Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

UFDC Membership

Aggregations:
Digital Military Collection

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October – December 2014 Perspective 1 MG Steve Jones Developing Effective Leadership Competencies in Military Social Workers 3 COL Jennifer L. Humphries; COL (Ret) Reginald W. Howard Evolution of the Combat and Operational Stress Control Detachment 8 MAJ Jason I. Dailey; CPT Victoria L. Ijames The Psychosocial Challenges of Conducting Counterinsurgency Operations 14 COL Derrick Arincorayan; Larry Applewhite PhD; et al Sleep and the Use of Energy Products in a Combat Environment 22 LTC Wendi M. Waits; Michael B Ganz, PhD; Theresa Schillreff, OTR/L; CPT Peter J. Dell Telebehavioral Health: Practical Applic ation in Deployed and Garrison Settings 29 CPT Michelle M. Garcia; Kristin J. Lindstrom, PsyD Effectiveness of Telebehavioral Health Program Nurse Case Managers (NCM): 36 Data Collection Tools and the Proce ss for NCM-Sensitive Outcome Measures Judy Carlson, EdD, APRN; Roslyn Cohen, MSN; Wynona Bice-Stephens, EdD, RN Military Service Member and Veteran Self Repo rts of Efficacy of Cranial Electrotherapy 46 Stimulation for Anxiety, Posttraumatic St ress Disorder, Insomnia, and Depression Daniel L. Kirsch, PhD; et al Raising the Clinical Standard of Care for Suicidal Soldiers: 55 An Army Process Improvement Initiative Debra Archuleta, PhD; David A. Jobes, PhD; Lynette Pujol, PhD; et al Mild Traumatic Brain Injury in the Military : Improving the Referral/Consultation Process 67 MAJ Charles Watson Directorate of Treatment Programs: Providing Behavioral Health Services 73 at the US Disciplinary Barracks LTC Nathan Keller; et al The Effects of Military Deployme nt on Early Child Development 81 Dana R. Nguyen, MD; Juliana Ee, PhD; Cristobal S. Berry-Caban, PhD; Kyle Hoedebecke, MD The Effect of Deployment, Distress, and Perceived Social Support on 87 Army Spouses’ Weight Status LTC Tammy L. Fish; Donna Harrington, PhD; Me lissa H. Bellin, PhD; Terry V. Shaw, PhD Applying the Korem Profiling System to Domestic Violence 96 CPT Victor Johnson; Chandra Brown, LMSW Understanding the Student Veterans’ Colle ge Experience: An Exploratory Study 101 2 LT Timothy Olsen; Karen Badger, Ph D, MSW; Michael D. McCuddy, MSW Mental Health Outreach and Scre ening Among Returning Veterans: 109 Are We Asking the Right Questions? Karen Bloeser, MSW; Kelly K. McCarron, PsyD; et al Skilled and Resolute A New Offering from the Bord en Institute History Series 118 COL Betsy Vane, Army Nurse Corps Historian BEHAVIORAL HEALTH: INCREASING RESILIENCY AND ENDURANCE

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October – December 2014 The Army Medical Department Center & School PB 8-14-10/11/12 Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspx A Professional Publication of the AMEDD Community The Army Medical Department Journal [ISSN 1524-0436] is published quarterly for The Surgeon General by the AMEDD Journal Office, USAMEDDC&S, AHS CDD 3630 Stanley RD STE B0204, JBSA Fort Sam Houston, TX 78234-6100. Articles published in The Army Medical Department Journal are listed and indexed in MEDLINE, the National Library of Medicine’s premier bibliographic database of life sciences and biomedical information. As such, the Journal’ s articles are readily accessible to researchers and scholars throughout the global scientific and academic communities. CORRESPONDENCE: Manuscripts, photographs, official unit requests to receive copies, and unit address changes or deletions should be sent via email to usarmy.jbsa.medcom-ameddcs.list.amedd-journal@mail.mil, or by regular mail to the above address. Telephone: (210) 221-6301, DSN 471-6301 DISCLAIMER: The AMEDD Journal presents clinical and nonclinical professional information to expand kn owledge of domestic & international military medical issues and technolo gical advances; promote collaborative partnerships among Services, components, Corps, and specialties; convey clinical and health service support information; and provide a peer-reviewed, high quality, print medium to encourage dialog ue concerning healthcare initiatives. Appearance or use of a commercial product name in an article published in the AMEDD Journal does not imply endorsement by the US Government. Views expressed are those of the author(s) and do not necessarily reflect official policies or positions of the De partment of the Army, Department of the Navy, Department of the Air Force, Department of Defense, nor any other agency of the US Government. The content does not change or supersede information in other US Army Publications. The AMEDD Journal reserves the right to edit all material submitted for publication (see inside back cover). CONTENT: Content of this publication is not copyright protected. Reprinted material must contain acknowledgement to the original author(s) and the AMEDD Journal OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical Department units and organiza tions, other US military medical organizations, and members of the worldwide professional medical community. LTG Patricia D. Horoho The Surgeon General Commander, US Army Medical Command MG Steve Jones Commanding General US Army Medical Department Center & School Administrative Assistant to the Secretary of the Army GERALD B. O’KEEFE 1421601 By Order of the Secretary of the Army: Official: Raymond T. Odierno General, United States Army Chief of Staff DISTRIBUTION: Special

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October December 2014 1 Perspective COMMANDERS INTRODUCTION MG Steve Jones Soldiering during the past 13 years of war has been tough, as tough as during any other time in our history. Soldiers endured deployments that were too frequent and too long, and their time at home was too short. While at home, the pace was often so fast that they looked forward to the next deployment as a break. As a result, Soldiers never fully mentally reset or reintegrated into their families. 1 Whether Soldiers see combat or not, every day on a deployment is Groundhog Day. The monotony, long hours, and lack of time off take their toll. For some, bore dom is interspersed with brief periods of high emotion and excitement. 2 The loss of a buddy can be particularly traumatic because it strips away the Soldiers feeling of invincibility. Continuous combat causes physical as well as psychological stress including sleep deprivation and both physical and mental fatigue. Many Soldiers live on energy drinks, some recover from operations by playing video games for hours into the night, others use alcohol and drugs. Redeployment brings new challenges. The unremitting pace upon return coupled with reintegration issues cause additional stress. Soldiers return to a life that lacks the excitement and meaning they experienced in combat. They relinquish positions of authoritysuch as serving as mayor of a townand in fact some of our Reserve job. These issues occur in the face of normal post com bat reactions which can lead to anger, violent behavior, and self-medication. Genetic factors may increase the likelihood of develop ing PTSD in some individuals. 3 A shared genetic dia thesis also leads to the association of PTSD and other behavioral health disorders. Genetic factors may also increase the exposure to trauma. Most of our Soldiers enlisted after September 11, 2001, and they joined our sensation seeking personality type known as the Type T personality. Environmental factors also play a role in the development of high risk Soldiers. 4 Adverse childhood experiences increase the risk for PTSD. A dysfunctional home and poor upbringing may produce a recruit without a strong value system and with poor life decision-making skills. They may produce a recruit with poor self-control, one prone to impulsive behavior who now faces high risk operational and personal environments. Deployments provide an environment where taking life threatening risks is an everyday occurrence. Every time Soldiers leave the wire, they face the threat of death from an IED or an ambush. Their risk taking is rewarded, a Soldier who attacks an enemy position across open terrain, or are recognized for their courage. With frequent expo sure they adapt. Their sense of danger erodes and they no longer worry about the risk. They lose their natural inhibition towards engaging in high risk behaviors, and they acquire the ability to commit violence on them selves and others One of the classic studies on human behavior in com bat is The Anatomy of Courage It was written by Lord Moran, Winston Churchills physician, based on his ex Royal Fusiliers in the First World War. He noted that courage is will power, its like money in the bank and no one has an unlimited supply. You can make deposits, but are always spending, and when your courage is used up, 5 The most effective way to destroy psychological strength is through poor leadership. There is an unwritten moral contract between leaders and their Soldiers. Leaders are expected to take care of their Soldiers, treat them fair ly, and share their hardships. In return, Soldiers follow orderseven though it may mean their death. 6 When leaders break that contract and fail to care for their Sol diers, when they mistreat them or cause unnecessary morale, respect, or discipline. was able to retain its morale in the face of the terrible slaughter. He noted the value of training, particularly that which instilled esprit de corps. He listed 5 factors THE HUMAN DIMENSION OF COMBA T

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2 http://www.cs.amedd.army.mil/amedd_journal.aspx important in maintaining high morale: regimental loy alty, the pride in belonging to a good battalion, high quality leaders who are trusted by their Soldiers, strong discipline, the sense of duty, and sound administration (providing adequate rations and ammunition). 7 These studies show that psychological strength can be built and sustained. Establishing a good command cli cipline is the foundation for developing morale. Training instills Army Values, the Warrior Ethos, discipline, and ness. Good health, rest, and nutrition, and a strong sup port network also help sustain a Soldiers strength. The Army has implemented several primary prevention programs to build and maintain the resilience of Soldiers and Families as part of the Ready and Resilient Cam paign. Comprehensive Soldier and Family Fitness de velops an individuals ability to face and cope with ad versity, adapt to change, recover, learn, and grow from setbacks. The Performance Triad promotes healthy be haviors including adequate physical activity, nutrition, and sleep. The behaviors improve physical and cognitive performance, resilience, reduce injuries and illness, and speed recovery. The Center for the Army Profession and Ethic promotes the Army Profession, Army Ethic, and Character Development. The Army Medical Department plays an important role commanders, and serving as a safety net for Soldiers and Families. However, the ultimate responsibility re mains with the unit commander, as noted in Change 1 to Medical Field Manual 8-10, Medical Service of Field Units dated June 28, 1946: Since the majority of the factors which determine mental health of troops fall within province of command, the main job of preventive of the line. 8 REFERENCES 1. Army Health Promotion, Risk Reduction, and Sui cide Prevention Report 2010 Washington, DC: US Dept of the Army; 2010. Available at: http://csf2. army.mil/downloads/HP-RR-SPReport2010.pdf. 2. Holmes R. Acts of War: The Behavior of Men in Battle New York, NY: The Free Press; 1985. 3. The Oxford Handbook of Traumatic Stress Disorders New York, NY: Ox ford University Press; 2012. 4. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Re lationship of childhood abuse and household dys function to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998;14(4):245-258. 5. Lord Moran. The Anatomy of Courage London, UK: Constable; 1945. 6. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character New York, NY: Mac Millan; 1994. 7. Morale: A Study of Men and Cour age London, UK: Cassell & Co Ltd; 1967. 8. Medical Field Manual 8-10: Medical Service of Field Units Washington, DC: War Department; 1942 (Chng 1 dtd 28 June 1946).[obsolete] THE HUMAN DIMENSION OF COMBAT

