Traumatized German soldiers with moral injury - value-based cognitive-behavioral group therapy to treat war-related shame

Introduction

During deployment, soldiers are confronted with potentially morally injurious events. In many cases, these events violate their personal values and belief systems, resulting in feelings of anger, alienation, guilt, and shame. The psychological distress caused by such transgressions is defined as moral injury. It remains unclear to date, which therapeutic interventions are most appropriate for addressing this specific psychological condition. This study examines the effectiveness of value-based cognitive-behavioral group therapy combining elements of cognitive-behavioral therapy, acceptance and commitment therapy, spiritual care, and adaptive disclosure therapy.

Materials and methods

This controlled study uses the Compass of Shame Scale to assess symptom severity among participants both before and after a three-week inpatient group therapy regimen for moral injury. An intervention group (n = 45) was compared to a waiting-list control group (n = 40). A one-way between subjects ANOVA was conducted to determine the differences between the two measurement points in the intervention group compared to the control group. A positive ethics vote from the Humboldt University Berlin (Charité) was available (No.EA1/092/15).

Results

A significant difference was found on the shame-associated maladaptive strategies subscales of attack self (F (1, 83) = 5.942, p = 0.017, Cohen's f = 0,27), withdrawal (F (1, 83) = 8.263, p = 0.005, Cohen's f = 0,32), and attack others (F (1, 83) = 10.552, p = 0.002, Cohen's f = 0,36) of the Compass of Shame Scale between the intervention group and the control group at the p < 0.05 level in the pre- and post-treatment (t1-t2) comparison.

Conclusion

This study suggests that the special therapeutic focus in cognitive-behavioral group therapy can alter shame-based maladaptive coping behaviors in response to war-related moral injury. This study provides further evidence that therapeutic approaches - through fostering a reconciliatory, compassionate, and forgiving approach toward oneself and others - target the underlying mechanisms of moral injury. Therefore, value-based cognitive-behavioral interventions should be considered as a standard element of trauma care in a military setting. Future studies should further examine such interventions in randomized control trials. It would also be particularly valuable for future studies to include a follow-up time point.

Effects of Unconventional Work and Shift Work on the Human Gut Microbiota and the Potential of Probiotics to Restore Dysbiosis

The work environment is a factor that can significantly influence the composition and functionality of the gut microbiota of workers, in many cases leading to gut dysbiosis that will result in serious health problems. The aim of this paper was to provide a compilation of the different studies that have examined the influence of jobs with unconventional work schedules and environments on the gut microbiota of workers performing such work. As a possible solution, probiotic supplements, via modulation of the gut microbiota, can moderate the effects of sleep disturbance on the immune system, as well as restore the dysbiosis produced. Rotating shift work has been found to be associated with an increase in the risk of various metabolic diseases, such as obesity, metabolic syndrome, and type 2 diabetes. Sleep disturbance or lack of sleep due to night work is also associated with metabolic diseases. In addition, sleep disturbance induces a stress response, both physiologically and psychologically, and disrupts the healthy functioning of the gut microbiota, thus triggering an inflammatory state. Other workers, including military, healthcare, or metallurgy workers, as well as livestock farmers or long-travel seamen, work in environments and schedules that can significantly affect their gut microbiota.

Assessment of physical activity among adolescents: a guide to the literature

Purpose

The aim of this article is to systematically review articles and annual reports concerning young peoples' physical activity (PA) and linking this to considerations of the state and national defense.

Method

A systematic search of the literature included an analysis of publications accessible in global databases and other available books, student papers, and projects. The articles and reports were categorized based on year of publication, methods used, age of respondents, sample size, country, and digital object identifier (DOI).

Results

The result of this search is an overview of the extent and manner in which the worldwide scientific community is addressing the current situation and the long-term development of the physical fitness of adolescents. This publication also maps to what extent professional publications and articles are addressing PA from the perspective of the needs of armies and armed forces of various countries around the world.

Conclusions

The article provides a systematic overview of methods used to measure PA, and an overview of articles dealing with assessing PA. The examined articles indicate that from the perspective of not only national defense, but also health and overall quality of life, in particular, we need initiatives to encourage and motivate young people to increase their everyday PA. The research therefore also includes an overview of factors that may considerably influence PA. The results ascertained in this publication will be used, i.a. for investigating a longitudinal defense research project of the Ministry of Defense of the Czech Republic in which the authors are participating.

Outcomes Following Combined Posterior Labral and SLAP Repair in Military Patients Younger Than 35 Years

BACKGROUND

Members of the military are known to experience disproportionately high rates of both glenohumeral instability and superior labrum anterior-posterior (SLAP) tears when compared with civilian populations. Although the outcomes after simultaneous repair of Bankart and SLAP lesions have been well described, there is a paucity of literature available regarding the operative management of posterior instability with concomitant superior labral pathology.

PURPOSE

To compare outcomes of combined arthroscopic posterior labral and SLAP repair with those of isolated posterior labral repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All consecutive patients younger than 35 years who underwent arthroscopic posterior labral repair from January 2011 to December 2016 with a minimum follow-up of 5 years were identified. From this cohort of eligible patients, all individuals who had undergone combined SLAP and posterior labral repair (SLAP cohort) versus posterior labral repair alone (instability cohort) were then identified. Outcome measures including the visual analog scale score, Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, Rowe instability score, and range of motion were collected pre- and postoperatively and scores were compared between groups.

RESULTS

In total, 83 patients met the inclusion criteria for the study. All patients were active-duty military at the time of surgery. The mean follow-up was 93.79 ± 18.06 months in the instability group and 91.24 ± 18.02 months in the SLAP group (P = .5228). Preoperative SANE and ASES scores were significantly worse in the SLAP group. Both groups experienced statistically significant improvements in outcome scores postoperatively (P < .0001 for all), and there were no significant differences in any outcome scores or range of motion between groups. In total, 39 patients in the instability cohort and 37 in the SLAP cohort returned to preinjury levels of work (92.86% vs 90.24%, respectively; P = .7126), and 38 instability patients and 35 SLAP patients returned to preinjury levels of sporting activity (90.48% vs 85.37%, respectively; P = .5195). Two patients in the instability group and 4 patients in the SLAP group were medically discharged from the military (4.76% vs 9.76%; P = .4326), and 2 patients in each cohort had experienced treatment failure at the final follow-up (4.76% vs 4.88%; P > .9999).

CONCLUSION

Combined posterior labral and SLAP repair led to statistically and clinically significant increases in outcome scores and high rates of return to active-duty military service that did not differ significantly from the results after isolated posterior labral repair. The results of this study indicate that simultaneous repair is a viable treatment option for the management of combined lesions in active-duty military patients <35 years of age.

Motives of Tobacco Use Among Young Adults in the United States Air Force

PURPOSE

Research has focused on cigarette use motives and have not included military personnel. The current study assessed tobacco use motives for different products, and differences within males and females and those with different racial identities given historical disparities in tobacco use.

DESIGN

A cross-sectional survey about tobacco use was administered from October 2019 to February 2022.

SETTING

Four Technical Training bases in the US.

SAMPLE

Air Force Airmen who used tobacco (N = 3243).

MEASURES

Questions were about sociodemographic characteristics, tobacco use, and the Tobacco Motives Inventory (representing affect regulation, boredom, enhancement, and social motives).

ANALYSIS

Linear regressions assessed associations between overall tobacco use and motives. Stratified analyses assessed associations between tobacco use and motives among males and females, and individuals from different racial backgrounds. Logistic regressions assessed differences in motives and use of different tobacco products between "some day" and "everyday" users.

RESULTS

Overall, boredom (B = .09, SE = .01) and affect regulation (B = .05, SE = .00) motives were associated with higher tobacco use. Males and females and individuals from different racial backgrounds endorsed different motives, but all endorsed boredom as a motive for higher tobacco use. Individuals who used cigarettes, e-cigarettes, or smokeless tobacco "some days" endorsed higher social motives than everyday users, but everyday users endorsed different motives across products.

CONCLUSION

There are motives differentiating between "some day" and "everyday" users of tobacco products, which may need to be differentially targeted in intervention programs. Additionally, there are some overlapping motives (affect regulation, boredom) that may be beneficial to address with all tobacco users.

Peer- and web-based interventions for risky drinking among US National Guard members: Mission Strong randomized controlled trial

AIMS

To test separatel the efficacy of a web-based and a peer-based brief intervention (BI), compared with an expanded usual care control (EUC) group, among military reserve component members using alcohoI in a hazardous and harmful manner.

