Preventing Psychological Disorders in Service Members and Their Families An Assessment of Programs (2014) / Chapter Skim
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4 EVIDENCE FOR DEPARTMENT OF DEFENSE INTERVENTIONS FOR PREVENTING PSYCHOLOGICAL DISORDERS
4 EVIDENCE FOR DEPARTMENT OF DEFENSE INTERVENTIONS FOR PREVENTING PSYCHOLOGICAL DISORDERS
Pages 85-134
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From page 85... ...
The chapter begins with an overview of DOD prevention interventions. It includes findings from a recent comprehensive assessment of DOD psychological health and traumatic brain injury (TBI)
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Selecting a Sample of Programs for Assessment Deciding that there was little value in duplicating RAND's efforts and considering the fast-track nature of this study, the committee concentrated its assessment on a sample of DOD prevention programs and interventions. The committee focused on interventions with strong relevance to the targeted areas of this study and for which significant information and research findings were available in the literature.
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Three programs -- Battlemind, Comprehensive Soldier Fitness, and Combat Operational Stress Control -- are discussed in more detail below. See Chapter 5, What Should Be Measured?
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A randomized controlled trial involving 2,297 soldiers looked at Battlemind Debriefing and Battlemind Training interventions that were held 1 month post-deployment. The study found that Battlemind had positive effects on psychological health when compared to stress education, but only for those with high levels of combat exposure.
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For example, in The Comprehensive Soldier Fitness Program Evaluation Report #3: Longitudinal Analysis of the Impact of Master Resilience Training on Self-Reported Resilience and Psychological Health Data (Lester et al., 2011b) , in a pre–post
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. With regard to the prevention of PTSD, Steenkamp and colleagues assert that no data at all support the effectiveness of the Penn Resiliency Program for adults; instead, they say, the best evidence for PTSD prevention can be found not in universal prevention programs like CSF, but in selective and indicated prevention programs, whose strongest effects are in preventing chronic PTSD in those who are already self-reporting clinically diagnosable stressrelated symptoms (Bryant et al., 1998)
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program whose goals are to prevent, identify, and treat combat and operational stress problems. Although the COSC program is being implemented in the Marine Corps and Navy, the generic concept of combat operational stress control informs activities in other service branches, albeit with different approaches.
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(Red) DEFINITION DEFINITION DEFINITION DEFINITION • Optimal functioning • Mild and transient • More severe and • Clinical mental • Adaptive growth distress or impairment persistent distress or disorder • Wellness • Always goes away impairment • Unhealed stress injury FEATURES • Low-risk • Leaves a scar causing life impairment • At one's best CAUSES • Higher-risk TYPES • Well-trained and • Any stressor CAUSES • PTSD prepared FEATURES • Life threat • Depression • In control • Feeling irritable, • Loss • Anxiety • Physically, mentally, anxious, or down • Moral injury • Substance abuse and spiritually fit • Loss of motivation • Wear and tear FEATURES • Mission-focused • Loss of focus FEATURES • Symptoms persist and • Motivated • Difficulty sleeping • Loss of control worsen over time • Calm and steady • Muscle tension or • Panic, rage, or • Severe distress or • Having fun other physical changes depression social or occupational • Behaving ethically • Not having fun • No longer feeling like impairment normal self • Excessive guilt, shame, or blame FIGURE 4-1 Stress continuum model sponsored by the Marine Corps.
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found that CBT prevents onset of PTSD in trauma-exposed individuals2 who meet the criteria for ASD. The CBT 2 Individuals were civilians who had experienced motor vehicle accidents, industrial accidents, nonsexual assault, or mild traumatic brain injury.
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evaluated eight randomized controlled trials of multi-session psychotherapies and found no evidence of PTSD prevention. In fact, they found that a trend for increased PTSD symptoms at 3- to 6-month follow-ups.
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. Most randomized controlled trials that have examined psychological debriefing for the prevention of PTSD have used onetime debriefings of victims of motor vehicle accidents or crimes, such as rape.