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October December 2014 3 Developing Effective Leadership Competencies in Military Social Workers COL Jennifer L. Humphries, MS, USA COL (Ret) Reginald W. Howard, MS, USA ABSTR A CT Military social workers are facing transformative times in that demand for military social work has increased and become more complex, challenging, and diverse due to the last 13 years of combat experiences. Developing military social work leaders must be deliberate, continuous, and progressive in order to impact and improve organizational performance in the healthcare delivery system. The transformational leadership model has been proven to be effective in both the mili tary and social service organizations. The strength of this leadership model coincides well with the values of the social work profession. Incorporating leadership development in a clinical Master of Social Work program has the potential to improve service provision and offer strategies for military social workers to effectively manage the ongoing challenges Over the last decade, military social work became more complex, challenging, and diverse due to ever-evolving changes in military operations, budget constraints due to sequestration, and anticipated reductions in force structure. Furthermore, the consolidation of behavioral healthcare teams combined with ongoing media cover age of the psychosocial effects of wartime deployments ers. Demand for behavioral health services has steadi ly risen from operational and combat support brigade leaders, active-duty service members, and their fami lies, all of whom reasonably expect clinical providers to understand the deployment and home front challenges imposed on them by an extended period of continuous care costs have necessitated constant review, analysis, and revisions to healthcare business practices. Relatedly, there is a persistent need to synchronize and standard ize Army behavioral healthcare services which has led to the creation of multidisciplinary behavioral health departments and the integration of behavioral health care in primary care settings. Therefore, military social workers can expect to be called upon to perform in a variety of positions including clinical, staff, command, education, and training assignments. For these reasons, rigorous clinical education augmented with training in leadership models applicable to the human domain is in creasingly important for military social workers. While many effective leadership models coincide well with the social work profession, transformational leadership em phasizes ways to manage more complex environments, ture in a manner consistent with core social work values. The Army-Fayetteville State University (FSU) Master of Social Work (MSW) Program educates future mili tary social workers for the Army, Navy, and the Army National Guard. The program uniquely incorporates coursework in leadership development into a clinicallyfocused social work curriculum. Blending leadership skills with graduate level clinical education and training has the potential to increase organizational performance while enhancing the quality of care delivered to our military members and families. This article describes the current transformative times in military behavioral healthcare delivery and the challenges social work of care team. An evidence-based leadership model, and its connection to social work values, is presented as a best-practice approach to leading the behavioral health transformation. Implications for preparing military so cial work graduate students to meet the challenges of a demanding future are addressed. TOD A YS BEH A VIOR A L HE A LTHC A RE ENVIRONMENT Todays military behavioral healthcare environment is undergoing a transformation that began with the attacks on 9/11/2001 and accelerated with the lengthy operations in Iraq and Afghanistan. There have been unpredictable and intense levels of urban combat and multiple, extend ed tours of duty which have resulted in behavioral health consequences 1-3 and increased utilization rates of behav ioral healthcare. 1,2 Furthermore, research has shown that 4,5 challenges in family and close relationships, 6 and can potentially impact a family members ability to become a caregiver. 7,8 Moreover, 13 years of combat deployments will most likely produce long-term consequences for those indi viduals who have served in the warzone. The Nation al Vietnam Veterans Readjustment Study (NVVRS) demonstrated that combat exposure leads to problems in family functioning years after returning from the

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4 http://www.cs.amedd.army.mil/amedd_journal.aspx combat zone. 9 Additionally, veterans with higher levels of war-related trauma and posttraumatic symptomatolo greater domestic violence than those without trauma. 9 Reanalysis of NVVRS data revealed that, in addition to PTSD, alcoholism, depression, and anxiety were preva lent maladies in both male and female Vietnam veterans. 9 Further research indicates that veterans exposed to high to develop problems in psychosocial functioning than those with low exposure. 10 Further, those with PTSD are more likely to report marital, parental, and other family adjustment problems, including domestic violence. 11 In addition to psychosocial challenges, other potential longincreased risk for externally-caused mortality. 12-14 Evi dence suggests that the association of wartime service with various physical and behavioral health problems portends that the demand for military behavioral health services will remain high for the foreseeable future. As the military begins to transition from its combat mis sion in Afghanistan, the focus will shift to resetting the force while simultaneously experiencing troop reduc tions and resource constraints. 15 Anticipating these chal lenges, the Army Medical Command prepared Army Medicine StrategyThe Road Ahead based on 3 stra tegic imperatives: create capacity, enhance diplomacy, and improve stamina. 16 To this end, Behavioral Health Service Line Policy, Consolidated Army Behavioral Health was published to establish a seamless system of behavioral healthcare designed to address the residual effects of the war within a resource constrained environ ment. 17 The policy mandates a complete transformation from a traditional stovepipe* model of care to a proac tive, integrated, metrics-driven and patient-centered unites psychiatry, psychology, and social work into a consolidated department of behavioral health within the a diverse behavioral healthcare delivery system will necessarily possess superior clinical expertise and the ecuting complex programs. 17 Leadership that maximizes performance improvement, manages precious resources and mitigates the stress experienced by the behavioral health team is perhaps the critical factor in successfully transforming the behavioral healthcare system. LE A DING IN A TR A NSFORMING ENVIRONMENT Successfully navigating through a transformative organizations to successfully adapt to the new practice milieu. In this setting, effective leadership combines expert clinical knowledge, management abilities, and a positive attitude to coordinate the work of diverse, spe cialized professionals to produce patient-centered ser vice delivery. Ideally, these skills inspire trust in lead thouse, 18 of individuals to achieve a common goal that is guided ence, leadership does not exist. Leadership is not a trait or list of characteristics that reside in the leader; it is a transactional event that occurs between the leader and their team. 18 Leadership in the current operational en vironment requires one to motivate a multidisciplinary team to provide quality healthcare services. Transformational leadership emphasizes the interactive, relational aspects between the leader and the organiza tion by inspiring the team to look beyond self-interest and work collectively for a greater purpose. Leaders and their team are transformed through a commitment to a higher set of moral values and a common goal. 19 The transformational leadership model has 4 components: alized consideration, and intellectual stimulation. 20 propriate behavior. Inspirational motivation entails the leaders abilities to motivate not simply through rewards and punishment, but largely by effective performance. 21 Transformational leaders motivate their teams by en couraging them to transcend self-interests by making them more aware of desired outcomes and how their efforts impact the organizations goals. Individualized consideration demonstrates genuine need and con cern for team members; relationships energize action and build cohesion. Intellectual stimulation manifests through challenging individuals to rise to higher levels of performance. 20 Leaders encourage others to think critically to introduce innovation and new ideas for im proving outdated and unproductive practices. Transfor mational leaders activate higher order needs of the team by inspiring them to work toward common goals and en couraging individuals to reach their full potential while working within a value-based framework. 22-24 TR A NSFORM A TION A L LE A DERSHIP A ND MILIT A RY SOCI A L WORK livering behavioral health services during the past 13 years of war, and have the potential to be transforma DEVELOPING EFFECTIVE LEADERSHIP COMPETENCIES IN MILITARY SOCIAL WORKERS to strictly up and down lines of control, inhibiting or preventing cross-organizational communication.

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October December 2014 5 health. Much of their potential is rooted in the good work practice. Clearly, the social work professions val ues of service, integrity, importance of human relation ships, and dignity and worth of a person closely align with transformational leadership thinking. Similar to a transformational leader using inspirational motivation through a shared vision and goals, social workers are attracted to the profession with a passion to improve the lives of others. When in leadership positions, military social workers can use this passion and commitment to others to formulate a vision and arouse others to achieve these shared objectives. Military social work leaders de serving the organization rather than self-interests. As the transformational leadership model appreciates the importance of relationships, so to do social work pro fessionals. In social work, the primary mission is to en hance well-being and helping to meet the basic human needs of all people. 25 As described by Pumphrey, 26 so cial workers believe that every person should be regard accelerated by purposeful assistance and active encour agement from others. Relationships are the vehicle for positive change and growth. These core principles be come instrumental in developing an organizational vi sion and are fundamental motivators for social workers in practice. Conveying this principle through leading by example provides others with a motivation, or pur pose, greater than themselves. Transformational leader ship focuses on the leader-team relationship in forming a foundation to work toward the greater good; the under lying belief is that all leadership, at its core, is relational. Others have described the merits of transformational lead ership and have provided empirical evidence to support incorporating it into human service organizations. Fisher encouraged social workers to learn more about motiva ership as a framework to consider adopting in practice. 21 The values inherent in leading from a transformational perspective have made it a common theme among social work leaders with some supervisors intuitively applying its principles. 27,28 Research has demonstrated that factors cantly correlated with social work leader outcomes of ef fectiveness, satisfaction, and extra effort. 29,30 Qualitative data have shown that transformational leadership could be a contributing factor in understanding the potential tive change in the complex child welfare system. 31 This core attributes of effective leadership in a simple, clear, relevant, and consensually acceptable manner. 32 DEVELOPING LE A DERS IN THE ARMY-FS U MS W PROGR A M In the Army, leadership development is a deliberate, continuous, sequential, and progressive process that oc curs within a value-based framework. 33 In addition to expected to assume leadership roles with increasing lev els of responsibility as they gain active-duty experience. Therefore, to develop military social workers prepared to succeed in todays complex and dynamic healthcare environment, it is important to augment traditional pro fessional military education with specialized leadership training early in their careers. The Army-FSU MSW program, based at the Army Medical Department Center and School, was estab ioral health providers with active-duty social workers. The programs curriculum was designed to produce clinical social workers with a concentration in mental health and substance use treatment. As the program evolved, it became clear that the clinical education and training should be supplemented with an additional emphasis on leadership. Therefore, leadership develop ment strategies were infused throughout the curriculum and augmented with a distinct course on management and leadership. The course highlights unique aspects of managing behavioral health operations in a military environment that includes legal/ethical considerations, constructing a business case analysis, and exercising quality management with an emphasis on the creden tialing process. Students learn principles of effective management styles that develop skills in team building, encourage participatory decision-making, and promote organizational productivity consistent with transforma tional leadership theory. As a way of establishing verti cal integration between practice competencies, students are tasked to develop a comprehensive strategic plan to guide a community-based social service program they designed in a previous course. The assignment requires students to apply critical thinking to understand the from a leadership perspective. Particularly relevant to social work leadership, an emphasis is placed on the im portance of developing positive relationships with both supervisors and subordinates through effective commu nication that empowers others to make good decisions. The courses capstone assignment requires students to deliver a presentation that articulates their leadership philosophy and management style, and establishes clear expectations for team members. In order to infuse leadership development throughout the curriculum, faculty members were purposely and