DESIGN

In the randomized controlled trial, participants were assigned to: [1] web-based BI with web-based boosters (BI + web), [2] web-based BI with peer-based boosters (BI + peer) or [3] enhanced usual care (EUC).

SETTING

Michigan, USA.

PARTICIPANTS

A total of 739 Michigan Army National Guard members who reported recent hazardous alcohol use; 84% were male, the mean age was 28 years.

INTERVENTION

The BI consisted of an interactive program guided by a personally selected avatar. Boosters were delivered either on the web or personally by a trained veteran peer. A pamphlet, given to all participants, included information on hazardous alcohol use and military-specific community resources and served as the EUC condition.

MEASUREMENTS

The primary outcome measure was binge drinking episodes in the past 30 days, measured at 12 months after the BI.

FINDINGS

All randomized participants were included in the outcome analyses. In adjusted analyses, BI + peer [beta = -0.43, 95% confidence interval (CI) = -0.56 to -0.31, P < 0.001] and BI + web (beta = -0.34, 95% CI = -0.46 to -0.23, P < 0.001) reduced binge drinking compared with EUC.

CONCLUSION

This satudy was a web-based brief intervention for hazardous alcohol use, with either web- or peer-based boosters, reduced binge alcohol use among Army National Guard members.

Discriminating Mild Traumatic Brain Injury and Posttraumatic Stress Disorder Using Latent Neuroimaging and Neuropsychological Profiles in Active-Duty Military Service Members

OBJECTIVE

Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) commonly occur among military Service Members and Veterans and have heterogenous, but also overlapping symptom presentations, which often complicate the diagnoses of underlying impairments and development of effective treatment plans. Thus, we sought to examine whether the combination of whole brain gray matter (GM) and white matter (WM) structural measures with neuropsychological performance can aid in the classification of military personnel with mTBI and PTSD.

METHODS

Active-Duty US Service Members ( n = 156; 87.8% male) with a history of mTBI, PTSD, combined mTBI+PTSD, or orthopedic injury completed a neuropsychological battery and T1- and diffusion-weighted structural neuroimaging. Cortical, subcortical, ventricular, and WM volumes and whole brain fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) were calculated. Latent profile analyses were performed to determine how the GM and WM indicators, together with neuropsychological indicators, classified individuals.

RESULTS

For both GM and WM, respectively, a 4-profile model was the best fit. The GM model identified greater ventricular volumes in Service Members with cognitive symptoms, including those with a diagnosis of mTBI, either alone or with PTSD. The WM model identified reduced FA and elevated RD in those with psychological symptoms, including those with PTSD or mTBI and comorbid PTSD. However, contrary to expectation, a global neural signature unique to those with comorbid mTBI and PTSD was not identified.

CONCLUSIONS

The findings demonstrate that neuropsychological performance alone is more robust in differentiating Active-Duty Service Members with mTBI and PTSD, whereas global neuroimaging measures do not reliably differentiate between these groups.

Introduction to the special issue on criterion measurement

Criterion identification and measurement is often an afterthought in criterion-related validation research. Yet it is essential in determining what predictor measures to use in operational settings. Accordingly, this special issue discusses recent advances in addressing the "criterion problem" in U.S. military enlisted personnel selection and classification research. In this introductory paper, broad issues regarding criterion identification and measurement in the military and previous research on this topic are reviewed and subsequent papers, which address specific criterion issues and describe an unprecedented joint-service criterion project, are introduced.

Targeting Perceived Burdensomeness to Reduce Suicide Risk

Perceived burdensomeness (PB), defined by an intractable perception of burdening others, often reflects a false mental calculation that one's death is worth more than one's life and has been supported as a significant risk factor for suicide. Because PB often reflects a distorted cognition, it may serve as a corrective and promising target for the intervention of suicide. More work on PB is needed in clinically severe and in military populations. Sixty-nine (Study 1) and 181 (Study 2) military participants at high baseline suicide risk engaged in interventions targeting constructs relating to PB. Baseline and follow-up measures (at 1, 6, 12, 18, and 24 months) of suicidal ideation were administered, and various statistical approaches-including repeated-measures ANOVA, mediation analyses, and correlating standardized residuals-explored whether suicidal ideation decreased specifically by way of PB. In addition to utilizing a larger sample size, Study 2 included an active PB-intervention arm (N = 181) and a control arm (N = 121), who received robust care as usual. In both studies, participants improved considerably regarding baseline to follow-up suicidal ideation. The results of Study 2 mirrored those of Study 1, corroborating a potential mediational role for PB in treatment-related improvements in suicidal ideation in military participants. Effect sizes ranged from .07-.25. Interventions tailored at decreasing levels of perceived burdensomeness may be uniquely and significantly effective in reducing suicidal thoughts.

Childhood adversity, combat experiences, and military sexual trauma: a test and extension of the stress sensitization hypothesis

BACKGROUND

U.S. veterans report high rates of traumatic experiences and mental health symptomology [e.g. posttraumatic stress disorder (PTSD)]. The stress sensitization hypothesis posits experiences of adversity sensitize individuals to stress reactions which can lead to greater psychiatric problems. We extend this hypothesis by exploring how multiple adversities such as early childhood adversity, combat-related trauma, and military sexual trauma related to heterogeneity in stress over time and, subsequently, greater risk for PTSD.

METHODS

1230 veterans were recruited for an observational, longitudinal study. Veterans responded to questionnaires on PTSD, stress, and traumatic experiences five times over an 18-month study period. We used latent transition analysis to understand how heterogeneity in adverse experiences is related to transition into stress trajectory classes. We also explored how transition patterns related to PTSD symptomology.

RESULTS

Across all models, we found support for stress sensitization. In general, combat trauma in combinations with other types of adverse experiences, namely early childhood adversity and military sexual trauma, imposed a greater probability of transitioning into higher risk stress profiles. We also showed differential effects of early childhood and military-specific adversity on PTSD symptomology.

CONCLUSION

The present study rigorously integrates both military-specific and early life adversity into analysis on stress sensitivity, and is the first to examine how sensitivity might affect trajectories of stress over time. Our study provides a nuanced, and specific, look at who is risk for sensitization to stress based on previous traumatic experiences as well as what transition patterns are associated with greater PTSD symptomology.

military veterans

BACKGROUND

Homelessness is a major public health problem among U.S. military veterans. However, contemporary, population-based data on the prevalence, correlates, and mental health burden of homelessness among veterans are lacking.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of veterans (n = 4069). Analyses examined the prevalence and correlates of homelessness, as well as the independent associations between homelessness and current probable psychiatric conditions, suicidality, and functioning.

RESULTS

The lifetime prevalence of homelessness was 10.2% (95% confidence interval 9.3-11.2). More than 8-of-10 veterans reported experiencing their first episode of homelessness following military service, with a mean of 10.6 years post-discharge until onset (s.d. = 12.6). Adverse childhood experiences (ACEs), cumulative trauma burden, current household income, younger age, and drug use disorder emerged as the strongest correlates of homelessness (49% of total explained variance). Veterans with a history of homelessness had elevated odds of lifetime suicide attempt, attempting suicide two or more times, and past-year suicide ideation [odd ratios (ORs) 1.3-3.1]. They also had higher rates of current probable posttraumatic stress disorder, major depressive, generalized anxiety, and drug use disorders (ORs 1.7-2.4); and scored lower on measures of mental, physical, cognitive, psychosocial functioning (d = 0.11-0.15).

CONCLUSIONS

One in ten U.S. veterans has experienced homelessness, and these veterans represent a subpopulation at substantially heightened risk for poor mental health and suicide. ACEs were the strongest factor associated with homelessness, thus underscoring the importance of targeting early childhood adversities and their mental health consequences in prevention efforts for homelessness in this population.

