal toll on the targets of the aggression. The extant literature contains limited studies related to physiological variables in predicting the perpetration of workplace relational aggression. Using survey data from a large US military sample (N = 2290), this research tested a hypothesized indirect effects model of sleep and relational aggression against unit members. Results suggest that subjective sleep duration and discontinuity are associated indirectly with perpetrating relational aggression against unit members through higher levels of poor mental health symptoms. Moreover, this association was more robust at higher versus lower levels of trait anger. This research is among the first to examine sleep disturbance or mental health as potential upstream factors associated with instigating relational aggression in the workplace. This is also among the first scientific studies on perpetrating relational aggression against unit members in the US military.

Determinants of mental and physical health treatment-seeking among military personnel.

BACKGROUND: Although research has documented factors influencing whether military personnel seek treatment for mental health problems, less research has focused on determinants of treatment-seeking for physical health problems. AIMS: To explicitly compare the barriers and facilitators of treatment-seeking for mental and physical health problems. METHOD: US soldiers (n = 2048) completed a survey with measures of barriers and facilitators of treatment-seeking for mental and physical health problems as well as measures of somatic symptoms and mental health. RESULTS: The top barrier for both mental and physical health treatment-seeking was a preference for handling problems oneself. The top facilitators for both symptom types were related to treatment improving quality of life. Differential endorsement of barriers occurred for treatment of mental versus physical health symptoms. In contrast, facilitators were endorsed more for physical than for mental health treatment. While there were few gender differences, officers reported more barriers and facilitators than did enlisted personnel. Screening positive for mental or physical health problems was associated with greater endorsement of both barriers and facilitators for physical and mental health treatment, respectively. CONCLUSIONS: The leading barriers and facilitators for seeking treatment for mental health and physical problems are relatively similar, suggesting that health education should consider decision-making in seeking both mental and physical healthcare. Interventions should be tailored to reduce barriers for officers and improve facilitators for junior enlisted personnel, and address barriers and facilitators for service members screening positive for a mental or physical health problem.

Witnessing Acute Stress Reaction in Team Members: The Moderating Effect of Peer-Based Training.

Individuals who witness team members exhibiting symptoms of an acute stress reaction (ASR) in the middle of a high-stress operational event may be negatively affected; ASR-related training may moderate this impact. In the present study, 560 Israeli soldiers were surveyed about ASR exposure, posttraumatic stress disorder (PTSD) symptoms, public stigma, and whether they had received ASR-related training. This training, called YaHaLOM, is a Hebrew acronym that outlines steps for managing ASR in team members. Controlling for combat exposure, greater exposure to ASR symptoms was associated with more overall PTSD symptoms, PTSD cluster symptoms, and public stigma. YaHaLOM training buffered these relationships for PTSD, intrusion and avoidance symptoms, and public stigma. The findings suggest that such training may help teams in high-risk occupations better manage ASR exposure.

Magnitude of problematic anger and its predictors in the Millennium Cohort.

BACKGROUND: Problematic anger is intense anger associated with elevated generalized distress and that interferes with functioning. It also confers a heightened risk for the development of mental health problems. In military personnel and veterans, previous studies examining problematic anger have been constrained by sample size, cross-sectional data, and measurement limitations. METHODS: The current study used Millennium Cohort survey data (N = 90,266) from two time points (2013 and 2016 surveys) to assess the association of baseline demographics, military factors, mental health, positive perspective, and self-mastery, with subsequent problematic anger. RESULTS: Overall, 17.3% of respondents reported problematic anger. In the fully adjusted logistic regression model, greater risk of problematic anger was predicted by certain demographic characteristics as well as childhood trauma and financial problems. Service members who were in the Army or Marines, active duty (vs. reserves/national guard), and previously deployed with high levels of combat had increased risk for problematic anger. Veterans were also more likely to report problematic anger than currently serving personnel. Mental health predictors included posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and comorbid PTSD/MDD. Higher levels of positive perspective and self-mastery were associated with decreased risk of problematic anger. CONCLUSION: Not only did 1 in 6 respondents report problematic anger, but risk factors were significant even after adjusting for PTSD and MDD, suggesting that problematic anger is more than an expression of these mental health problems. Results identify potential targets of early intervention and clinical treatment for addressing problematic anger in the military and veteran context.

LINKS Training and Unit Support for Mental Health: a Group-randomized Effectiveness Trial.

The LINKS curriculum, adapted from Britt et al. (2018a), was designed to improve unit climate, knowledge, and attitudes about mental health treatment seeking in military personnel. The present study extends this research by examining implementation options, comparing the effectiveness of LINKS to an active control condition with training delivered by non-experts and comparing modules that varied in training length. Eight Army platoons were randomly assigned to one of four conditions: (1) 1-h Active Control, (2) 2-h Active Control, (3) 1-h LINKS, or (4) 2-h LINKS. Two platoons were assigned to each condition. Surveys were administered at pre-training (T1), post-training (T2), and 3 months later (T3). Eighty-four participants completed all study phases. Regardless of training content, participants receiving the 2-h modules reported greater training acceptability than those receiving the 1-h modules. At T3, participants in the LINKS conditions reported more mental health knowledge than participants in the Active Control conditions. Sustained effects were also observed on a number of treatment barriers and facilitators, with the LINKS conditions generally leading to better outcomes. At T3, 2-h LINKS condition participants reported receiving more mental health treatment relative to the other conditions. Findings suggest that LINKS can be effectively delivered by non-expert trainers, is a viable intervention for targeting mental health treatment-seeking, and is optimally packaged in a 2-h module. The training might benefit from additional leadership training efforts.

Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward.

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

Depression among military spouses: Demographic, military, and service member psychological health risk factors.

BACKGROUND: More than a decade of war has strained service members and their families and the psychological health of military spouses is a concern. This study uses data from the largest study of military families in the United States to examine the demographic, military-specific, and service member mental health correlates of probable diagnosis of major depressive disorder (MDD) among military spouses. METHODS: Data were from service member-spouse dyads from all branches of the U.S. military. Demographic and military-specific factors were assessed using administrative personnel records and survey data. RESULTS: Of the 9,038 spouses, 4.9% had a probable diagnosis of MDD. In unadjusted models, spouses of service members who deployed and experiencecd combat-related events, were enlisted, had a probable posttraumatic stress disorder (PTSD) diagnosis, or screened positive for alcohol misuse were more likely to screen positive for MDD. In adjusted models, only spouses married to enlisted service members or those with PTSD had increased risk for MDD. Other demographic and military-related factors associated with MDD in spouses included less educational attainment, unemployment, having four or more children, and having prior military service (although not currently serving in the military) in the adjusted models. CONCLUSIONS: Findings characterize demographic, military, and service member psychological health factors that are associated with depression among military spouses. These findings imply that deployment alone may not negatively affect military spouses, but rather it may be the mental health impact on the service member, especially PTSD that increases the odds for MDD among military spouses.

Can Anger Be Helpful?: Soldier Perceptions of the Utility of Anger.

Studies have found that soldiers returning from combat deployment report elevated levels of anger and aggression. The present study examined the perception that anger was helpful in performing occupationally related duties and whether this perception was associated with mental health problems, somatic symptoms, and functioning. Soldiers (N = 627) completed a survey 4 months after their deployment to Afghanistan and again 3 months later. When examining anger over time, findings revealed four groups of different latent classes: low stable (resilient), high stable (chronic), decreasing over time (improved), and increasing over time (delayed problems). For two of the groups (chronic and delayed problems), perceiving anger as helpful was closely related to anger reactions. Perceiving anger as helpful was also associated with worse mental health symptoms. Further work in understanding how to mitigate this positive perception of anger in prevention initiatives may be useful in addressing anger reactions.

Coping Strategies as Moderators of the Association Between Combat Exposure and Posttraumatic Stress Disorder Symptoms.

The present research examined selected coping strategies as moderators of the relationship between combat exposure and posttraumatic stress disorder (PTSD) symptoms among service members who were deployed to Iraq (N = 2,023) and Afghanistan (N = 1,023). A three-factor model of coping was confirmed for both military operations: positive emotion-focused, self-blame, and prayer/spirituality. Positive emotion-focused coping was inversely associated with PTSD symptoms (r = -.14) and buffered service members from the negative effects of combat exposure in both Iraq (r2 = .01) and Afghanistan (r2 = .02). Self-blame coping was positively associated with PTSD symptoms in both samples (Iraq, r = .36; Afghanistan, r = .29) but only magnified the relationship between combat exposure and PTSD symptoms among service members in Iraq (r2 = .01) . These findings were replicated when controlling for unit cohesion and symptoms of depression. Prayer/spirituality coping was not significantly associated with PTSD symptoms, regardless of combat exposure. Discussion focuses on how specific positive emotion-focused coping strategies may be helpful for military personnel in combat operations given the uncontrollable and chaotic nature of the environment. Implications include providing training for deploying personnel that covers the use of these positive emotion-focused coping strategies and the potential problems with self-blame. Such training may also be suitable for other high-risk occupations in which employees face uncontrollable situations.

Attention and interpretation processes and trait anger experience, expression, and control.

This study explored attention and interpretation biases in processing facial expressions as correlates of theoretically distinct self-reported anger experience, expression, and control. Non-selected undergraduate students (N = 101) completed cognitive tasks measuring attention bias, interpretation bias, and Spielberger's State-Trait Anger Expression Inventory (STAXI-2). Attention bias toward angry faces was associated with higher trait anger and anger expression and with lower anger control-in and anger control-out. The propensity to quickly interpret ambiguous faces as angry was associated with greater anger expression and its subcomponent of anger expression-out and with lower anger control-out. Interactions between attention and interpretation biases did not contribute to the prediction of any anger component suggesting that attention and interpretation biases may function as distinct mechanisms. Theoretical and possible clinical implications are discussed.

Longitudinal determinants of mental health treatment-seeking by US soldiers.

BACKGROUND: Studies with members of the armed forces have found a gap between reports of mental health symptoms and treatment-seeking. AIMS: To assess the impact of attitudes on treatment-seeking behaviours in soldiers returning from a combat deployment. METHOD: A sample of 529 US soldiers were surveyed 4 months (time 1) and 12 months (time 2) post-deployment. Mental health symptoms and treatment-seeking attitudes were assessed at time 1; reported mental healthcare visits were assessed at time 2. RESULTS: Factor analysis of the total time 1 sample revealed four attitude factors: professional concerns, practical barriers, preference for self-management and positive attitudes about treatment. For the subset of 160 soldiers reporting a mental health problem at time 1, and controlling for mental health symptom severity, self-management inversely predicted treatment-seeking; positive attitudes were positively related. CONCLUSIONS: Results demonstrate the importance of broadening the conceptualisation of barriers and facilitators of mental healthcare beyond stigma. Techniques and delivery models emphasising self-care may help increase soldiers' interest in using mental health services.