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6 http://www.cs.amedd.army.mil/amedd_journal.aspx carefully selected. Currently, the 8 faculty members have over 160 years of clinical and leadership experi ence enables them to incorporate leadership principles and competencies in all foundation and concentration courses. Additionally, throughout the 14 months of edu cation and training, senior military social workers are invited to lecture on proven leadership strategies that have been instrumental in improving organizational performance, policy development, and operational plan ning. To augment classroom leadership instruction dur ing the Social Work Internship Program, students must complete 10 web-based modules from the Joint Medical Skills Institute which enhance their classroom instruc tion. Topics include labor relations, human resources, toring. Evidence thus far, based on the performance of the programs 131 graduates, suggests that the approach used by the Armys MSW program has been effective. As of March 2014, 96% have passed the Licensed Mas surpassing the 82% national rate. 34 Perhaps more im portantly, of the 38 who have further completed their 2-year Social Work Internship and have become inde pendent providers, almost all have deployed with com bat brigades to Afghanistan. Furthermore, they serve in vital positions in operational units located overseas as leaders of family advocacy teams within the medical treatment facilities and in command of a combat stress control detachment. OBSERV A TIONS A ND CONCL U SIONS Leadership is an essential military skill. Therefore, skillful leadership can shape the well-being of military care provided. As the operating environment becomes increasingly challenging, positive leadership may be the decisive factor in determining future success. This is certainly true in todays military behavioral health sec tor. The transforming operational context, declining resources, evolving business practices, and increased demand for services have underscored the need for ef fective leadership strategies. For military social work to contribute to accomplishing our shared mission, the fol lowing observations are offered: clinical competencies as well as leadership skills that are effective across a diverse range of opera tional and healthcare settings. Military social workers operate in a distinctive en vironment with unique demands and challenges. these conditions is best accomplished by training them in a military-centric training program early in their careers. Leadership skills can be learned through education and sharpened with experience. Integrating leader ship training with social work core values in the Armys MSW curriculum prepares future leaders to solve tomorrows problems. ceed in positions with increasing levels of respon sibility, they should be assigned to leadership posi tions commensurate with their rank. are prepared to provide consultation to unit command ers, advocate for service members, and lead behavior al healthcare teams. The strengthening of leadership talents in military social workers early in their career development has the potential to enhance behavioral health outcomes. While further program evaluation is necessary to fully understand the impact of incorporat ing leadership education into a clinical MSW curricu military social work practice, graduate education must include specialized leadership training. REFERENCES 1. Hoge CW, Auchterlonie JS, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006;295(9):1023-1032. 2. Smith TC, Ryan MA, Wingard DL, et al. New on set and persistent symptoms of posttraumatic stress disorder self-reported after deployment and combat exposures: prospective population based US mili tary cohort study. BMJ 2008;336(7640):366-371. 3. Jacobson IG, Ryan MAK, Hooper TI, et al. Al cohol use and alcohol-related problems before and after military combat deployment. JAMA 2008;300(6):663-675. 4. Tanielian T, Jaycox LH. InvisibleWounds of War: Psychological and Cognitive Injuries, Their Con sequences, and Services to Assist Recovery Santa Monica, CA: RAND Corporation; 2008. 5. Hoge CW, Castro CA, Messer, SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New Engl J Med. 2004;351:13-22. 6. Karney BR, Crown JS. Families Under Stress: An Assessment of Data, Theory, and Research on Mar riage and Divorce in the Military Santa Monica, CA: RAND Corporation; 2007. 7. Galovski T, Lyons JA. Psychological sequelae of combat violence: A review of the impact of PTSD on the veterans family and possible intervention. Aggress Violent Behav 2004;9(5):477-501. DEVELOPING EFFECTIVE LEADERSHIP COMPETENCIES IN MILITARY SOCIAL WORKERS

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October December 2014 7 8. Figley CR. Coping with stressors on the home front. J Soc Issues 1993:49(4):51-71. 9. Kulka RA, Schlenger WE, Fairbank JA, et al. Con tractual Report of Findings from the National Viet nam Veterans Readjustment Study. Research Tri angle Park, NC: Research Triangle Institute; 1988. Available at: http://www.ptsd.va.gov/professional/ research-bio/research/nvvrs-docs.asp. Accessed July 15, 2014. 10. Jordan BK, Schlenger WE, Hough R, et al. Life disorders among Vietnam veterans and controls. Arch Gen Psychiatry 1991;48:207-215. 11. Jordan BK, Marmar CR, Fairbank JA, et al. Prob lems in families of male Vietnam veterans with posttraumatic stress disorder. J Consult Clin Psy chol 1992; 60(6):916-926. 12. OToole BI, Catts SV, Outram S, Pierse KR, Cock burn J. The physical and mental health of Aus tralian Vietnam veterans 3 decades after the war and its relation to military service, combat, and posttraumatic stress disorder. Am J Epidemiol 2009;170(3):318-330. 13. Yaffe K, Vittinghoff E, Lindquist K, et al. Posttrau matic stress disorder and risk of dementia among US veterans. Arch Gen Psychiatry 2010;67(6):608-613. 14. Boscarino JA. Posttraumatic stress disorder and mortality among US Army veterans 30 years after military service. Ann Epidemiol 2006;16(4):248-256. 15. Army 2020: Generating Health and Discipline in the Force Ahead of the Strategic Reset-Report 2012 Washington, DC: US Dept of the Army; 2012. Available at: http://usarmy.vo.llnwd.net/e2/c/down loads/235822.pdf. Accessed July 15, 2014. 16. Horoho PD, Brock DA. Army Medicine Strategy, Army Surgeon General; 2012. Available at: http:// Army%20Medicine%20Strategy%202020.pdf. Ac cessed December 15, 2013. 17. US Army Medical Command. Memorandum: Be havioral Health Service Line Policy, Consolidated Army Behavioral Health (BH). October 29, 2013. OTSG/MEDCOM Policy Memo 13-059. 18. Northouse PG. Leadership: Theory and Practice 6th ed. Thousand Oaks, CA: SAGE Publications, Inc; 2013. 19. Burns JM. Leadership New York, NY: Harper & Row; 1978. 20. Bass BM, Riggio RE. Transformational Leader ship New York, NY: Psychology Press; 2006. 21. Fisher E. Motivation and leadership in social work management: a review of theories and related stud ies. Adm Soc Work 2009;33:347-367. 22. Yukl G. Leadership in Organizations. 6th ed. Up per Saddle River, NJ: Prentice Hall; 2006. 23. Bass BM. Bass & Stogdills Handbook of Leader ship: Theory, Research & Managerial Applications New York, NY: The Free Press; 1990. 24. Avolio BJ. Full Leadership Development: Building the Vital Forces in Organizations Thousand Oaks, CA: SAGE Publications, Inc; 1999. 25. Code of Ethics of the National Association of So cial Workers. Washington, DC: National Associa tion of Social Workers; 2008. Available at: http:// www.socialworkers.org/pubs/code/default.asp. Ac cessed July 16, 2014. 26. Pumphrey MW. The Teaching of Values and Ethics in Social Work New York, NY: Council on Social Work Education; 1959. 27. Bargal D, Schmid H. Recent themes in theory and research on leadership and their implications for management of the human services. Adm Soc Work 1989;13:37-54. 28. Arches JL. Connecting to communities: transfor mational leadership from Africentric and feminist perspectives. J Sociol Soc Welf 1997;24:113-124. 29. Gellis ZD. Social work perceptions of transforma tional and transactional leadership in health care. Soc Work Res 2001;25:17-25. 30. Mary N. Transformational leadership in human ser vice organizations. Adm Soc Work 2005;29:105-118. 31. McGuire LE, Howes P, Murphy-Nugen A, George K. Leadership as advocacy: the impact of a title IV-E supported MSW education on a public child welfare agency. J Public Child Welf 2011;5:213-233. 32. Holosko MJ. Social work leadership: iden tifying core attributes. J Hum Beh Soc Env 2009;19:448-459. 33. Competent, and Agile Washington, DC: US Dept of the Army; October 12, 2006. 34. Association of Social Work Boards. Exam Candi dates: Pass rates [2013]. Available at http://www. aswb.org/exam-candidates/about-the-exams/passrates/. Accessed June 12, 2014. AU THORS COL Humphries is Program Director, Army-Fayetteville State University Master of Social Work Program, Army Medical Department Center and School, Joint Base San Antonio Fort Sam Houston, Texas. COL (Ret) Howard is the Social Work Internship Pro gram Coordinator, Army Medical Department Center and School, Joint Base San Antonio Fort Sam Houston, Texas.