Physical Fitness in Relationship to Depression and Post-Traumatic Stress Disorder During Pregnancy Among U.S. Army Soldiers

Background: Depression and post-traumatic stress disorder (PTSD) are prevalent in pregnancy, especially among military members. These conditions can lead to adverse birth outcomes, yet, there's a paucity of evidence for prevention strategies. Optimizing physical fitness is one understudied potential intervention. We explored associations between prepregnancy physical fitness and antenatal depression and PTSD in soldiers. Materials and Methods: This was a retrospective cohort study of active-duty U.S. Army soldiers with live births between 2011 and 2014, identified with diagnosis codes from inpatient and outpatient care. The exposure was each individual's mean Army physical fitness score from 10 to 24 months before childbirth. The primary outcome was a composite of active depression or PTSD during pregnancy, defined using the presence of a code within 10 months before childbirth. Demographic variables were compared across four quartiles of fitness scores. Multivariable logistic regression models were conducted adjusting for potential confounders selected a priori. A stratified analysis was conducted for depression and PTSD separately. Results: Among 4,583 eligible live births, 352 (7.7%) had active depression or PTSD during pregnancy. Soldiers with the highest fitness scores (Quartile 4) were less likely to have active depression or PTSD in pregnancy (Quartile 4 vs. Quartile 1 adjusted odds ratio 0.55, 95% confidence interval 0.39-0.79). Findings were similar in stratified analyses. Conclusion: In this cohort, the odds of active depression or PTSD during pregnancy were significantly reduced among soldiers with higher prepregnancy fitness scores. Optimizing physical fitness may be a useful tool to reduce mental health burden on pregnancy.

Comments on the articles dealing with individual performance criteria that are included in this special issue of Military Psychology

Individual performance criterion measurement is central to effective personnel management in the military services, and to all other organizations as well. The articles in this special issue summarize the state of the art in all major phases of performance criterion development and assessment. The overall record, while it varies in terms of current progress across the major parts, is admirable. What's next is an equally thorough examination of the utility of validity.

standard prolonged exposure therapy on PTSD in military personnel and veterans: a non-inferiority randomised controlled trial

BACKGROUND

A short, effective therapy for posttraumatic stress disorder (PTSD) could decrease barriers to implementation and uptake, reduce dropout, and ameliorate distressing symptoms in military personnel and veterans. This non-inferiority RCT evaluated the efficacy of 2-week massed prolonged exposure (MPE) therapy compared to standard 10-week prolonged exposure (SPE), the current gold standard treatment, in reducing PTSD severity in both active serving and veterans in a real-world health service system.

METHODS

This single-blinded multi-site non-inferiority RCT took place in 12 health clinics across Australia. The primary outcome was PTSD symptom severity measured by the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) at 12 weeks. 138 military personnel and veterans with PTSD were randomised. 71 participants were allocated to SPE, with 63 allocated to MPE.

RESULTS

The intention-to-treat sample included 138 participants, data were analysed for 134 participants (88.1% male, M = 46 years). The difference between the mean MPE and SPE group PTSD scores from baseline to 12 weeks-post therapy was 0.94 [95% confidence interval (CI) -4.19 to +6.07]. The upper endpoint of the 95% CI was below +7, indicating MPE was non-inferior to SPE. Significant rates of loss of PTSD diagnosis were found for both groups (MPE 53.8%, SPE 54.1%). Dropout rates were 4.8% (MPE) and 16.9% (SPE).

CONCLUSIONS

MPE was non-inferior to SPE in significantly reducing symptoms of PTSD. Significant reductions in symptom severity, low dropout rates, and loss of diagnosis indicate MPE is a feasible, accessible, and effective treatment. Findings demonstrate novel methods to deliver gold-standard treatments for PTSD should be routinely considered.

Military Standard Testing of Commercially Available Supraglottic Airway Devices for Use in a Military Combat Setting

INTRODUCTION

Airway obstruction is the second leading cause of death on the battlefield. The harsh conditions of the military combat setting require that devices be able to withstand extreme circumstances. Military standards (MIL-STD) testing is necessary before devices are fielded. We sought to determine the ability of supraglottic airway (SGA) devices to withstand MIL-STD testing.

METHODS

We tested 10 SGA models according to nine MIL-STD-810H test methods. We selected these tests by polling five military and civilian emergency-medicine subject matter experts (SMEs), who weighed the relevance of each test. We performed tests on three devices for each model, with operational and visual examinations, to assign a score (1 to 10) for each device after each test. We calculated the final score of each SGA model by averaging the score of each device and multiplying that by the weight for each test, for a possible final score of 2.6 to 26.3.

RESULTS

The scores for the SGA models were LMA Classic Airway, 25.9; AuraGain Disposable Laryngeal Mask, 25.5; i-gel Supraglottic Airway, 25.2; Solus Laryngeal Mask Airway, 24.4; LMA Fastrach Airway, 24.4; AuraStraight Disposable Laryngeal Mask, 24.1; King LTS-D Disposable Laryngeal Tube, 22.1; LMA Supreme Airway, 21.0; air-Q Disposable Intubating Laryngeal Airway, 20.1; and Baska Mask Supraglottic Airway, 18.1. The limited (one to three) samples available for testing provide adequate preliminary information but restrict the range of failures that could be discovered.

CONCLUSIONS

Lower scoring SGA models may not be optimal for military field use. Models scoring sufficiently close to the top performers (LMA Classic, AuraGain, i-gel, Solus, LMA Fastrach, AuraStraight) may be viable for use in the military setting. The findings of our testing should help guide device procurement appropriate for different battlefield conditions.

Development and Validation of the Military Minority Stress Scale

Despite affecting nearly 3% of active-duty service members, little is known about how LGBT-related stress experiences may relate to health outcomes. Thus, the present study sought to create a Military Minority Stress Scale and assess its initial reliability and construct validity in a cross-sectional study of active-duty LGBT service members (N = 248). Associations between 47 candidate items and health outcomes of interest were analyzed to retain those with substantial betas. Item response theory analyzes, reliability testing, invariance testing, and exploratory factor analysis were performed. Construct validity of the final measure was assessed through associations between the sum score of the final measure and the health outcomes. The final 13-item measure demonstrated an excellent reliability (ω = 0.95). Bivariate linear regressions showed significant associations between the sum score of the measure and overall health (β = -0.26, p < 0.001), overall mental health (β = -0.34, p < 0.001), physical health (β = 0.45, p < 0.001), life satisfaction (β = -0.24, p < 0.001), anxiety (β = 0.34, p < 0.001), depressive symptoms (β = 0.37, p < 0.001), suicidality (β = 0.26, p < 0.001), and PTSD (β = 0.42, p < 0.001), respectively. This study provides the first evidence that minority stressors in the military setting can be operationalized and measured. They appear to have a role in the health of LGBT service members and may explain the continued health disparities experienced by this population. Little is known regarding the experiences of LGBT active-duty service members, including experiences of discrimination. Understanding these experiences and their associated health outcomes during military service may therefore help and guide further etiological studies and intervention development.

Grit and uncertainty: Grit predicts performance and West Point graduation during pandemic conditions

Grit, or the passionate pursuit of long-term goals, is an important predictor of performance and success across various domains, including within some military contexts. Whether grit predicts such outcomes at a military service academy during a multi-year period of prolonged uncertainty, however, is unknown. Using institutional data collected prior to the COVID-19 pandemic onset, we assessed how well grit, physical fitness test scores, and entrance examination scores predicted performance in academic, military, and physical domains, as well as on-time graduation for 817 cadets from the West Point Class of 2022. This cohort spent more than 2 years of their time at West Point functioning under the uncertainty of pandemic-related conditions. Multiple regression results showed that grit, fitness test, and entrance examination scores were all significant predictors of performance outcomes in the academic, military, and physical domains. Results from binary logistic regression showed that, in addition to physical fitness, grit scores significantly predicted graduation from West Point and accounted for unique variance. Consistent with results from pre-pandemic studies, grit was an important predictor of performance and success for West Point cadets even under pandemic conditions.

Shooter ready? Integrating mental skills training in an advanced sniper course

Performance psychology has increased in usage and popularity; however, we contend that within the elite spheres of the military, there is a need for research and development to fit the context and environment. In this study, we describe an explorative case study on the integration of mental skill training techniques to an advanced sniper course in the Norwegian Armed Forces. We evaluate the impact through triangulation and examine results on the course, perceptions of the participants, and observations from the instructors. In addition, we conducted a 1-year follow-up to get participants' experience of translating the skills beyond the course. The results show that the mental skill training package influenced both results and performance in a positive manner; however, as a novel field, further research is warranted to establish a best practice to enhance performance for elite military forces.

Psychological and functional outcomes following a randomized controlled trial of surf and hike therapy for U.S. service members

Introduction

Exercise-based interventions have established benefits for the treatment of depression and other psychological outcomes; however, limited data exist evaluating psychological, social, and functional outcomes for exercise outdoors.