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, who also failed to find evidence for efficacy in PTSD prevention of 14 days of propranolol or gabapentin administered within 48 hours of traumatic injury compared to placebo in a small randomized controlled trial. Hydrocortisone also has been tested under the rationale that low cortisol levels are associated with PTSD.
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From page 97... ...
Psychological debriefing is ineffective and possibly harmful; it is believed that required single-session debriefing with a review of trauma details is contraindicated and should be avoided. Although SSRI antidepressants have demonstrated efficacy for PTSD, a recent randomized controlled trial failed to show efficacy of escitalopram for PTSD prevention.
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This section also describes a large-scale research effort that aims to inform ongoing health promotion, risk reduction, and suicide prevention efforts. Suicide Crisis Lines Each of the services prominently posts on its suicide prevention website the 800 number for the Military Crisis Line.
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, the program has been reviewed by a panel of three suicide prevention experts and "found to meet standards of accuracy, safety, and programmatic guidelines." The ASIST program for gatekeepers uses a 2-day training workshop. Its specific aims are to Identify soldiers who have suicidal ideation; Comprehend how gatekeepers' beliefs and attitudes affect suicide intervention; Search for a shared understanding of reasons for suicidal ideation and reasons for living; Assess risk and develop a plan to increase safety from suicidal behavior for an agreed amount of time; and Follow up on safety commitments and ascertain whether additional help is needed (Ramchand et al., 2011)
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That is because the program requires that soldiers who are identified as having depression or PTSD symptoms be screened for suicide risk. Primary care provider education is one of only two effective types of suicide prevention programs according to an influential review article (Mann et al., 2005)
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International experts who reviewed the literature on suicide prevention interventions concluded that the restriction of access to lethal means is one of the few suicide prevention policies with proven effectiveness (Mann et al., 2005)
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Comprehensive Suicide Prevention Program Responding to a spike in its suicide rate, in 1997 the U.S. Air Force (USAF)
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Summary DOD sponsors numerous types of suicide prevention programs, most of which vary by service (Ramchand et al., 2011)
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Appendix G includes a full descriptive analysis of the SUD programs that committee reviewed. This section is organized by the types of DOD substance abuse prevention interventions profiled in that committee's report -- drug testing, community-level education and outreach, service member education and training, screening and brief intervention, environmental strategies -- and discusses the available evidence for these interventions.
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The authors concluded that this finding suggests that the policies had their greatest effect by altering substance use trajectories that had already started. Community-Level Education and Outreach Aside from drug testing, DOD relies heavily on campaign-style prevention programs, including That Guy and the national Red Ribbon campaign.
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A randomized controlled trial of the program involving 24 Air Force bases and more than 50,000 active-duty military members found reductions in alcohol abuse and prescription drug use (as well as suicidality and partner physical abuse) , after controlling for the level of integrated delivery system functioning and command support (Heyman et al., 2011)
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. DAPAs manage substance abuse prevention programs and conduct prevention education courses, including Alcohol-AWARE, Personal Responsibility and Values Education and Training, Alcohol and Drug Abuse Management Seminar for Leaders/Supervisors, and Skills for Life.
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Armed Forces (IOM, 2013b) , the committee concluded that the military has a unique opportunity to communicate consistent messages about drinking, illicit drug use, and non-medical use of prescription drugs and to control environmental factors driving heavy drinking and prescription drug misuse.
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Some of these measures entail tight regulation of prescription dispensing and control and over-the-counter sales, physician education, and increased enforcement of prescription regulations. In addition, the Office of National Drug Control Policy has environmental prevention strategies that correspond with the prescription regimes of Babor and colleagues (Babor et al., 2010a; ONDCP, 2013)
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. The sections below describe four programs -- third location decompression, Real Warriors, Yellow Ribbon Reintegration Program, and Wounded Warrior Programs -- that are
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. The TLD program of the Canadian Armed Forces has two goals: to minimize distress and offer guidance on how to manage common problems related to the transition; and to promote help-seeking for psychological health and transition problems by reviewing personal signs and symptoms and refuting common misperceptions.