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8 http://www.cs.amedd.army.mil/amedd_journal.aspx The structure of units providing combat stress control has continued to develop through lessons learned from 1 2 2 in 1965 was made up of 23 behavioral health personnel: 2 teams in the new table of organization and equipment 2 Prevention Section was designed to support troops far 3 3 the doctrine established in Field Manual (FM) 4-02.51 4 FM 4-02.51 Evolution of the Combat and Operational Stress Control Detachment ABSTR A CT

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October December 2014 9 FM 4-02.51 FM 4-02.51 CONFLICTING STR U CT U RES OF THE COSC DET A CHMENT FM 4-02.51 4 splits command and control elements and limited support per ventive Section is comprised of 4 teams of 4 personnel of split-based advanced behavioral health treatment and 4 tachment has a much different structure than that found Restricted access document Table 1 Current Combat and Operational Stress Control Detachment Organization and Structure as Established in FM 4-02.51 4 Headquarters Section Fitness Section Preventive Section AOC or MOS Position AOC or MOS Position AOC or MOS Position 05A Commander 60W Psychiatrist 73B Psychologist 70B Field Medical Assistant 65A Occupational Therapist 73A Social Worker 68X40 Detachment Sergeant 66R Psychiatric Nurse Practitioner 68X20 Behavioral Health NCO 92Y20 Supply Sergeant 68L20 Occupational Therapy NCO 68X10 Behavioral Health Specialist 42A10 Human Resource Specialist 68L20 Occupational Therapy NCO 73B Psychologist 91B10 Wheeled Vehicle Mechanic 68X20 Behavioral Health NCO 73A Social Worker 92G10 Cook 68X20 Behavioral Health NCO 68X20 Behavioral Health NCO 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist 73B Psychologist 68X10 Behavioral Health Specialist 73A Social Worker 60W Psychiatrist 68X20 Behavioral Health NCO 65A Occupational Therapist 68X10 Behavioral Health Specialist 66R Psychiatric Nurse Practitioner 73B Psychologist 68L20 Occupational Therapy NCO 73A Social Worker 68L20 Occupational Therapy NCO 68X20 Behavioral Health NCO 68X20 Behavioral Health NCO 68X10 Behavioral Health Specialist 68X20 Behavioral Health NCO 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist AOC indicates area of concentration (officers). MOS indicates military occupational specialty (enlisted).

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10 http://www.cs.amedd.army.mil/amedd_journal.aspx 5 therefore allows easier split-based operations between detachment in that each is capable of both restoration aligned restoration services into one section and treat PROPOSED STR U CT U RE OF THE COSC DET A CHMENT modular treatment teams consisting of 1 to 2 providers area of operations is large enough to support 2 restora Table 2 Current Combat and Operational Stress Control Detachment Organization and Structure as Published in FY 15 TO&E. Headquarters Section Main Support Element Forward Support Element AOC or MOS Position AOC or MOS Position AOC or MOS Position 05A Commander 60W Psychiatrist 60W Psychiatrist 68X40 Detachment Sergeant 68L20 Occupational Therapy NCO 68X20 Team Chief 70B Executive Officer 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist 92Y20 Supply NCO 73B Psychologist 73B Psychologist 91B10 Vehicle Mechanic 68X20 Team Chief 68X30 Behavioral Health NCO 91D10 Generator Mechanic 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist 56A Chaplain 73A Social Worker 73A Social Worker 56M10 Chaplain Assistant 68L10 Occupational Therapy Specialist 68X20 Team Chief 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist 67D Behavioral Science Officer 67D Behavioral Science Officer 68X20 Team Chief 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist 68L10 Occupational Therapy Specialist 66R Psychiatric Nurse Practitioner 66R Psychiatric Nurse Practitioner 68X20 Team Chief 68L20 Occupational Therapy NCO 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist 65A Occupational Therapist 65A Occupational Therapist 68X30 Behavioral Health NCO 68X20 Team Chief 68X10 Behavioral Health Specialist 68X10 Behavioral Health Specialist Position not staffed in garrison. Staffed with predesignated active duty health professionals by the AMEDD Professional Filler System for deployments. AOC indicates area of concentration (officers). MOS indicates military occupational specialty (enlisted). EVOLUTION OF THE COMBAT AND OPERATIONAL STRESS CONTROL DETACHMENT

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October December 2014 11 would seem to be more akin to that listed within current doctrine with a functional organization consisting of a restoration-focused section and a separate treatmenteas into 2 identical combined sections as per the current a generator mechanic is of obvious use in an austere en 5 The loss of a human resources technician in communication equipment required for the detachments process can nonetheless be used given that new materiel 6 To summarize the above discus doctrine orga nization Although training materiel leadership and edu cation is evident that some personnel facilities policy cations specialist to operate and maintain the assigned tion Platoon in turn incorporates all the occupational Platoon consolidates all other providers and behavioral CONCL U SION AMEDD Journal cited the need to redesign medical units to make them ible and responsive when supporting combatant com 7 bat and operational stress control in a wide range of through a return to doctrinal principles with the addi tion of a few added capabilities as described above and Chemical, biological, radiological, nuclear Military occupational specialty

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12 http://www.cs.amedd.army.mil/amedd_journal.aspx and manning can also be prioritized between platoons revalidate processes and unit structures to maintain Ve hicle Me chanic ( 91 B10 ) Exe cu tive Officer ( 70B) Tr aining NCO ( 68X20 ) Patie nt Admin/ Ord e rly ( 68 G 10 ) Ge ne rator Me chanic ( 91 D 10 ) Su pply NCO ( 92Y 20) Co mmu nication ( 25U10) Co mmand e r ( 05A) De tachme nt Serge ant ( 68X40 ) *Be havio ral Science Office r ( 67D) *Psychiatric Nu rse Practitio ne r ( 66R ) Office r-in-Charge Clinical Operatio ns ( 73A ) Plato o n Serge ant ( 68X30) Te am Chie f ( 68X20) Te am Chie f ( 68X20) Te am Chie f ( 68X20) Te am Chie f ( 68X20) *Psychiatrist ( 60W) Psycho lo gist ( 73B ) *So cial Wo rke r ( 73A ) *Psychiatric Nu rse Practitione r ( 66R ) *Be havio ral Science Officer ( 67D) Be havio ral He alth Spe cialist ( 68X10) Be havio ral He alth Spe cialist ( 68X10) Be havio ral He alth Spe cialist ( 68X10) Be havio ral He alth Spe cialist ( 68X10) Proposed structure for the Combat and Operational Stress Control Detachment. Designators in parentheses are either area of Position not staffed in garrison. Staffed with predesignated active duty health professionals by the AMEDD Professional Filler System for deployments. Chaplain Assistant ( 56M10) Chaplain ( 56A ) Occu patio nal The rapy Spe cialist ( 68L10) Occu patio nal The rapy NCO ( 68L20) *Occu patio nal The rapist ( 65A ) Plato o n Serge ant ( 68X30) Re sto ratio n Office r-in-Charge ( 65A ) Te am Chie f ( 68X20) Te am Chie f ( 68X20) *Psychiatrist ( 60W) Psycho lo gist ( 73B ) Be havio ral He alth Spe cialist ( 68X10) Be havio ral He alth Spe cialist ( 68X10) Be havio ral He alth Spe cialist ( 68X10) Be havio ral He alth Spe cialist ( 68X10) Be havio ral He alth Spe cialist ( 68X10) Be havio ral He alth Spe cialist ( 68X10) Restoration (65A) EVOLUTION OF THE COMBAT AND OPERATIONAL STRESS CONTROL DETACHMENT

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October December 2014 13 REFERENCES War Psychiatry. War Psychiatry. Mil Med. Field Manual 4-02-51. Combat and Operational Stress Control combat operational stress control throughout the Work. Manual for the Operation of the Joint Capabilities Integration and Development System US Army Med Dep J AU THORS

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14 http://www.cs.amedd.army.mil/amedd_journal.aspx Over the past decade, much has been written about the psychosocial sequelae experienced by military person Shortly after operations commenced, Hoge and col that had deployed to Iraq or Afghanistan and found that many met the screening criteria for major depression, generalized anxiety, or posttraumatic stress disorder 1 bat deployments to alcohol misuse, 2,3 sleep disturbance, 4 aggression, 5 6 mild traumatic brain injury (mTBI) and its related psychological and physi 7 ings of Hoge et al associating PTSD and depression 8-12 In a descriptive study of behavioral healthcare use by Soldiers conducting coun terinsurgency (COIN) operations the authors reported anxiety and adjustment disorders to be common reasons 13 Deployment experiences such as combat exposure and multiple com exhibiting post-traumatic stress symptoms after return 14 Evidence suggests that some individuals may be more vulnerable to psychological distress due to ers and those serving in combat occupations have been new-onset PTSD and depression after serving in a com 15 Others believed to be susceptible to postde suicidal ideation, displayed behavioral disturbances, or experienced strained partner relationships while de 16 Furthermore, those who engage in warzone experiences that violate deeply held 17 While a great deal has been learned about the personal struggles stemming from current wartime service, we tially an important distinction given the evolution of the military strategy, tactics, techniques, and procedures employed over the course of 2 lengthy overseas con surge in combat deployments to Operation Iraqi Free dom in 2007, COIN emerged as the nations prevailing Iraq, at the time considered somewhat controversial, 18 is widely credited with establishing a more secure and stable environment prior to the 2011 withdrawal of US learned from the successes gained in Iraq, COIN was formally adopted in Afghanistan, supported by a mod objective of COIN is to sever the connection between insurgents and the populace by providing security and 19 Adjusting tactics to The Psychosocial Challenges of Conducting Counterinsurgency Operations Larry Applewhite, PhD ABSTR A CT Counterinsurgency (COIN) operations have served as the fundamental component of the nations military study of descriptive data obtained from a retrospective records review of 140 service members deployed to The most common problems reported by Soldiers were operational stress characterized by anxiety, fear, ir

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October December 2014 15 culture of coalition forces, reallocating resources, and 20 In both theaters of operations, transitioning from conventional to irregu lar warfare created multiple challenges for the small unit military forces must understand local cultural dynam 21 22 COIN needs leaders mands of being combat effective and culturally com 23 From a tactical perspective, this means small ver Soldiers to clear buildings of suspected insurgents 24 to justify detaining a suspected insurgent and, perhaps more importantly, to cultivate tactical sources, or con improvised explosive devices (IEDs) before they can 25,26 of COIN theory, to establish trust, improve life in the communities, and create a sense of security for the local populace, requires conducting dismounted patrols, tar geted searches, and, when necessary, engaging the en emy within the constraints of strict rules of engagement 25 Achieving these seemingly security patrols with engaging the local people neces 26 Soldiers operating in such tuitive, must be resilient and adaptable to the prolonged psychological and moral demands exerted by the COIN 27 Clearly, if COIN is to remain a central component of the nations military strategy, it is necessary that we further explore the threats to healthy psychosocial functioning study we describe the psychosocial problems reported by service members both during and after their deploy lenges experienced by the Soldiers from the perspective by offering observations to consider in supporting fu METHODOLOGY In this exploratory study we used a retrospective records review protocol to identify and describe the problems in psychosocial functioning reported by 140 service members during and after their deployment to Operation health records of 139 Soldiers and one airman who were assigned to, or supported, an active component brigade combat team (BCT) that operated from a forward operat ing base (FOB) located in the Logar Province of Eastern months of a deployment in theater from September 2011 support from the BCTs combat/operational stress con ed behavioral health specialists, augmented by a US Air Force combat stress team consisting of one active-duty The behavioral health providers supported a large geo graphical area that included the FOB and 12 combat a behavioral health clinic collocated with the FOBs level II medical facility, the teams routinely conducted 48 hours to maintain contact with Soldiers assigned to clinical records and provider notes available through the Armed Forces Health Longitudinal Technology Appli cation (AHLTA) system of those who received behav ics, referral information, presenting problem, primary diagnosis, exposure to combat, number of deployments, intervention provided, and postdeployment behavioral RES U LTS Demographics The clinical population consisted of 119 (85%) males