Methods

The current study sought to expand knowledge about the breadth of effects following outdoor exercise interventions by using data from a randomized control trial comparing Surf and Hike Therapy among 96 U.S. active duty service members with major depressive disorder (MDD). Assessments examining psychological symptoms and functioning were completed before and after the 6-week programs, and 3 months following program completion. Participants also completed assessments before and after each exercise session. Multilevel modeling was used to determine whether psychological and functional outcomes (anxiety, positive and negative affect, resilience, pain, and physical and social functioning) improved for service members receiving Surf or Hike Therapy, and whether improvements differed by intervention.

Results

Study findings showed improved anxiety (p < 0.001), negative affect (p < 0.001), psychological resilience (p = 0.013), and social functioning (p < 0.001) following program participation, with no differences by intervention. Positive affect, pain, and physical functioning did not significantly improve after the program. Within sessions, positive affect (p < 0.001) and pain (p = 0.036) changed, and to a greater extent for those in the Surf Therapy condition.

Conclusion

Study results suggest that both Surf Therapy and Hike Therapy can improve psychological symptoms and social functioning impairments that commonly co-occur among service members with MDD, but Surf Therapy may provide enhanced immediate effects on positive affect and pain.

Clinical trial registration

ClinicalTrials.gov, NCT03302611.

Management of a Special Warfare Trainee With Repeat Exertional Heat Stroke: A Case Study

CONTEXT

Exertional heat stroke (EHS) is the most deadly form the exertional heat illness with a higher incidence among active duty US military members than in the general population. Current guidelines on EHS recovery timelines and return to duty vary among the military branches. In some cases, individuals experience prolonged heat and exercise intolerance with repeat exertional heat illness events, which can complicate the recovery process. Management and rehabilitation of such individuals is unclear.

CASE PRESENTATION

This manuscript addresses the case and management of a US Air Force Special Warfare trainee who experienced 2 episodes of EHS, despite early recognition, gold standard treatment, and undergoing 4 weeks of a stepwise recovery after an initial EHS.

MANAGEMENT AND OUTCOMES

After the second episode, a 3-step process was utilized, consisting of a prolonged and personalized recovery period, heat tolerance testing using Israeli Defense Force advanced modeling, and stepwise reacclimatization. This process allowed the trainee to successfully recover from repeat EHS and return to duty, and set a framework for future repeat EHS treatment guidelines.

CONCLUSIONS

In individuals with repeat EHS, a prolonged recovery period followed by heat tolerance testing can be used to demonstrate appropriate thermotolerance and safely clear an individual to begin stepwise reacclimatization. Overall, patient care and military readiness may be improved by unified Department of Defense guidelines for return to duty after EHS.

Applying the Socioecological Model to Map Factors Associated with Military Physical Activity Adherence

Physical activity (PA) within the military can have large effects on the soldier's health, productivity, and ability to meet tasks. This study aims to identify the factors associated with PA adherence during military service, applying the socioecological model, which classifies the factors influencing health behaviors into individual, social, and environmental levels. This cross-sectional survey was carried out among 500 soldiers aged 18 to 49 years in the Israeli Defense Forces. Statistical analysis to assess associations between PA and individual, social, and environmental factors included correlations, variance analyses, and multivariable linear regression. PA rates were higher among men soldiers in combat positions. Individual level factors, such as intention to perform PA (β = 0.42, p < 0.001), and self-efficacy regarding PA (β = 0.20, p < 0.001) were associated with PA among men and women. However, social norms were associated with PA only among men (β = 0.24, p < 0.001). The physical environment was not associated with PA adherence (β = -0.04, p = 0.210). Conclusions: Developing interventions on the individual level for all military personnel and interventions on the social level, mainly for men, could help increase levels of PA in the military.

Resources and Support for Sexual Assault Survivors Receiving Services From the U.S. Air Force: What Survivors Say They Need for Recovery

Sexual assault (SA) is a serious challenge faced by the U.S. military. Participants in this study included men and women who volunteered in response to a call for survivors of SA. Participants included active duty and reserve U.S. Air Force (USAF) members, spouses of service members, or civilian employees for the USAF (beneficiaries). The primary research question was, "if you could design the perfect response system to support survivors, what would be included in this system?" The research team conducted in-depth interviews with nine survivors. Next, 82 survivors completed a survey agreeing or disagreeing with strategies identified by interview participants to improve services for survivors and offered additional suggestions. Analysis revealed survivor recommendations to improve SA services.

Long-term risk for mental health symptoms in Dutch ISAF veterans: the role of perceived social support

BACKGROUND

Military personnel deployed to combat and peacekeeping missions are exposed to high rates of traumatic events. Accumulating evidence suggests an important association between deployment and the development of other mental health symptoms beyond post-traumatic stress disorder.

METHODS

This study examined the prevalence of agoraphobia, anxiety, depression, and hostility symptoms in a cohort of Dutch ISAF veterans (N = 978) from pre-deployment up to 10 years after homecoming. The interaction of potential moderating factors with the change in mental health symptoms relative to pre-deployment was investigated at each time point.

RESULTS

The probable prevalence of agoraphobia, anxiety, depression, and hostility symptoms significantly increased over time to respectively 6.5, 2.7, 3.5, and 6.2% at 10 years after deployment. Except for hostility symptoms, the probable prevalence at 10 years after deployment was the highest compared to all previous follow-up assessments. Importantly, less perceived social support after returning from deployment was found as a risk factor for all different mental health symptoms. Unit support was not associated with the development of mental health problems.

CONCLUSIONS

This study suggests a probable broad and long-term impact of deployment on the mental health of military service members. Due to the lack of a non-deployed control group, causal effects of deployment could not be demonstrated. Continued effort should nevertheless be made in the diagnosis and treatment of a wide range of mental health symptoms, even a decade after deployment. The findings also underscore the importance of social support after homecoming and its potential for the prevention of long-term mental health problems.

Financial Impact of Embedded Injury-Prevention Experts in US Army Initial Entry Training

CONTEXT

The US Army embedded injury-prevention experts (IPEs), specifically athletic trainers and strength and conditioning coaches, into initial entry training (IET) to limit musculoskeletal (MSK) conditions and their negative consequences. However, little is known about the financial impact of IPEs.

OBJECTIVE

To assess whether IPEs were associated with fewer sunk training costs due to MSK-related early discharges from service.

DESIGN

Retrospective cohort study.

SETTING

Database of US Army soldiers' administrative, medical, and readiness records.

PATIENTS OR OTHER PARTICIPANTS

A total of 198 166 soldiers (age = 20.7 ± 3.2 years, body mass index = 24.4 ± 3.5 kg/m2) who began IET during 2014 to 2017.

MAIN OUTCOME MEASURE(S)

Early discharge from service was defined as occurring within 6 months of beginning IET. All IET sites employed IPEs from 2011 to 2017, except for 2 sites during April to November 2015. Soldiers who began IET at these 2 sites during these times were categorized as not having IPE exposure. All others were categorized as having IPE exposure. The unadjusted association between IPE access and MSK-related early discharge from service was assessed using logistic regression. Financial impact was assessed by quantifying differences in yearly sunk costs between groups with and those without IPE exposure and subtracting IPE hiring costs.

RESULTS

Among 14 094 soldiers without IPE exposure, 2.77% were discharged early for MSK-related reasons. Among 184 072 soldiers with IPE exposure, 1.01% were discharged. Exposure to IPEs was associated with reduced odds of MSK-related early discharge (odds ratio = 0.36, 95% CI = 0.32, 0.40, P < .001) and a decrease in yearly sunk training costs of $11.19 to $20.00 million.

CONCLUSIONS

Employing IPEs was associated with reduced sunk costs because of fewer soldiers being discharged from service early for MSK-related reasons. Evidence-based recommendations should be developed for guiding policy on the roles and responsibilities of IPEs in the military to reduce negative outcomes from MSK conditions and generate a positive return on investment.