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The campaign's stated purposes are to build resilience, facilitate recovery, and support reintegration from deployment. The campaign is sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
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Using the Hero2Hired website, reserve component service members and veterans can search for positions in private industry that match well to their military specialties. The program also provides resume assistance, interview preparation, and skills assessment tools to help reserve component service members match their skills and interests with potential careers (Yellow Ribbon Reintegration Program, 2013b)
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. A recent DOD directive instructs all military services to align their sexual assault prevention policies with the central SAPR program (DOD, 2013a)
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the Secretary of Defense. Although the training does appear to reach most service members, this exercise arose out of the concern that some of the servicespecific elements of the SAPR program are not standardized across the services, are inconsistent in their application, and are missing critical evaluation components needed to measure their effectiveness (DOD Sexual Assault Prevention and Response Office, 2012)
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; however, it is not readily apparent which ones are considered prevention programs. OSD offices with family-related programs and activities include Office of the Deputy Assistant Secretary of Defense for Health Affairs; o Force Health Protection and Readiness o TRICARE Management Agency o Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury o Uniformed Services University of the Health Sciences' School of Medicine Office of the Assistant Secretary of Defense for Reserve Affairs Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy Office of the Deputy Under Secretary of Defense for Wounded Warrior Care and Transition Policy The Office of the Assistant Deputy Secretary of Defense for Military Community and Family Policy (MC&FP)
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. It builds on a program review project started by MC&FP, in collaboration with the Penn State University Clearinghouse for Military Family Readiness, to assess the effectiveness of military family support programs.
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is a family-centered resiliency training program developed by researchers at the University of California, Los Angeles, and Harvard University and implemented under contract with the Navy. Adapted from an evidence-based family-centered preventive intervention for civilian families, the FOCUS program is designed to meet the specific needs of military families facing combat operational stress associated with wartime deployments, reintegration issues, and combat-related physical and psychological injuries.
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Another resiliency program for families is Military Pathways, a multi-component program that uses universal and selective prevention approaches designed to help educate and support military families in coping with deployment stress, recognizing signs and symptoms of psychological health problems, and building resiliency and to help service members reconnect with their children. Program components include educational materials and anonymous, psychological health and alcohol-use self-assessments accessible online, via the phone, and through special events held at installations (Military Pathways, 2013)
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. In the second study, DOD included questions on the use of non-medical counseling in the May 2010 Military Family Life Survey for military spouses and a paired subset of active-duty personnel.
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For example, Cognitive Behavioral Couple Therapy (Monson et al., 2012) for PTSD is an evidence-based intervention designed to target both PTSD symptoms and couple functioning; in a randomized controlled trial it was found to lead to a significantly greater reduction in PSTD symptoms and significantly greater relationship satisfaction when compared with a waitlist control.
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. SUD Prevention for Military Families While some SUD-prevention resources target military spouses and children, no single uniform DOD program provides comprehensive SUD-prevention programming for dependents, and the committee authoring Substance Use Disorders in the U.S.
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. In studies of civilian populations, there is evidence supporting the restriction of access to lethal means in cases of domestic violence.
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The committee is also concerned DOD does not systematically consider the cost-effectiveness of its programs to ensure that resources are directed to programs that see the greatest results per dollar spent. For military families, the committee found no DOD universal prevention programs for which there is an evidence base.
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2012. Serving Military Families in the 21st Century.
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2008. Treatment of acute stress disorder: A randomized controlled trial.
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2011. Suicide prevention programs through community intervention.
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2013. The Comprehensive Soldier and Family Fitness Program Evaluation Report #4: Evaluation of Resilience Training and Mental and Behavioral Health Outcomes.
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2011b. The Comprehensive Soldier Fitness Program Evaluation Report #3: Longitudinal Analysis of the Impact of Master Resilience Training on Self-Reported Resilience and Psychological Health Data.
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2005. Suicide prevention strategies: A systematic review.
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armed forces: A cluster randomized controlled trial. Journal of Consulting & Clinical Psychology 80(3)
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2013. Post-traumatic stress disorder: Review of the Comprehensive Soldier Fitness Program.
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2013c. Suicide Prevention Training.
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2013. A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors.
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