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16 http://www.cs.amedd.army.mil/amedd_journal.aspx (66%), were relatively young, aged between 19 and by 17 (12%) African Americans, 6 (4%) Hispanics, 3 Forty-two (30%) reported being single, never married police, motor transport operator, wheeled vehicle me chanic, unit supply, or logistical specialist, with a sig Fourteen medical personnel, including combat medics who directly supported the COPs, comprised 10% of the (96%), were enlisted with 37 (26%) being in the junior many, 47 (34%), had previous deployment experience Referral Information ion aid stations and the Level II troop medical clinic re 23 (16%) referrals whereas Chaplains sent a relatively Nearly half, 67 (48%), of those seen by behavioral health had been involved in combat either through direct con Presenting Problem Operational stress, characterized by anxiety, fear, irri tability, frustration and feeling isolated, was the most commonly reported problem affecting 39 (28%) Sol viduals sought behavioral healthcare for depression or nessing a traumatic event, including several who saw combat casualties and one who witnessed an Afghan an array of psychological reactions including anxiety, depression, nightmares, exhaustion, trouble concentrat ing, and intrusive images of the event that led 12 (9%) ported marital problems that either developed or escalat ed during the deployment, creating multiple symptom atic responses including anger, sadness, decreased appe Those expressing suicidal ideation variously reported being depressed, irritable, on edge, frustrated as well being under investigation, and negligently discharging a weapon were circumstances that contributed to some Soldier assigned to the BCT did commit suicide but had abuse, in spite of strict prohibitions against alcohol and drug possession, resulted in 2 (1%) referrals for evalu ation; one for alcohol intoxication, the other for inhal behavioral health services for various reasons; 2 were concerned about having an mTBI, 2 reported somatic complaints, and 2 had concerns regarding family prob PRIM A RY DI A GNOSES This deployment predated the release of the Diagnostic vironmental and operational conditions, behavioral tors of distress but whose symptoms did not constitute a met the diagnostic criteria for a Depressive Disorder, THE PSYCHOSOCIAL CHALLENGES OF CONDUCTING COUNTERINSURGENCY OPERATIONS

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October December 2014 17 Soldiers reported disturbed sleep, Primary Insomnia was diagnosed for those interested only in improving those who presented with symptoms related to failing diagnostic assessment had yet to be completed for a Sol dier who was initially seen but unfortunately was later Intervention and Disposition Behavioral health intervention was predominantly ac cessed on the main FOB but was also offered at the some individuals, 36 (26%), were seen only once, on average, Soldiers attended 4 sessions, including the ini times for brief individual supportive therapy that used more extensive support as evi denced by attending 25 sessions; however, the individual was able to remain in theater and contrib control and stress management, was sporadically conducted de pending upon provider availabil scribed by battalion surgeons and mented the treatment of 58 (41%) division psychiatrist was acces sible via telebehavioral health for consultation on cases involving jority, 117 (84%), remained on, or 3 (2%) had restrictions limiting (9%) Soldiers had to be medically evacuated for psychiatric reasons with 5 (3%) redeploying early for disposition was unclear in 3 (2%) Postdeployment Follow-up ployment engaged services for psychosocial challenges 69 (49%), were seen at behavioral health clinics for a wide range of problems including adjustment disorders, PTSD, depression, anxiety, sleep disturbance, and oc Family Advocacy Program (FAP), 3 for spouse abuse 11 (8%) were seen by both behavioral health and ASAP, 6 (4%) by behavioral health and FAP, and 2 (1%) were behavioral health for depression and was evaluated at tion indicating that the remaining 44 (31%) Soldiers re COMMENT As expected, behavioral health clients treated in theater were typically young, male, enlisted Soldiers on their pursue services at their own voli tion for an array of psychosocial problems that ranged from com bat-related psychological trauma Consistent with previous re ports, 6,13,16 underrepresented in the clinical protective factors that minimize the impact of psychological dis tress during combat deployments, or social barriers-to-care contin ue to exist that inhibit them from NCOs, rarely engage the behav ioral healthcare system while de The increasing number of mili tary suicides over the past sev eral years is widely recognized; therefore, it is not surprising that suicidal ideation complicated the Distribution of Diagnoses. Primary Diagnosis No. Diagnosed (N=140) %N Occupational Problems 25 18% Adjustment Disorder with Depressed Mood 8 6% with Anxiety 3 2% with Anxiety and Depressed Mood 4 3% Unspecified 9 6% PTSD 18 13% Partner Relational Problems 15 11% Depressive Disorder, NOS 10 7% Major Depressive Disorder 1 <1% Dysthymic Disorder 1 <1% No Diagnosis 11 8% Combat/Operational Stress 9 6% Anxiety Disorder, NOS 9 6% Primary Insomnia 8 6% Relational Problems 2 1% Life Circumstances Problems 2 1% Intermittent Explosive Disorder 1 <1% Social Phobia 1 <1% Missing Data 3 2% Criteria: Diagnostic and Statistical Manual of Mental Disorders IV-TR (DSM-IV-TR) Not listed in DSM-IV-TR.

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18 http://www.cs.amedd.army.mil/amedd_journal.aspx health providers, coordinating closely with unit lead ership, initiated safety plans and provided treatment safely remain in country to hopefully achieve a sense of mastery over their distress and build resiliency by con tributing to their units success for the remainder of the theless, the unfortunate suicide of a Soldier assigned to The combination of numerous deployment stressors such as a harsh climate, austere living conditions, and duty at isolated outposts, compounded by family separa tion, created conditions ripe for operational stress reac strain healthy relationships and may hinder the healing the deterioration of an intimate relationship from afar seems to lead to a sense of helplessness and depression as Soldiers struggle with the inability to return home to substances, albeit small in number, may be particularly programs in the combat zone places the onus on the be havioral health team to deliver services to this popula tion and can jeopardize the continuity of care for those Perhaps the most surprising feature of the deployment was the apparent frequency and intensity of combat 28 The extent to which Soldiers reported experiencing enemy contact indicates ronment that required offensive and defensive measures between combat and PTSD 1,29-31 suggests that enemy been exacerbated by a perceived insider threat spurred 32 Nevertheless, there may be other intrinsic aspects of a COIN deployment that uniquely contribute to adverse perhaps represented by the NCOs in this study, must cope with the demands of performing the dual role of maneuvers to secure the local populace, enforce strict rules of engagement, exercise cultural competency with members of the host nations security forces during 33,34 Furthermore, 17 on moral injury adds another interesting dimension for considering possible threats to when an individual conducts acts contrary to, or fails to prevent others from violating, deeply held values and 17 in part, by instilling a warrior ethos that becomes the within the code include a dedication to ones mission, defeating the enemy, perseverance, and an obligation to to establish rules of engagement to constrain overly 28 There may be circumstances when Soldiers it means to them to be a warrior, while being tactically sound, or adhere to the strategically imperative rules ence frustration, guilt, and the anxiety of facing pos Establishing access to behavioral healthcare for Sol diers dispersed throughout a large geographical area combat stress team enabled the BCT providers to insti tute outreach to the outlying COPs while maintaining therapeutic interventions using cognitive behavioral and strengthening resiliency as the vast majority of cli Options for group therapeutic approaches were limited THE PSYCHOSOCIAL CHALLENGES OF CONDUCTING COUNTERINSURGENCY OPERATIONS

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October December 2014 19 only by the need to divide behavioral health coverage between supporting the main clinic and conducting out ic treatment, incorporated as an adjunct to the combat stress program, was readily available through coordina proved to be an effective tool for engaging psychiatric many, it appears that the psychosocial challenges they experienced while deployed may have followed them An exploratory study using descriptive data derived from a retrospective review of healthcare records certainly as being representative of the entire BCT and therefore our ability to generalize beyond the study group is lim afterwards may have differed appreciably both demo health records available in AHLTA only included those who received treatment within the militarys behavioral healthcare system after returning home; others may have OBSERV A TIONS While recognizing that more rigorous analysis is needed the following observations for further consideration: Accounting for behavioral health support should be a priority in planning a COIN deployment due to the uniquely complex and stressful operational characteristics, including combat exposure, that Establishing adequate behavioral health support with providers from others services, therefore, op Effectively supporting COIN operations requires behavioral health providers who have clinical ex perience in military settings and are capable of chological trauma and conducting traumatic event Innovative practices, such as telebehavioral health and circuit riding, need to be further developed and Further development of a seamless system of be havioral healthcare is critical for ensuring early in tervention and continuity of care for Soldiers deter CONCL U SIONS A military capable of conducting COIN to support emerging democracies is an essential strategic compo an insurgency entails exposing Soldiers to a dynamic, multifaceted, and potentially dangerous environment that can mentally and emotionally strain those respon of factors that threaten psychological health, behavioral health support has emerged as an essential component a COIN deployment requires establishing access to be havioral healthcare that can respond to a wide-spectrum intrinsic to COIN missions, the behavioral health team should consist of experienced personnel who can re Further, it is important that those individuals believed REFERENCES ghanistan, mental health problems and barriers to New Engl J Med cohol use and alcohol-related problems before JAMA pact of deployment on the psychological health sta tus, level of alcohol consumption, and use of psy Mil Med Predictors of sleep disturbances in Operation Iraqi Freedom/Operation Enduring Freedom veterans Mil Med disorder, depression, and aggression in OEF/OIF Mil Med