The Purple Heart and suicide risk in Post-9/11 U.S. Army Combat Veterans with a traumatic brain injury: A mixed methods study

Active service members and Veterans with a combat-related traumatic brain injury (TBI) are four times more likely to attempt suicide than those without a TBI. TBIs are the signature injuries of the Post-9/11 conflicts and Combat Veterans (i.e., current and former service members who deployed in support of a combat mission) with these injuries are entitled to receive the Purple Heart medal. However, potentially tens of thousands of Combat Veterans did not receive, or were denied the Purple Heart during the first decade of the Global War on Terrorism because a TBI was not documented during the deployment. To our knowledge, this is the first study to explore the meaning of the Purple Heart and examine the impact of the Purple Heart on Army Combat Veterans with a combat-related TBI. Findings from this mixed methods study revealed that not receiving the Purple Heart is associated with increased suicide risk and lower quality of life after a brain injury. Additionally, thwarted belongingness, perceived burdensomeness, and perceived military institutional betrayal are associated with increased suicide risk in Army Combat Veterans with a TBI. This mixed methods study provides important insights into how Army culture is perceived and the power of the Purple Heart among this high-risk group of Combat Veterans.

Efficacy of closed cell wet-suit at various depths and gas mixtures for thermoprotection during military training dives

Purpose: To evaluate a closed-cell wet-suit for thermal protective capability during extreme cold water exposure at various depths. Methods: Thirteen (n = 13) elite military divers who were tasked with cold-water training, participated in this study. To mimic various depths, the Ocean Simulation Facility (OSF) at the Navy Experimental Diving Unit (NEDU) was pressurized to simulate dive depths of 30, 50, and 75fsw. Water temperature remained at 1.8-2.0°C for all dives. Four divers dove each day and used the MK16 underwater breathing apparatus with gas mixes of either N202 (79:21) or HeO2 (88:12). Mean skin temperature (T_SK) (Ramanathan, 1964), core temperature (Tc), hand and foot readings were obtained every 30 min for 30 and 50fsw and every 15 min during the 75fsw dive. Results: T_C was significantly reduced across all dives (p = 0.004); however, was preserved above the threshold for hypothermia (post dive Tc = 36.5 ± 0.4). There was no effect of gas mix on T_C. T_SK significantly decreased (p < 0.001) across all dives independent of depth and gas. Hand and foot temperatures resulted in the termination of three of the dives. There were no significant main effects for depth or gas, but there were significant main effects for time on hand temperature (p < 0.001) and foot temperature (p < 0.001). Conclusion: Core temperature is maintained above threshold for hypothermia. Variatioins in T_C and T_SK are a function of dive duration independent of depth or gas for a closed-cell wet-suit in cold water at various depths. However, both hand and foot temperatures reached values at which dexterity is compromised.

Stability of SARS-CoV-2 on the Army Combat Uniform and Recommendations for Cleaning

SARS-CoV-2 is the virus responsible for the disease that is known as COVID-19. While there have been numerous studies detailing the survival rates of SARS-CoV-2 on various materials, there are currently no published data regarding whether this virus is stable on standard military uniforms. Consequently, there are no standard operating procedures for washing uniforms once exposed to the virus. This study aimed to determine whether SARS-CoV-2 could be removed from Army combat uniform material by washing with a commercially available detergent and tap water. Washing the fabric with detergent followed by a rinse step with tap water effectively removes detectable viral particles. Importantly, it was found that washing with hot water alone was not effective. Therefore, it is recommended that military personnel wash their uniforms with detergent and water as soon as possible after exposure to SARS-CoV-2; hot water should not be used as a substitute for detergent.

Midterm Outcomes Following Combined Biceps Tenodesis and Anterior Labral Repair in Active Duty Military Patients Younger than 35 Years

BACKGROUND

Superior labrum anterior-posterior (SLAP) lesions and anterior instability are common causes of shoulder pain and dysfunction among active-duty members of the United States military. However, little data have been published regarding the surgical management of type V SLAP lesions.

PURPOSE

To compare the outcomes of arthroscopic-assisted subpectoral biceps tenodesis and anterior labral repair with those of arthroscopic SLAP repair (defined as contiguous repair spanning from the superior labrum to the anteroinferior labrum) for type V SLAP tears in active-duty military patients younger than 35 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All consecutive patients from January 2010 to December 2015 who underwent arthroscopic SLAP repair or combined biceps tenodesis and anterior labral repair for a type V SLAP lesion with a minimum 5-year follow-up were identified. The decision to perform type V SLAP repair versus combined biceps tenodesis and anterior labral repair was based on the condition of the long head of the biceps tendon (LHBT). Labral repair was performed in patients who had a type V SLAP tear with an otherwise clinically and anatomically healthy LHBT. Combined tenodesis and repair was performed in patients with evidence of LHBT abnormalities. Outcomes including the visual analog scale (VAS) score, the Single Assessment Numeric Evaluation (SANE) score, the American Shoulder and Elbow Surgeons (ASES) shoulder score, the Rowe instability score, and range of motion were collected preoperatively and postoperatively, and scores were compared between the groups.

RESULTS

A total of 84 patients met the inclusion criteria for the study. All patients were active-duty service members at the time of surgery. A total of 44 patients underwent arthroscopic type V SLAP repair, and 40 patients underwent anterior labral repair with biceps tenodesis. The mean follow-up was 102.59 ± 20.98 months in the repair group and 94.50 ± 27.11 months in the tenodesis group (P = .1281). There were no significant differences in preoperative range of motion or outcome scores between the groups. Both groups experienced statistically significant improvements in outcome scores postoperatively (P < .0001 for all); however, compared with the repair group, the tenodesis group reported significantly better postoperative VAS (2.52 ± 2.36 vs 1.50 ± 1.91, respectively; P = .0328), SANE (86.82 ± 11.00 vs 93.43 ± 8.81, respectively; P = .0034), and ASES (83.32 ± 15.31 vs 89.90 ± 13.31, respectively; P = .0394) scores. There were no differences in the percentage of patients who achieved the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state for the SANE and ASES between the groups. Overall, 34 patients in each group returned to preinjury levels of work (77.3% vs 85.0%, respectively; P = .3677), and 32 patients (72.7%) in the repair group and 33 patients (82.5%) in the tenodesis group returned to preinjury levels of sporting activity (P = .2850). There were no significant differences in the number of failures, revision surgical procedures, or patients discharged from the military between the groups (P = .0923, P = .1602, and P = .2919, respectively).

CONCLUSION

Both arthroscopic-assisted subpectoral biceps tenodesis combined with anterior labral repair and arthroscopic SLAP repair led to statistically and clinically significant increases in outcome scores, marked improvements in pain, and high rates of return to unrestricted active duty in military patients with type V SLAP lesions. The results of this study suggest that biceps tenodesis combined with anterior labral repair produces comparable outcomes to arthroscopic type V SLAP repair in active-duty military patients younger than 35 years.

The impact of the pandemic on the perception of stress and danger, and the adjustment of psychiatric and general medical staff of German military hospitals

Introduction

The COVID-19 pandemic changed not only the working conditions but also the private conditions we live in. Health care professionals especially were confronted with multiple stressors, e.g., the risk of infection, lack of staff, and high workloads.

Methods

To estimate some of the pandemic-related impacts this anonymous personnel survey was conducted in two German military hospitals (Hamburg and Berlin). This study presents a comparative analysis of the hospital staff in general vs. the psychiatric personnel (N = 685) at two measurement time points (MTPs) in April 2021 (n = 399) and December 2021 (n = 286). The survey contains the German version of the Covid Stress Scale (CSS) to assess the perceived level of pandemic-related stress, the Patient Health Questionnaire (German Version: PHQ-D) to screen for three major mental disorders, and the adjustment disorder-New Module (ADNM) to estimate the problems of adaptation to change.

Results

The results showed a process of adaptation over the two MTPs with significant stress reduction at MTP2 in the general staff. The psychiatric staff did not report significantly higher pandemic-related symptoms. Quite the contrary, not only did the CSS show significantly lower xenophobia, traumatic stress, and compulsive checking, but the PHQ also showed lower stress symptoms and somatic symptoms at both MTPs. Also, the ADNM scores delivered evidence for a more effective adaptation process in psychiatric personnel (e.g., depressive mood, avoidance, anxiety).

Discussion

The presented results must be interpreted while taking the unique situations of German military clinics into account. The supply of protective material was sufficient and there was no dramatic shortage of psychiatric staff during the pandemic. The inpatients were quite often (40%) elective treatments for trauma-related disorders, which could be discontinued in the case of a COVID-19 infection. The results of this study showed good adaptative skills among the psychiatric staff in military hospitals, which could be interpreted as a sign of good resilience. This might have led to lower stress-related symptoms during the COVID-19 pandemic.

