A Public Health Framework for Preventing Mental Disorders in the Context of Pandemics

A Call to Validate the Stress Continuum Model

INTRODUCTION

Since the start of the Global War on Terrorism, exponential demands have been put on military personnel, their families, and the military health care system. In response to a Department of Defense Task Force on Mental Health, the U.S. military began developing and fielding programs to promote the psychological health of its personnel. As part of these initiatives, the Navy and Marine Corps developed the Stress Continuum model. The Stress Continuum is a stress classification system ("ready," "reacting," "injured," and "ill") that provides a common language for identifying, engaging, and intervening when stress reactions or stress injuries are present in military personnel. It is the foundation for resilience and prevention efforts across the Navy and Marine Corps. Although the Stress Continuum has strong face validity, is consistent with current theory, and has been agreed up by expert consensus, it has yet to be empirically validated. The goal of the current article is to begin to empirically validate the Stress Continuum using validated measures of psychological stress.

MATERIALS AND METHODS

We conducted a retrospective analysis of Stress Continuum data (n = 2,049) collected as part of a program evaluation of two Navy operational stress control programs. Receiver operating characteristic (ROC) curves and analyses were conducted to determine the classification quality of the Stress Continuum using a validated measure of stress (a brief version of the Perceived Stress Scale [PSS-4]).

RESULTS

For the first ROC curve, we used the "ill" category (vs. the other three categories) to identify the cut point on the PSS-4. PSS-4 cut point values of 9 and 10, respectively, maximized sensitivity and 1-specificity values. Using the chi-square test, we further found that a more accurate prediction for those in the "ill" category was using the cut point of 9 (79%) relative to 10 (71.8%). For the second and the third ROC curves, we used the "ill" and "injured" categories (vs. the other two categories) and "ill," "injured," and "reacting" categories (vs. the "ready" category), respectively. No optimal cut points on the PSS-4 were identified for these models, indicating that the PSS-4 could not reliably differentiate true-positive and false-positive rates.

CONCLUSIONS

We found that the "ill" category of the Stress Continuum was predictive of higher levels of stress on the validated measure of perceived stress. Thus, our findings strongly suggest that the individuals in the "ill" zone likely warrant some type of intervention by a trained professional.

FUTURE RESEARCH

The Navy has recently leveraged the Stress Continuum to create the Stress-o-Meter to support the fundamental principles of early recognition, peer intervention, and connection to services at the unit level. The Stress-o-Meter serves as a prevention tool that has the capability to collect information about stress levels throughout the entire unit at any time. Continued work on validating the Stress Continuum model and making it easily accessible to military units will ensure service members get the support they need and leaders are able to address the psychological health of their units.

Untapped Potential: Local Health Departments' Involvement in Behavioral Health Preparedness Planning and Recovery Through a Population Behavioral Health Framework

Due to the COVID-19 pandemic, there is an increased demand for behavioral health services in an already strained public health system. Thus, there is a critical need to shift to a population behavioral health framework to address the scope and magnitude of the behavioral health crisis. Local health departments (LHDs) are positioned and purposed to assist in this work by implementing behavioral health surveillance, prevention, and early intervention strategies. Two surveys conducted by the National Association of County and City Health Officials (NACCHO) were used for this analysis, the 2018 Preparedness Profile survey and the 2020 Forces of Change survey. In 2018, a little over half of LHDs involved behavioral health groups in their planning coalitions, and three-quarters of LHDs addressed behavioral health in preparedness planning. However, in 2020, LHDs implementing a behavioral health response during COVID-19 was substantially lower than the planning phases: strategy to support the public health system, including behavioral health (20%); specific initiative for individuals with behavioral health needs (48%); or targeted messaging for people with behavioral health needs (25%). The findings of this analysis indicate that as of 2020, LHDs’ involvement in behavioral health is still minimal and the potential for LHDs to reduce burden on the public health system is not being maximized. For LHDs to provide more behavioral health services they will require support in the form of funds, technical assistance, education on best practices, and the support and authority to expand services in behavioral health.

Stress, PTSD, and COVID-19: the Utility of Disaster Mental Health Interventions During the COVID-19 Pandemic

Purpose of review

In the context of an ongoing, highly uncertain pandemic, disaster mental health measures can increase community capacity for resilience and well-being, support formal mental health treatment, and help address the risk for mental health reactions in high-stress occupations. The purpose of this review is to summarize the literature on disaster mental health interventions that have been helpful both prior to and during the pandemic in a broad range of applications, including for use with high-stress occupations in an effort to mitigate risk for post-traumatic stress disorder (PTSD) and other mental health sequelae.

Recent findings

Evidence-based and evidence-informed disaster mental health interventions, frameworks, and treatments have been studied in pilot studies, non-randomized trials, and randomized clinical trials prior to and in the context of the current COVID-19 pandemic. The studies have demonstrated feasibility and acceptability of these modalities and improved perceived support, as well as significant reductions in distress, and mental health symptoms such as depression, anxiety, and PTSD.

Summary

A disaster mental health approach to the COVID-19 pandemic can generate opportunities for prevention and support at multiple levels with timely interventions tailored for different concerns, cultures, and available resources.