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20 http://www.cs.amedd.army.mil/amedd_journal.aspx J Psychiatr Res New Engl J Med Am J Psychiatry the tangible consequences of invisible combat Rand Review ment intensity on post-traumatic stress disorder: Mil Med tom increases in Iraq-deployed soldiers: compari son with nondeployed soldiers and associations with baseline symptoms, deployment experienc J Trauma Stress problems and functional impairment among active Arch Gen Psy chiatry care use by Soldiers conducting counterinsurgency Mil Med BMC Psych post-traumatic stress disorder and depression Mil Med J Hum Behav Soc Environ Mil Med Armed Forces Soc The Gamble: General David Petraeus and the American Military Adventure in Iraq Little America: The War Within the War for Afghanistan Army Mag Io Sphere Mil Psychol Infantry In fantry Infan try Mil Rev Field Manual 3-24.2: Tactics in Counterinsurgency nam veterans: Analysis of premilitary, military, J Consult Clin Psychol War veterans: a population-based survey of 30,000 Am J Epidemiol Baseline self-reported functional health and vul nerability to post-traumatic stress disorder after combat deployment: prospective US military co BMJ Mental Health Advisory Team (MHAT) 9: Opera tion Enduring Freedom (OEF) 2013 THE PSYCHOSOCIAL CHALLENGES OF CONDUCTING COUNTERINSURGENCY OPERATIONS

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October December 2014 21 AU THORS

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22 http://www.cs.amedd.army.mil/amedd_journal.aspx Over the past decade, the use of energy products and metabolism-inducing dietary supplements, which often doxine, nicotinamide, B vitamins, and herbal deriva tives, 1 has reapidly escalated worldwide. Energy drinks have led this trend, comprising a $4.8 billion industry in the United States in 2008, and was predicted to grow to $19.7 billion by 2013. 2 Alternative energy products, such as shots, gels, powder packets, pills, and gum, are also on the rise. Nearly 35% of teenagers, more than 50% of college students, and 45% of deployed service members are estimated to regularly consume energy drinks. 3-6 The military demographic is the prime target for ener gy drink advertising campaigns, 7 but as of this writing there are only 2 published studies addressing the use of energy products by deployed personnel. 5,6 Troops have used energy products such as caffeine and nicotine for ages in an effort to combat the fatigue and sleep deprivation that is inevitable in a combat environ ment. Thirty-one percent of Army Soldiers in one recent study reported taking dietary supplements to increase energy 7 and the presence of sleep disturbances in de ployed populations is well-established. 8-11 Investigators have demonstrated that individuals who have been awake for 23 hours have psychomotor impairments equivalent to people who are legally intoxicated. 12 Even continued partial sleep deprivation, ie, sleeping only 4 to 5 hours a night on a continual basis, can have demon strable results on cognitive performance. 13 Since 2009, US Army doctrine has recommended the prescribed use of over-the-counter stimulants to promote wakeful 14 However, modern warfare often requires troops to re main highly alert for much longer periods of time, likely contributing to the growing popularity and expanding Commercially available energy products are infused with various amounts of caffeine. 15 Caffeine is char acterized by the Food and Drug Administration as a oz. 16 However, while most caffeinated sodas fall below this threshold, many energy products clearly exceed it. In fact, only 3 of the 28 most popular non-soda energy drinks in America contain less than 71 mg of caffeine Sleep and the Use of Energy Products in a Combat Environment LTC Wendi M. Waits, MC, USA Michael B. Ganz, PhD Theresa Schillreff, OTR/L CPT Peter J. Dell, MS, USA ABSTR A CT Background: The use of energy products appears to be widespread among deployed personnel, presumably to combat fatigue and sleep deprivation. However, these products have been associated with unpleasant side ef fects and adverse events, including insomnia, mood swings, fatigue, cardiac arrest, and even death. Objective: To quantify the sleep habits and energy products used among deployed service members in Afghani stan from 2010-2011. Methods: Participants completed an anonymous survey querying their demographic information, sleep habits, combat exposure, and energy product use. Results: Respondent data: 83% experienced some degree of insomnia; 28% were using a prescription or overthe-counter sleep aid; 81% reported using at least one energy product daily. The most frequently consumed energy products were caffeinated coffee and soda. Only 4 energy products were used more frequently during deployment than prior to deployment: Rip-It, Tiger, Hydroxycut, and energy drink powders. On average, re spondents who increased their use consumed only 2 more servings per week during deployment than they had prior to deployment. Only degree of combat exposure, not quantity of energy products consumed, predicted degree of insomnia. Conclusion: Energy product consumption by service members during deployment was not dramatically differ ent than predeployment and was not associated with insomnia.

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October December 2014 23 per 12 oz. 16 Caffeine has a number of unpleasant side effects when taken in excess, 17,18 and energy products have been increasingly associated with serious adverse effects, including tachycardia, hypertension, seizures, bowel ischemia, mania, psychosis, cardiac arrest, and sudden death. 19-27 It has even been suggested that caffeine may contribute to the development of combat stress re actions such as posttraumatic stress disorder (PTSD). 28 Physiological risks seem especially high when energy products (including dietary supplements) are taken prior to vigorous exercise or combined with other psychoac tive substances. 29 Since deployed troops often ingest en ergy products containing a cocktail of psychoactive sub stances, and since they are frequently physically active during deployment, it is imperative that their consump tion of these substances be more closely investigated. The authors endeavored to quantify the overall use of energy products among deployed personnel, as well as to see if environmental factors such as sleep habits, combat exposure, and sleep deprivation placed certain populations at risk for heavier use. METHODS Research Design This study involved the administration of an anonymous survey to evaluate energy product use and sleep behav iors among deployed International Security Assistance Force personnel. Although deployed personnel may have different reasons for consuming wake-promoting ener gy products and metabolism-inducing energy products, we chose to inquire about both types because they can both affect sleep and they share a similar adverse effect as possible in nonclinical settings (ie, in supported units as gyms, MWR facilities) at forward operating bases visited by the investigators throughout Afghanistan. Participants Inclusion criteria included English-speaking military and civilian personnel deployed or working in Afghani stan in support of Operation Enduring Freedom. Local nationals, non-English speakers, and individuals aged less than 18 years were excluded from participation. In vestigators emphasized that participation was entirely voluntary and that surveys were anonymous. Partici walk-about missions (staging areas, motor pools, of encountered during daily activities (military quarters, dining facilities, recreation facilities, laundry facilities, also used at some locations. Instruments The survey administered was created by 2 of the authors (W. M. W. and M. B. G.) and included questions about demographics, occupation, frequency of shift changes, number of roommates, use of sleep aides, combat expo sures, sleep habits, and energy product use. The survey incorporated the Combat Exposure Scale 30 and the Pitts burgh Sleep Symptom QuestionnaireInsomnia (PSSQI), also known as the Insomnia Symptom Question naire. 31 Study variables came directly from the survey. Data Collection Once recruited, participants were given the choice of returning their survey to the survey box or to the inves tigator. Completed surveys were secured by the investi gators in their respective clinical areas. Data collection ceased once the target number of surveys was reached. RES U LTS Participants (N=183) in this study were mostly male with a median age of 27 years and an age range of 18-58. Junior enlisted service members were the most frequent they completed the survey, but their length of time in country varied, with an average of 6.6 months. Other relevant demographic data is highlighted in the Table. The majority of participants (66%) indicated that they were required to change their occupational hours at least once. Respondents reported the following rates of shift change: never=44%, less than once per month=25%, every 1 to 14 days=23%, and every 15 to 30 days=9%. Most participants had multiple roommates: 45.4% of the sample reported having 4 to 9 roommates, 19.7% stated they had 2 or 3 roommates, 13.1% stated they had only one roommate, 12.0% had 10 or more roommates, and 9.3% lived alone. Figure 1 depicts the raw data of sample-wide number of consumers by product type reported by participants both 30 days prior to and during their deployment. There were raw-value increases in number of total consumers from the predeployment period to the deployed period for only 6 of the 15 assessed energy products (Figure 2). However, the total number of consumers across all energy products was statistically unchanged from the predeployment and deployment periods ( t =0.402, P =.694). Nevertheless, energy products were consumed at a faster rate during deployment compared to prede ployment: That is, 24.0 servings per week on average during deployment compared to 16.6 servings per week prior ( t =-3.34, P =.001). The energy products that were

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24 http://www.cs.amedd.army.mil/amedd_journal.aspx consumed most often by the entire sample, both during deployment and at home, were caffeinated coffee and soda. However, during deployment, rates of consumption in the prework out supplement Hydroxycut and the free and widely available energy drink Rip-It ( t =-2.051, P =.042 and t =-3.434, P =.001, respectively). Surprisingly, we found no statisti cal difference in energy product use among respondents of different rank, gender, or military occupa tional specialty. Additionally, energy product users were no more likely than nonusers to have frequent shift changes or use sleep aids. However, consumption of energy products was positively correlated with the total number of sleep-inhibiting bedtime habits ( r =0.204, P =.006). Addi tionally, respondents with no room mates ( P =.047) and those with 10 or more roommates ( P =.047) were less likely to use energy products than those with one roommate, although unclear. Finally, despite the lack of statistical difference among differ ent occupations, several groups were found to be particularly frequent (food service, transportation, signal/ communications, and aviation) and infrequent (supply/logistics, military police/security, maintenance, de tainee operations, and ground com bat) consumers of energy products. Participants were asked about their engagement in activities believed to either promote or inhibit sleep within one hour of bedtime (Figure 3). Two was the median number of sleep-inhibiting behaviors in which participants engaged at bedtime across the entire sample. Only 15 respondents denied having any negative bed time habits. They were more likely to be female, older in age, and from the following occupations: ground troops, transportation, and medical. Insomnia symptoms were assessed with the PSSQ-I. Based on established cut-offs, 24% of the sample met criteria for an insomnia diagnosis worthy of clinical attention. Pro portions of the sample that reported moderate to extreme levels of in somnia symptoms are represented in Figure 4. Figure 5 details the distri bution of moderate to extreme types of psychosocial impairment that re spondents reported were caused by their insomnia. The most commonly reported impairments were feel ing fatigued during the day, feeling insomnia bothersome, feeling their concentration was affected, and feel ing their occupational functioning was affected. As many as 83% of the sample re ported that at least one area of their life was negatively affected by their insomnia symptoms at moderate to extreme levels, and 63% indicated that at least one area of impairment was extreme. Eighty-three percent of the sample also indicated that at least one of their insomnia symp level, and 20% of the sample re ported that the frequency of their symptoms was Always (5-7 nights per week). However, only 28% of the sample used either a prescription or over-the-counter sleep aid. As expected, insomnia symptoms and severity were positively cor related with the use of a sleep aide ( r =0.322, P =.005). However, no sig insomnia and any other pertinent variable, including frequency of shift changes ( r =0.126, P =.295), num ber of roommates ( r =0.18, P =.879), level of combat exposure ( r =-0.041, P =.734), number of sleep-inhibiting bedtime habits ( r =-0.150, P =.213), and quantity of en ergy products consumed ( r =-0.145, P =.229). COMMENT sive analysis of energy product use by military personnel in a deployed environment. It is a preliminary study con ducted with a relatively small population, but nonetheless Distribution of Demographic Data for Study Participants Variable (N= 183 ) n %N Gender Male 148 81% Female 22 12% Not indicated 13 7% Age (years) 18-25 76 42% 26-35 71 39% 35-45 27 15% 46+ (maximum is 58) 8 4% Omitted 1 0 Rank E1-E4 84 46% E5-E9 76 42% WO1-WO3 16 9% O4 and above 2 1% Military/Civilian Military 179 98% Civilian 1 0 Not indicated 3 1% Average time in theater 6.6 months Job in theater Ground combat operations 20 11% Aviation 12 7% Military police/ security 10 5% Detainee operations 6 3% EOD/mine clearing operations 0 0 Civil affairs 0 0 Maintenance 16 9% Construction 1 0 Supply/logistics 27 15% Personnel/ administration 5 3% Military intelligence 3 2% Food service 2 1% Signal/ communications 6 3% Transportation 10 5% Medical 40 22% Other 25 14% SLEEP AND THE USE OF ENERGY PRODUCTS IN A COMBAT ENVIRONMENT