Neuropsychological deficit profiles for service members with mild traumatic brain injury

BACKGROUND

Neuropsychological deficits are generally assessed in terms of absolute level of functioning, e.g. high average, average, low average, although there is increased interest in calculating indices of relative degree of decline, e.g. mild, moderate, severe.

OBJECTIVE

To examine differences in demographic, psychiatric, and military-specific characteristics for relative degree of decline in neuropsychological profiles attributed to traumatic brain injuries (TBIs) among service members (SMs).

METHODS

Data were drawn from an existing clinical database of 269 SMs who received neuropsychological evaluations for TBI (Wechsler Test of Adult Reading, Wechsler Adult Intelligence Scale, California Verbal Learning Test, Delis-Kaplan Executive Function System) at a military treatment facility between 2013 and 2018. Independent sample t-tests and one-way ANOVA tests with pairwise comparisons were performed.

RESULTS

Memory and problem-solving abilities were the most and least affected domains, respectively. Greater relative decline was observed among male and White SMs and those with post-traumatic stress disorder (PTSD). By contrast, there were no differences in relative decline according to military rank or work status.

CONCLUSION

Relative degree of decline after TBI among SMs is differentially impacted according to neuropsychological domain, with greater impairment among male and White SMs as well as those with PTSD.

Transgender Military Experiences: From Obama to Trump

On September 20, 2011, President Barack Obama repealed the Don't Ask, Don't Tell (DADT) policy allowing Lesbian, Gay, and Bisexual (LGB) people to openly serve in the U.S. military even though transgender service members were not afforded the same protections. On July 23, 2015, Obama's Secretary of Defense Ash Carter officially rescinded the transgender ban. For this study, survey data was collected from 26 transgender service members beginning in October 2018 and ending in December 2018. A second series of interviews was conducted with seven cisgender veterans beginning in August 2020 and ending in January 2021. The dual purpose of this study was to investigate transgender service members' experiences during the Obama administration and through the first years of the Trump administration. Secondly, interviews were conducted with cisgender veterans from roughly the same service time period. Findings provide a glimpse into the lives of transgender active duty service members post-DADT and during the Trump Administration ban. Data also reveals how a sample of cisgender veterans view policy and other issues surrounding transgender active duty service personnel. Participants from both groups agreed that unit cohesion and readiness was not negatively impacted by transgender active duty military personnel and that inclusion was a positive and unifying factor.

Racial burdens in the work experiences of state-supported Black chaplains

To understand and improve the experiences of Black chaplains, it is essential to consider how they experience and are integrated into their workplaces. This article draws from interviews with ten Black chaplains in the military and prisons. In light of historic, state-sanctioned, discrimination in these institutions, we ask how these chaplains experience their workplaces racially. All experience racial burdens in the workplace as part of being the first or only Black chaplain or in response to overt racial discrimination. They identify few to no formal workplace efforts to support them as Black chaplains and spoke of resistance to informal efforts that have been tried over the years. State and federal workplaces must recognize the racial burdens Black chaplains' experiences and take action to respond to and support these systemic workplace issues.

COVID-19 Pandemic Responses among National Guard Service Members: Stressors, Coping Strategies, Sleep Difficultiesand Substance Use

The National Guard (NG) served as a critical component of the US COVID-19 response while concurrently managing personal COVID-19 responses. Understanding pandemic-related concerns, sleep difficulties, increased substance use, and stress management strategies can promote readiness for subsequent disasters. We surveyed 3221 NG service members (75% Army; 79% enlisted; 52% 30-49 years; 81% male) during COVID-19 (August-November 2020). Almost half were activated in response to COVID-19 (mean = 18.6 weeks) and completed the survey 2-3 months post-activation. Service members indicated great concern about family health (39%), the indefinite nature of the pandemic (35%), and their financial situation (23%). Over one-third reported changes in usual sleep amount, 33% described poor sleep quality, and 21% had trouble falling/staying asleep. Increased substance use was reported by 30%, including increased alcohol (13.5%), tobacco (9%), and caffeine/energy drinks (20.1%) consumption. Chi-square analyses and analyses of variance found those who activated reported more increased tobacco and caffeine/energy drink use versus non-activated, with no sleep difficulties nor alcohol use differences. Helpful stress management strategies included spending time outdoors (53%), exercising (48%), talking to family/friends (38%), and having a daily routine (38%). Specific health-, financial-, and job-related stressors were associated with COVID-19. Incorporating stress management in planning/preventive efforts promotes resilience during disasters.

Limitations of benefit finding as a coping mechanism for combat-related PTSD symptoms

Benefit finding has been identified as a buffer of the combat exposure-PTSD symptom link in soldiers. However, benefit finding may have a limited buffering capacity on the combat-PTSD symptom link over the course of a soldier's post-deployment recovery period. In the present study, soldiers returning from Operation Iraqi Freedom (OIF) were surveyed at two different time periods post-deployment: Time 1 was 4 months post-deployment (n = 1,510), and Time 2 was at 9 months post-deployment (n = 783). The surveys assessed benefit finding, PTSD symptoms, and combat exposure. Benefit finding was a successful buffer of the cross-sectional relationship between combat exposure and PTSD reexperiencing symptoms at Time 1, but not at Time 2. In addition, the benefit finding by combat interaction at time 1 revealed that greater benefit finding was associated with higher symptoms under high combat exposure at Time 2 after controlling for PTSD arousal symptoms at Time 1. The results of the present study indicate that benefit finding may have a buffering capacity in the immediate months following a combat deployment, but also indicates that more time than is allotted during the post-deployment adjustment period is needed to enable recovery from PTSD. Theoretical implications are discussed.

Pre- and Perinatal Risk Factors for Child Maltreatment in Military Families Across the First Two Years of Life

Military families are exposed to a unique constellation of risk factors, which may impact maltreatment outcomes. The present study examined prospective relationships between demographic, health, birth-related, and military-specific risk factors identified prior to a child's birth on their risk for maltreatment in the first two years of life. Data from the Millennium Cohort Study, Department of Defense (DoD) operational records and Family Advocacy Program data on met-criteria maltreatment, and Birth and Infant Health Research program data on suspected maltreatment were linked for 9076 service member parents. Discrete time survival analysis showed that preterm birth increased risk of maltreatment while parents' older age, physical health, and service in the Navy or Air Force decreased risk. Building on DoD's New Parent Support Program, findings suggest the need for universal and targeted prevention efforts, beginning during pregnancy, which limit or eliminate risk factors for maltreatment in military families.

Moral injury and peri- and post-military suicide attempts among post-9/11 veterans

BACKGROUND

Our goal was to examine the association between moral injury, mental health, and suicide attempts during military service and after separation by gender in post-9/11 veterans.

METHODS

A nationally representative sample of 14057 veterans completed a cross-sectional survey. To examine associations of exposure to potentially morally injurious events (PMIEs; witnessing, perpetrating, and betrayal) and suicidal self-directed violence, we estimated two series of multivariable logistic regressions stratified by gender, with peri- and post-military suicide attempt as the dependent variables.

RESULTS

PMIE exposure accounted for additional risk of suicide attempt during and after military service after controlling for demographic and military characteristics, current mental health status, and pre-military history of suicidal ideation and attempt. Men who endorsed PMIE exposure by perpetration were 50% more likely to attempt suicide during service and twice as likely to attempt suicide after separating from service. Men who endorsed betrayal were nearly twice as likely to attempt suicide during service; however, this association attenuated to non-significance after separation in the fully adjusted models. In contrast, women who endorsed betrayal were over 50% more likely to attempt suicide during service and after separation; PMIE exposure by perpetration did not significantly predict suicide attempts before or after service among women in the fully adjusted models.

CONCLUSIONS

Our findings indicate that suicide assessment and prevention programs should consider the impact of moral injury and attend to gender differences in this risk factor in order to provide the most comprehensive care.

Exploring Influences of Eating Behaviors Among Emerging Adults in the Military

OBJECTIVE

Identify factors influencing eating behaviors among emerging adults in the military.

DESIGN

Focused ethnography using interviews, observations, and artifacts for data.

SETTING

Three US Naval installations.

PARTICIPANTS

Thirty-two active-duty Sailors aged 18-25 years.

ANALYSIS

Qualitative data were organized in NVivo and analyzed sequentially to categorize culturally relevant domains and themes using a social ecological model (SEM). Descriptive statistics were used to describe questionnaire data in SPSS (version 27.0, IBM, 2020).

