Combat and Operational Stress Control Interventions and PTSD: A Systematic Review and Meta-Analysis

Outcome metrics utilized in evaluations of programs and interventions for combat and operational stress: A review of psychometric properties

The Department of Defense has mandated combat and operational stress control (COSC) efforts for the Services since 1999. Although several COSC-related programs have been implemented, few have undergone evaluation, and no standardized metrics have been established to assess their effectiveness and utility. The purpose of this review was to characterize the content and psychometrics of measures that have been utilized as outcome metrics in evaluations of COSC-related programs and interventions. Systematic literature searches were conducted for publications that: a) evaluated at least one measure from U.S. service members who participated in a program or intervention to prevent or reduce the adverse effects of combat and operational stress; and b) reported U.S. data on the internal consistency, test-retest reliability, convergent validity, and sensitivity/specificity of the identified measures. This process identified 15 measures for which psychometric properties were reviewed for acceptability based on recommended criteria. Identified measures varied from well-validated measures to newer instruments for which more data is needed on one or more of the target psychometric properties. Aside from internal consistency, psychometric data from U.S. military samples were sparse. Results further suggested that some measures might have reduced sensitivity in service members under certain conditions, such as large-scale screening. Additional studies are needed to validate COSC-relevant measures in service members. Future evaluations of programs and interventions for combat and operational stress should select measures that will increase the consistency of the literature, allow comparisons across studies, and ensure alignment with the objectives of identified programs.

Incidence of mental disorders in soldiers deployed to Afghanistan who have or have not experienced a life-threatening military incident-a quasi-experimental cohort study

Introduction

There is very good international research on deployment-related mental disorders in military personnel. The incidence rates show a very wide range. A new strategy is therefore proposed in order to achieve better standardization and thus better comparability of the studies. In addition to a non-deployed comparison group, we propose to compare deployed soldiers with and without critical military incidents during the deployment. This additional distinction makes it possible to differentiate between the influencing variables of actual threat and general deployment stress.

Methods

N = 358 male combat soldiers deployed to Afghanistan were included in the study. Clinical interviews were conducted several days before deployment and after deployment. Of them, n = 80 soldiers suffered a life-threatening military incident during deployment, whereas 278 soldiers did not. Odds ratios (OR) were calculated for the groups with and without critical military incidents and the new onset for PTSD, anxiety disorders and depressive disorders.

Results

When comparing both groups, we found significantly higher 1-year incidence rates in the group with critical military incidents: 6.4% vs. 1.1% (OR 6.2) for post-traumatic stress disorder (PTSD); 7.0% vs. 1.1% (OR 6.5) for depression; and 15.9% vs. 2.8% (OR 6.6) for anxiety disorders. The 1-year incidence rate of mental multimorbidity (PTSD with anxiety or depression) was 4.8% vs. 0.4% (OR 12.0).

Discussion

These results indicate that life-threatening military incidents during military deployment are important to mental health. As the different threat levels of the various missions are taken into account, additional predictors could be determined more precisely in further research.

Identifying Stress-Exacerbated Thermal-Injury Induced MicroRNAs

Using a model of combat and operational stress reaction (COSR), our lab recently showed that exposure to an unpredictable combat stress (UPCS) procedure prior to a thermal injury increases pain sensitivity in male rats. Additionally, our lab has recently shown that circulating extracellular vesicle-microRNAs (EV-miRNAs), which normally function to suppress inflammation, were downregulated in a male rat model of neuropathic pain. In this current study, male and female rats exposed to UPCS, followed by thermal injury, were evaluated for changes in circulating EV-miRNAs. Adult female and male Sprague Dawley rats were exposed to a UPCS procedure for either 2 or 4 weeks. Groups consisted of the following: nonstress (NS), stress (S), NS + thermal injury (TI), and S + TI. Mechanical sensitivity was measured, and plasma was collected at baseline, throughout the UPCS exposure, and post-thermal injury. EV-miRNA isolation was performed, followed by small RNA sequencing and subsequent data analysis. UPCS exposure alone resulted in mechanical allodynia in both male and female rats at specific time points. Thermal-injury induction occurring at peak UPCS resulted in increased mechanical allodynia in the injured hind paw compared to thermal injury alone. Differential expression of the EV-miRNAs was observed between the NS and S groups as well as between NS + TI and S + TI groups. Consistent differences in EV-miRNAs are detectable in both COSR as well as during the development of mechanical sensitivity and potentially serve as key regulators, biomarkers, and targets in the treatment of COSR and thermal-injury induced mechanical sensitivity. PERSPECTIVE: This article presents the effects of unpredictable combat stress and thermal injury on EV-contained microRNAs in an animal model. These same mechanisms may exist in clinical patients and could be future prognostic and diagnostic biomarkers.

Pre-deployment aggressiveness, combat exposure and moral injury as contributors to posttraumatic stress symptoms among combatants: A two-year prospective study

Combatants who are exposed to events which transgress deeply held moral beliefs might face lasting psychopathological outcomes such as Moral Injury (MI) and posttraumatic stress symptoms (PTSS). However, insight about pre-deployment personality factors which might facilitate the MI process and its negative consequences is sparse. In this prospective study, we examined pre-deployment aggressiveness as a possible predictor of exposure to combat and potentially morally injurious events (PMIEs), trauma-related guilt and shame and PTSS among Israeli active-duty combatants. A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements (T1: 12 months before enlistment, T2: 6 months following enlistment-pre deployment, and T3: 18 months following enlistment-post deployment). Participants' characteristics were assessed via semi-structured interviews (T1) and validated self-report measures of aggressiveness (T2), combat exposure, PMIEs and PTSS (T3) between 2019 and 2021. Results show that higher levels of pre-deployment aggressiveness predicted both combat exposure and PMIEs-'betrayal'. Combat exposure mediated the association between aggressiveness and PTSS post deployment. Importantly, pre-deployment aggressiveness was significantly associated with the PMIEs-'betrayal' that are associated with trauma-related guilt and shame, which in turn were associated with high levels of PTSS post deployment. Our results highlight the implications of pre-deployment aggressiveness for different forms of exposure to potentially traumatic events during military service. Identification of at-risk combatants for PTSS following exposure to PMIEs of betrayal might provide these combatants with a tailor-made type of preparation regarding moral and ethical situations, which should be investigated in future studies.

Building a critical incident peer response team: A full theatre team welfare intervention

The psychological impact (second victim effect) of in-theatre critical incidents is increasingly recognised. Different styles of psychological support programme have recently been published, including some utilising 'near in time' peer support. Most of these programmes either target their support to individuals, or focus on one vocational group rather than the multidisciplinary team. However, the in-theatre team consists of different craft groups who nonetheless function as a single team and are therefore 'peers'. This paper sets out the design and implementation of a critical incident peer response programme at Waikato Hospital, New Zealand, which provides peer-led group psychological first aid to full theatre teams. The programme is administered by trained representatives from multiple in-theatre craft groups including nurses, midwives, anaesthetic technicians, recovery room nurses, surgeons and anaesthetists. It emphasises team education and peer support, and has a wholly welfare focus. The programme has voluntary participation but mandatory activation triggers so that individuals do not need to seek support actively at a time when they may not recognise the need to do so. The programme is becoming embedded in the Waikato Hospital theatre culture so that participating in psychological support is normalised following a critical event. This framework is shared in the hope that it will assist other hospitals to develop welfare interventions to support full theatre teams.