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October December 2014 25 tions for future deployments and research. The redistribution of energy product consumption toward a select high-use population was interest uct availability is believed to play some role, since 2 of the 4 products consumed more frequently and by more people during deployment (RipIt and Ti ger) are widely available in Afghanistan but are other 2 products (Hydroxycut and energy powders) may have been popular among respondents due to their ease of use and storage compared to some other products listed on the survey. However, prod uct availability is unlikely to be the only contribut ing factor to increased use since coffee and tea did even the most austere dining environments. There was no statistical difference between the use of energy products and the presence of insom nia. This was somewhat reassuring given the high reported rates of insomnia and the potential health consequences of energy products. However, the high percentage of respondents reporting that their insomnia caused extreme levels of impairment is particularly given the complexity and hazardous nature In addition to its effects on cognitive function and re action time, sleep deprivation has recently been asso ciated with hostility, violence, sexual dysfunction, and increased pain sensitivity. 32-34 These are problems fre quently attributed to PTSD in combat veterans, but this data raises the question as to whether or not such prob lems may actually be due to sleep deprivation rather than trauma exposure. Clearly more research in this area is required. We were surprised by the lack of correlation between insomnia and traditional sleep-inhibiting variables, in cluding shift changes, roommates, combat exposure, bedtime habits, and quantity of energy products con sumed. We were also surprised by the lack of positive correlation between insomnia and energy product con sumption. We had predicted that respondents with in somnia would be high consumers of energy products because of their wake-promoting (and sleep inhibiting) properties, but such was not the case. Although there was a positive correlation between in somnia and the use of sleep aids, 83% of respondents than 30% reported regularly using a sleep aid, suggest ing that more than half of the respondents were suffer ing the effects of chronic, unmitigated sleep deprivation. We considered the possibility that the relatively low use of sleep aids was because respondents did not want to impair their ability to function if awakened emergently from sleep. However, the use of sleep aids was actually highest in 2 populations most likely to be awakened emergently: ground combat troops (45%) and medi unclear. The facts that respondents engaged in an average of 2 sleep-inhibiting activities before bedtime and that near ly one-third of respondents changed shifts at least once a month were somewhat concerning. Perhaps similarly concerning was the fact that higher-ranking respondents consumed energy products at the same frequency as lower-ranking respondents. Enhanced education about healthy sleep habits, the consequences of insomnia, and the potential dangers of energy products may be war ranted for both leaders and junior enlisted personnel. Limitations of this study include its relatively small sample size, retrospective survey design, potentially Figure 1 Total number of consumers of energy products by product type or brand name. 100 80 60 40 20 0 Deployment Predeployment Other Drink Tiger Gum Tea Red Bull NO-Xplode Rockstar Pill Rip-it Hydroxycut Shot Powder Soda Monster

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26 http://www.cs.amedd.army.mil/amedd_journal.aspx biased sampling (22% had a medical occupation), and reliance on self-report rather than laboratory measure ment and direct observation. Future research is needed to improve upon these design elements and to further as sess the relationship between insomnia, deployment en vironments, and energy products. Future investigations should assess the reason for individuals use of en ergy products (ie, wake promotion vs weight loss vs workout enhancement), and whether or not there is any correlation between these reasons and out comes such as sleep quality and duration. It would also be informative to track energy product use prospectively over time, including predeployment, during-deployment, and postdeployment consump tion. Subsequent investigations should also include inquiries about respondents desired amount of sleep, availability of sleep time, and satisfaction with sleep patterns. Finally, future research should endeavor to answer the question of whether or not prescription, wake-promoting medications have a role in modern combat operations. CONCL U SION Insomnia among our deployed population is ubiq uitous and multifactorial. Surprisingly, we found the use of energy products during deployment to be neither extreme nor clearly associated with in somnia, though it could still be argued that these products have the potential for unexpected health consequences and may warrant better regulation. Sleep, whether during deployment or after one re turns home, is imperative for the restoration and re newal of our physical and mental abilities. It is our hope that this article will contribute to the ongoing and will be used as a basis for continued research in the future. REFERENCES 1. Aranda M, Morlock G. Simultaneous determina feine and taurine in energy drinks by planar chro by electrospray ionization mass spectrometry. J Chromatogr A 2006;1131:253-260. 2. Heckman MA, Sherry K, Gonzalez de Mejia E. Energy drinks: an assessment of their market functionality, and regulations in the United States. Compr Rev Food Sci Food Saf 2009;9:303-317. 3. Seifert SM, Schaechter JL, Hershorin ER, Lipshultz, SE. Health effects of energy drinks on children, adolescents, and young adults. Pediatrics 2011;127(3):511-528. 4. Malinauskas BM, Aeby VG, Overton RF, Carpen ter-Aeby T, Barber-Heidal K. A survey of energy drink consumption patterns among college stu dents. Nutr J 2007;6:35. Figure 3. Percentages of study sample-endorsed sleepinhibiting habits at bedtime, by type. 70% 80% 60% 40% 50% 20% 10% 30% 0% 72% 63% 26% 30% 5% TV/Movie Video Games Computer Exercise Fast Music Energy Product 25% Figure 2. Mean number of servings of energy products by product type or brand name consumed per week. Notes: A indicates Sig P .05 B indicates Sig P .001. A 8 18 14 16 6 12 4 10 20 0 2 A B Deployment Predeployment Other Drink Tiger Gum Tea Red Bull NO-Xplode Rockstar Pill Rip-it Hydroxycut Shot Powder Soda Monster SLEEP AND THE USE OF ENERGY PRODUCTS IN A COMBAT ENVIRONMENT

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October December 2014 27 5. Toblin RL, Clarke-Walper K, Kok BC, Sipos ML, Thomas JL. Energy drink consumption and its association with sleep problems among U.S. service members on a combat deploymentAf ghanistan, 2010. MMWR Morb Mortal Wkly Rep 2012;61(44):895-898. 6. Jacobson IG, Horton JL, Smith B, eta al, for the Millennium Cohort Study Team. Bodybuilding, energy, and weight-loss supplements are associated with deployment and physical activity in U.S. mili tary personnel. Ann Epidemiol 2012;22(5):318-330. 7. Lieberman HR, Stavinoha TB, McGraw SM, White A, Hadden LS, Marriott BP. Use of dietary supplements among active-duty US Army soldiers. Am J Clin Nutr 2010;92:985-995. 8. Lieberman HR, Tharion WJ. Effects of caffeine, sleep loss, and stress on cognitive performance and mood during U.S. Navy SEAL training. Psy chopharmacol 2002;164:250-261. 9. Kryger MH, Pouliot Z, Peters M, Neufeld H, De laive K. Sleep disorders in a military population. Mil Med 2003;168(1):7-10. 10. WL. Sleep disturbance during military deployment. Mil Med 2008;173:230-235. 11. Seelig AD, Jacobson IG, Smith B, et al. Sleep pat terns before, during, and after deployment to Iraq and Afghanistan. Sleep 2010;33(12):1615-1622. 12. Dawson D, Reid K. Fatigue, alcohol and perfor mance impairment. Nature 1997;388(6639):235. 13. Dinges DF, Pack F, Williams K, et al. Cumulative sleepiness, mood disturbance and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep 1997;20:267-277. 14. Field Manual 6-22.5: Combat and Operational Stress Control Manual for Leaders and Soldiers Washington, DC: US Dept of the Army; March 18, 2009. 15. energy drinksa growing problem. Drug Alcohol Depend 2009;99(1-3):1-10. 16. Caffeine, 21 CFR 182.1180 (2011). Available at: http://www.gpo.gov/fdsys/granule/CFR-2011-ti tle21-vol3/CFR-2011-title21-vol3-sec182-1180/con tent-detail.html. Accessed August 3, 2014. 17. Curatolo PW, Robertson D. The health consequenc es of caffeine. Ann Intern Med 1983;98:641-653. 18. Karacan I, Thornby JI, Anch M, Booth GH, Wil liams RL, Salis PJ. Dose-related sleep disturbances induced by coffee and caffeine. Clin Pharmacol Ther 1976;20(6):682-689. 19. Steinke L, Lanfear DE, Dhanapal V, Kalus JS. Effect of energy drink consumption on he modynamic and electrocardiographic param eters in healthy young adults. Ann Pharmacother 2009;43(4):596-602. 20. Iyadurai SJ, Chung SS. New-onset seizures in adults: possible association with consump tion of popular energy drinks. Epilepsy Behav 2007;10(3):504-508. 21. Magee CD, Moawad FJ, Moses F. NO-Xplode: A case of supplement-associated ischemic colitis. Mil Med 2010;175:202-205. 22. Hedges DW, Woon FL, Hoopes SP. Caffeine-in duced psychosis. CNS Spectr 2009; 14(3):127-129. 23. Cerimele JM, Stern AP, Jutras-Aswad D. Psycho sis following excessive ingestion of energy drinks in a patient with schizophrenia. Am J Psychiatry 2010;167(3):353. Figure 4. Percentages of study sample who endorsed insom nia symptoms at moderate to severe levels, by type. Not Sound Awakenings Unrefreshing Falling Asleep Staying Asleep 82% 75% 76% 65% 75% 90% 70% 80% 60% 40% 50% 20% 10% 30% 0% Figure 5. Percentages of study sample who endorsed in somnia sequelae at moderate to extreme levels, by type. Social Irritable Sleepy Bothers You Other Parts of Life 60% 40% 50% 20% 10% 30% 0% 49% 49% 48% 38% 32% 32% 39% 54%