RESULTS

Leaders encouraged healthy eating through policies and messages, but cultural contradictions and environmental barriers undermined Sailors' efforts to eat healthily. Stress and resource constraints (intrapersonal), peer pressure (social), unhealthy food environments and lack of access to food preparation (environmental), and eating on the go because of mission-first norms (cultural) promoted unhealthy eating behaviors. Nutrition and culinary literacy (intrapersonal); peer support and leadership engagement (social); access to healthy, convenient, and low-cost foods (environmental); and indoctrination to healthy eating during recruit training (cultural) positively influenced eating behaviors.

CONCLUSION AND IMPLICATIONS

The eating behaviors of service members are influenced by many modifiable factors. Targeted education, leadership engagement, and policies that make nutritious foods easily accessible, appealing, and preferred are needed.

Exploring the Interaction Between Head-Supported Mass, Posture, and Visual Stress on Neck Muscle Activation

OBJECTIVE

Assess neck muscle activity for varying interactions between helmet, posture, and visual stress in a simulated "helo-hunch" posture.

BACKGROUND

Military aviators frequently report neck pain (NP). Risk factors for NP include head-supported mass, awkward postures, and mental workload. Interactions between these factors could induce constant low-level muscle activation during helicopter flight and better explain instances of NP.

METHOD

Interactions between physical loading (helmet doffed/donned), posture (symmetric/asymmetric), and visual stress (low/high contrast) were studied through neck muscle electromyography (EMG), head kinematics, subjective discomfort, perceived workload, and task performance. Subjects (n = 16) performed eight 30-min test conditions (varied physical loading, posture, and visual stress) while performing a simple task in a simulated "helo-hunch" seating environment.

RESULTS

Conditions with a helmet donned had fewer EMG median frequency cycles (which infer motor unit rotation for rest/recovery, where more cycles are better) in the left cervical extensor and left sternocleidomastoid. Asymmetric posture (to the right) resulted in higher normalized EMG activity in the right cervical extensor and left sternocleidomastoid and resulted in less lateral bending compared with neutral across all conditions. Conditions with high visual stress also resulted in fewer EMG cycles in the right cervical extensor.

CONCLUSION

A complex interaction exists between the physical load of the helmet, postural stress from awkward postures, and visual stress within a simulated "helo-hunch" seating environment.

APPLICATION

These results provide insight into how visual factors influence biomechanical loading. Such insights may assist future studies in designing short-term administrative controls and long-term engineering controls.

Promoting resilience and psychological wellbeing of military providers: The Navy Medicine Caregiver Occupational Stress Control (CgOSC) program

Military Medicine providers (sometimes referred to as caregivers) not only endure the stress of supporting the medical readiness of operational commands, they take on the continuous demands involved in providing direct care to military beneficiaries. Research shows that occupational stress and burnout impacts the health and wellbeing of providers, increases job turnover, and reduces the quality of patient care. Thus, interventions have aimed to reduce burnout and enhance the wellbeing of military providers. Although these efforts have shown promise, there is much room for improvement. Navy Medicine has implemented the Caregiver Occupational Stress Control (CgOSC) program at its commands, with the objectives to enhance provider wellbeing and resilience, improve retention, and ensure the quality of patient care. This article introduces the Navy Medicine CgOSC program, describes the implementation of the CgOSC program at Navy Medicine commands, and delineates how the program is tracked for program adherence. This tracking method can serve as a model for other healthcare organizations that are establishing programs that aim to promote the wellbeing of their providers.

Identifying Mental Health Profiles Among Adolescents Who Experienced a Recent Parental Deployment or Military-Related Family Separation

Accessing two independent samples of adolescents in military families in the United States who recently experienced parental separation (N = 573; N = 186), this study sought to identify adolescent mental health profiles indexed on multiple indicators. In other words, we asked how military adolescents fare after parental separation in terms of mental health indicators. Proximal family processes (family cohesion, conflict, and marital adjustment) were also examined in relation to mental health profiles as well as core adolescent outcomes, self-rated health, and school enjoyment. In both samples, three profiles emerged identifying similar structures of mental health profiles. Two-thirds of adolescents were in the lowest risk mental health group. Poor family cohesion and greater conflict were associated with the moderate and highest risk groups. The lowest risk group reported better health and greater school enjoyment. Family nurses and other health care professionals are encouraged to inquire about military connectedness, structural changes occurring within the family system, and family processes in relation to adolescent well-being.

Effects of Law Enforcement Load Carriage Systems on Muscle Activity and Coordination during Walking: An Exploratory Study

Law enforcement officers (LEOs) commonly wear a duty belt (DB) or tactical vest (TV) and from prior findings, these forms of load carriage (LC) likely alter muscular activity. However, studies on the effects of LEO LC on muscular activity and coordination are limited in the current literature. The present study examined the effects of LEO load carriage on muscular activity and coordination. Twenty-four volunteers participated in the study (male = 13, age = 24.5 ± 6.0 years). Surface electromyography (sEMG) sensors were placed on the vastus lateralis, biceps femoris, multifidus, and lower rectus abdominus. Participants completed treadmill walking for two load carriage conditions (duty belt and tactical vest) and a control condition. Mean activity, sample entropy and Pearson correlation coefficients were computed for each muscle pair during the trials. The duty belt and tactical vest resulted in an increase in muscle activity in several muscles; however, no differences between the duty belt and tactical vest were found. Consistently across the conditions, the largest correlations were observed between the left and right multifidus (r = 0.33-0.68) and rectus abdominus muscles (0.34-0.55). There were statistically small effects (p < 0.05, η² = 0.031 to 0.076) of the LC on intermuscular coordination. No effect (p > 0.05) of the LC on sample entropy was found for any muscle. The findings indicate that LEO LC causes small differences in muscular activity and coordination during walking. Future research should incorporate heavier loads and longer durations.

Assessment of the Use of Food Supplements by Military Personnel: Study Protocol and Results

Due to their specific mode of operation, military personnel are challenged physically as well as mentally. In most countries, the use of food supplements by military personnel is not regulated, and a high prevalence of supplementation is expected. However, data on this are scarce or very limited, without insights into the importance of supplementation for the intake of bioactive substances. Our goal was, therefore, to develop a study protocol to enable an assessment of the prevalence of using food supplements and an estimate of the contribution of supplementation practices to the dietary intake of specific nutrients and other compounds. The protocol was tested in a study of Slovene Armed Forces (SAF) personnel. Data were collected using an anonymous questionnaire in a sample of 470 participants from different military units-about half from the barracks located across the country, and the other half returning from military operations abroad. To provide meaningful results, we recorded the use of food supplements and functional foods available in single-sized portions (i.e., energy drinks, protein bars, etc.). Altogether, 68% of the participants reported supplementation, most commonly with vitamin, mineral, and protein supplements. Military rank, participation status in military operations, and physical activity were the main determinants of the specific supplements used. Surprisingly, a lower prevalence of overall and protein supplementation was observed in subjects returning from military operations abroad (62 vs. 74%) than in personnel stationed in barracks across Slovenia; however, the frequency of the use of energy drinks and caffeine supplements was higher in this population (25 vs. 11%). The study design allowed for estimations of the daily intake of supplemented bioactive compounds. We describe the challenges and approaches used in the study to support similar studies in the future and within other populations.

Gambling problems predict suicidality in recently transitioned military veterans

OBJECTIVE

This study investigated associations between gambling problems and suicidality in Australian veterans.

METHODS

Data drawn from n = 3,511 Australian Defence Force veterans who had recently transitioned to civilian life. Gambling problems were assessed using the Problem Gambling Severity Index (PGSI) and suicidal ideation and behaviour were assessed using items adapted from the National Survey of Mental Health and Wellbeing.

RESULTS

At-risk gambling and problem gambling were associated with increased odds of suicidal ideation [at-risk gambling: odds ratio (OR), 1.93; 95% confidence interval (CI), 1.47‒2.53; problem gambling: OR, 2.75; 95% CI 1.86‒4.06] and suicide planning or attempts (at-risk gambling: OR, 2.07; 95% CI, 1.39‒3.06; problem gambling: OR 4.22, 95% CI, 2.61‒6.81). The association with total scores on the PGSI and any suicidality was substantially reduced and became non-significant when controlling for the effects of depressive symptoms, but not financial hardship or social support.

CONCLUSIONS

Gambling problems and harms are important risk factors for suicide in veterans, and should be recognised in veteran-specific suicide prevention policies and programs, along with co-occurring mental health problems.

IMPLICATIONS FOR PUBLIC HEALTH

A comprehensive public health approach to reducing gambling harm should feature in suicide prevention efforts in veteran and military populations.

Moving Forward from Moral Injury: A Mixed Methods Study Investigating the Use of 3MDR for Treatment-Resistant PTSD

BACKGROUND

Exposure to trauma and potentially morally injurious events may lead to moral injury (MI). The link between MI and posttraumatic stress disorder (PTSD) may have particularly relevant implications for treatment-resistant PTSD (TR-PTSD). Multi-modal Motion-Assisted Memory Desensitization and Reconsolidation (3MDR), a technology-assisted exposure-based trauma therapy that has been used in the treatment of PTSD, may also be an acceptable modality for patients in the treatment of TR-PTSD and MI. This proof-of-concept study aimed to investigate (1) whether MI co-occurs in military members (MMs) and veterans with TR-PTSD, and (2) the perspectives of MMs and veterans with TR-PTSD utilizing 3MDR for MI.

METHODS

This study employed a mixed-methods clinical trial. Military Members and veterans participated in this study (N = 11) through self-reported questionnaires, video recordings of treatment sessions, and semi-structured interviews post-session and post-intervention, with longitudinal follow-up to 6 months.

RESULTS

MI scores correlated with self-reported measures of mental health symptoms related to PTSD. The thematic analysis revealed three emergent themes: (1) Realities of War, (2) Wrestling Scruples, and (3) Moral Sensemaking.

CONCLUSION

MI was highly correlated with TR-PTSD and themes regarding MI. This result, while preliminary, allows for the postulation that MI may be contributing to the continuation of PTSD symptoms in TR-PTSD, and that 3MDR may be an acceptable modality for addressing these symptoms in MMs and veterans.

Blast-Induced Neurotrauma Results in Spatially Distinct Gray Matter Alteration Alongside Hormonal Alteration: A Preliminary Investigation

Blast-induced neurotrauma (BINT) frequently occurs during military training and deployment and has been linked to long-term neuropsychological and neurocognitive changes, and changes in brain structure. As military personnel experience frequent exposures to stress, BINT may negatively influence stress coping abilities. This study aimed to determine the effects of BINT on gray matter volume and hormonal alteration. Participants were Canadian Armed Forces personnel and veterans with a history of BINT (n = 12), and first responder controls (n = 8), recruited due to their characteristic occupational stress professions. Whole saliva was collected via passive drool on the morning of testing and analyzed for testosterone (pg/mL), cortisol (μg/dL), and testosterone/cortisol (T/C) ratio. Voxel-based morphometry was performed to compare gray matter (GM) volume, alongside measurement of cortical thickness and subcortical volumes. Saliva analyses revealed distinct alterations following BINT, with significantly elevated testosterone and T/C ratio. Widespread and largely symmetric loci of reduced GM were found specific to BINT, particularly in the temporal gyrus, precuneus, and thalamus. These findings suggest that BINT affects hypothalamic-pituitary-adrenal and -gonadal axis function, and causes anatomically-specific GM loss, which were not observed in a comparator group with similar occupational stressors. These findings support BINT as a unique injury with distinct structural and endocrine consequences.

Posttraumatic Cognitions Differ Between Men and Women after Military Sexual Assault Revictimization in Their Contribution to PTSD Symptoms

Sexual revictimization is heightened among military service members and veterans and is associated with greater posttraumatic stress symptoms (PTSS) and severity. The heightened distress following revictimization may be due to posttraumatic cognitions (PTC), which include negative beliefs about the self and world, and self-blame. Moreover, it is unclear whether men and women experience different levels of PTC. The current study tested PTC (overall and subdomains) as a possible mediator between sexual revictimization and PTSS severity, and gender as a possible moderator of these associations. Revictimization was defined across time periods (military sexual assault [MSA] only vs. premilitary sexual trauma + MSA) and in military rape frequency (0, 1, 2+). Participants were 400 (n = 200 [50%] male) service members/veterans with a history of MSA and completed online, anonymous, self-report questionnaires. PTC mediated the association between revictimization and PTSS severity. A significant interaction of gender suggested that men reported high overall PTC and PTC about the self regardless of revictimization; by contrast, overall PTC and PTC about the self were lower for women in response to MSA only and increased with revictimization. Results also showed men were more sensitive to PTC about self-blame as it pertains to more severe PTSS compared to women. There were no unique gender interactions when assessing revictimization by rape frequency, although PTC (overall, all subdomains) significantly mediated the association between rape frequency and PTSS severity. PTC may be a beneficial target when treating PTSS in men, and may be especially heightened in women who have experienced revictimization.

The Role of Psychological Factors in Chronic Pain Treatment Outcomes in the Military

PURPOSE

Chronic pain treatment in the military includes complementary and integrative health (CIH) therapies that may affect psychological factors such as pain catastrophizing, chronic pain acceptance, pain self-efficacy, and patient activation. The unique roles that psychosocial factors play in how CIH approaches reduce pain are not clear. This study examined if a holistic pain management program improved pain outcomes through psychological mediators in service members with chronic pain.

DESIGN

Secondary analysis of a clinical trial.

METHODS

Active-duty service members (n = 210) were randomly assigned to a 3-week course of standard rehabilitative care or standard rehabilitative care combined with CIH therapies. Both treatments were followed by a 3-week functional restoration program. Study measures were completed pre- and post-treatment using the Military Health System's Pain Assessment Screening Tool and Outcomes Registry. Mediation analyses tested the indirect effects of the change in psychological factors before functional restoration on the change in pain impact (e.g., pain intensity, pain interference, functional status) after functional restoration.

RESULTS

All psychological factors except for chronic pain acceptance were related to improved pain impact (p<.05). Furthermore, a change in psychological factors prior to functional restoration was related to the change in pain impact after functional restoration. However, the addition of CIH therapies to standard rehabilitative care did not result in changes in pain outcomes mediated by the psychological factors.

CONCLUSIONS

Although psychological factors were related to pain outcomes, the effect of CIH therapies on chronic pain did not occur via a change in the four psychological factors.

Medic and Portable Pulse Oximeter Respiratory Rate Measurement Comparison to Waveform Capnography: A Prospective, Observational Study

BACKGROUND

The second leading cause of preventable battlefield death involves airway management. Tactical combat casualty care (TCCC) guidelines emphasize combat casualty airway, breathing and respiratory evaluation, including respiratory rate (RR) measurement. The current standard of practice for the US Army medics is to measure the RR by manual counting. Manual counting methods are operator-dependent, and medics face situational stressors limiting accurate measurement of RR in combat settings. To date, no published studies evaluate alternate methods of RR measurement by medics. The purpose of this study is to compare RR assessment by medics against waveform capnography and commercial finger pulse oximeters with continuous plethysmography.

MATERIALS AND METHODS

We conducted a prospective, observational study to compare Army medic RR assessments against plethysmography and waveform capnography RR. Assessments were performed prior to and following exertion at 30 and 60 seconds with both the pulse oximeter (NSN 6515-01-655-9412) and defibrillator monitor (NSN 6515-01-607-8629), followed by end-user surveys.

RESULTS

Of the 40 medics enrolled over a 4-month period, most were male (85%), and reported between less than 5 years of military and medical experience. The mean manual RR reported by medics at rest did not significantly differ from waveform capnography (14.05 versus 13.98, p is equal to 0.523); however, mean manual RR reported by medics on post-exertional subjects was significantly lower than waveform capnography (25.62 versus 29.77, p is less than 0.001). Time to medic-obtained RR was slower than the pulse oximeter (NSN 6515-01-655-9412) both at rest (-7.37 seconds, p is less than 0.001) and at exertion (-6.50 seconds, p is less than 0.001). While the mean difference in RR between the pulse oximeter (NSN 6515-01-655-9412) and waveform capnography in models at rest at 30 seconds was statistically significant (-1.38, p is less than 0.001). There was no overall statistically significant differences in RR between the pulse oximeter (NSN 6515-01-655-9412) and waveform capnography in models at exertion at 30 seconds and at rest and exertion at 60 seconds.

CONCLUSION

Resting RR measurement did not differ significantly; however, medic-obtained RR considerably deviated from both pulse oximeters and waveform capnography at elevated rates. Existing commercial pulse oximeters with RR plethysmography do not differ significantly from waveform capnography and should be investigated further for consideration in fielding across the force for RR assessment.