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28 http://www.cs.amedd.army.mil/amedd_journal.aspx 24. Machado-Vieira R, Viale CI, Kapczinski F. Mania associated with an energy drink: the possible role of caffeine, taurine, and inositol. Can J Psychiatry 2001;46:454-455. 25. Berger AJ, Alford K. Cardiac arrest in a young man following excess consumption of caffeinated energy drinks. Med J Aust 2009;190(1):41-43. 26. Chelben J, Piccone-Sapir A, Ianco I, Shoenfeld N, Kotler M, Strous RD. Effects of amino acid energy drinks leading to hospitalization in indi viduals with mental illness. Gen Hosp Psychiatry 2008;30(2):187-189. 27. Dhar R, Stout CW, Link MS, Homoud MK, Wein stock J, Estes NA 3rd. Cardiovascular toxicities of performance-enhancing substances in sports. Mayo Clin Proc. 2005; 80(10):1307-15. 28. 28 Iancu I, Dolberg OT, Zohar J. Is caffeine in volved in the pathogenesis of combat-stress reac tion? Mil Med 1996; 161(4):230-32. 29. Dhar R, Stout CW, Link MS, Homoud MK, Wein stock J, Estes NA III. Cardiovascular toxicities of performance-enhancing substances in sports. Mayo Clin Proc 2005;80(10):1307-1315. 30. Keane T, Fairbank J, Caddell J, Zimering R, Taylor K, Mora C. Clinical evaluation of a measure to as sess combat exposure. Psychol Assess 1989;1:53-55. 31. Okun ML, Kravitz HM, Sowers MF, Moul DE, Buysse DJ, Hall M. Psychometric evaluation of the Insomnia Symptom Questionnaire: a self-report measure to identify chronic insomnia. J Clin Sleep Med 2009;5(1):41-51. 32. Kamphuis J, Meerlo P, Koolhaas JM, Lancel M. Poor sleep as a potential causal factor in aggression and violence. Sleep Med 2012;13(4):327-334. 33. Andersen ML, Alvarenga TF, Mazaro-Costa R, one, sleep, and sexual function in men and women. Brain Res 2011;1416:80-104. 34. Okifuji A, Hare BD. Do sleep disorders contrib ute to pain sensitivity?. Curr Rehumatol Rep 2011;13(6):528-534. AU THORS LTC Waits is with the Directorate of Behavioral Health, Fort Belvoir Community Hospital, Fort Belvoir, Virginia. Dr Ganz is with the Department of Behavioral Health, US Army Health Center, Vicenza, Italy. Ms Schillreff is a registered Occupational Therapist in Tuckahoe, New Jersey. CPT Dell is with Behavioral Health Services, BG Craw ford F. Sams US Army Health Clinic, Camp Zama, Japan. SLEEP AND THE USE OF ENERGY PRODUCTS IN A COMBAT ENVIRONMENT

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October December 2014 29 We were introduced to telebehavioral health (TBH) by our arrival in Kandahar, Afghanistan, in March 2012 telemedicine as a way to deliver care through technol DEFINITIONS Telemedicine has been referred to as telehealth and 1 across distances via telecommunication technology, Telemedicine systems were established Afghanistan to the Landstuhl Regional Medical Center 2 Gillert 3 consultation at the National Naval Medical Center was ment over distance in military settings, telemedicine al lows delivery of behavioral health care to military forces 4 Although not an exhaustive list, behavioral health services delivered through telemedicine has been re to Myers and Turvey, behavioral health services is one readily used through videoconferencing because other medical instrumentation such as x-rays or CAT scans is 1 of interactive videoconferencing software with a cam ioral health care services delivered over the TBH sys mental status exams, counseling interventions, and con ADV A NT A GES OF TBH There are many advantages described in the literature for telemedicine can include children, elderly in nursing Cost reduction is dem costs within the military health system are reduced by avoiding unnecessary medical evacuation from theater Telebehavioral Health: Practical Application in Deployed and Garrison Settings

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30 http://www.cs.amedd.army.mil/amedd_journal.aspx its demonstrated effectiveness in diagnosing and treating mental illness, and its wide Telebehavioral health can be used across ics 11,12 1,4,10 1,4,10,11 4 Hoge et al 14 to service members who met the screening criteria of cording to Myers and Turvey, telemental health should In their lit erature review of video teleconferencing (VTC) with found that higher Patients should be Gusa rova 13 consent to telemedicine services and recommended ob taining both written and verbal informed consent from Although no recommend instituting emergency Myers and Turvey dis If such considerations are not addressed, they easily be CH A LLENGES OF TBH 3,10 12 4 cluding other medical or behavioral health staff at other sites, 10 al 12 12 TELEBEHAVIORAL HEALTH: PRACTICAL APPLICATION IN DEPLOYED AND GARRISON SETTINGS

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October December 2014 31 using TBH, as they will necessarily have to undergo 1 research demonstrating the effectiveness of TBH, My ers and Turvey 9 emergencies through an on-call system with local ac APPLIC A TIONS DU RING DEPLOYMENT Initially, 4 TBH sites were established within our area do not include the TBH systems established at the com communication was transmitted over a secure, dedicated dividual who refused treatment via TBH, therefore, his that care delivered via TBH would be substandard, we discovered that, in general, we did not notice substantial did not result in evacuation from theater to a higher level of care, was not noticeably different from our face-tolished treatment goals were met, including reduction of unfamiliar mode of treatment, we soon discovered that travel arrangements that ultimately would result in delay acutely suicidal or homicidal, had intent to act on his or

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32 http://www.cs.amedd.army.mil/amedd_journal.aspx crisis events could also refer to critical incidents that Whether in crisis interventions or cases with no elevated TBH assessment a referral for medication evaluation mented, we could communicate that directly to that aid livering care via TBH technology were related to con sions in which the system was unavailable or the call cases in which the TBH system was not functioning, the included determining the location of the TBH system at struments unless coordinated through the on site medical lowed seamless transition of care between the behavior counters, the TBH system was more effective in another existed with face-to-face encounters during site visits Another challenge our unit encountered with TBH in volved the number of dedicated, secure lines available at team and medical assets on location initially tried con TELEBEHAVIORAL HEALTH: PRACTICAL APPLICATION IN DEPLOYED AND GARRISON SETTINGS

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October December 2014 33 Lastly, TBH slightly changed the delivery of care in the resolved this challenge by sending the screening inven interventions were greatly affected by the absence of was mirrored, therefore, our hand gestures had to be the These challenges were overcome and diminished over APPLIC A TIONS IN GA RRISON the software necessary to conduct message and video exchange across the internet in real time and established each unit, so we were not allocated a dedicated line for cate the tent during a behavioral health or TBH encoun AM PM. Therefore, any emergent behavioral nearest emergency room or were managed by the unit then staffed the case with a licensed behavioral health of offering some behavioral health care versus none brigade conducted a training exercise at the National

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34 http://www.cs.amedd.army.mil/amedd_journal.aspx resentative, and to assist our behavioral health team in tion which had not been obtained, so TBH could not be for behavioral health care had continued at that rate for and more austere environments, such as some locations been unable to receive timely behavioral health care at in locations where they would otherwise be referred to CONCL U SION tages than disadvantages in the use of TBH technology, REFERENCES The Mental Health Professional and the New Technologies: A Hand book for Practice Today Government Computer News Department of Defense News [serial J Rehabil Res Dev html Telemental Health: Clin ical, Technical, and Administrative Foundations for Evidence-Based Practice Ann Gen Psychiatry Department of Defense News [serial Stars and Stripes TELEBEHAVIORAL HEALTH: PRACTICAL APPLICATION IN DEPLOYED AND GARRISON SETTINGS

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October December 2014 35 BMC Health Serv Res. BMC Public Health Int J Telerehabil SHS Web of Conferences New Engl J Med AU THORS Dr Lindstrom is a Clinical Psychologist in the Arches Te lebehavioral Health Clinic, Madigan Army Medical Cen

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36 http://www.cs.amedd.army.mil/amedd_journal.aspx As a part of our nations pursuit of improvements in pa tient care outcomes, continuity of care, and cost contain ment, the case manager has become a vital member of interdisciplinary teams and in health care agencies. The case manager acts as the patients key stakeholder in coordinating, collaborating, and communicating health care needs. 1 program. Where services may not otherwise be avail ioral health treatment to behavioral health providers technology over a secure network. There was a desire but processes to collect outcomes had not been fully de veloped, especially for the nurse case manager who was integrated into the multidisciplinary team. This article is a report of the development of the process es and surveys that captured the outcomes of the nurse case managers care in a telebehavioral health program. The project began with a systematic search of the litera ture by the authors, including general and military data bases on telebehavioral health, telehealth, nurse case management, nursing, social work, health promotion, and population health. Over 50 articles, chapters, re ports, and policies were reviewed and consolidated by the project leaders for the survey development. The cy, and patient empowerment concepts that are embed Four outcome surveys were developed, based on con cepts that were synthesized by the project leaders from the literature, and using rigorous survey development methodology: became evident from the literature and initial planning that the challenge with collecting outcome information from telehealth programs revolved around the logistics of making the surveys available to patients, providers, and collaborators at multiple sites and centralizing the data for analysis. Effectiveness of Telebehavioral Health Program Nurse Case Managers (NCM): Data Collection Tools and the Process for NCM-Sensitive Outcome Measures ABSTR A CT As a part of our nations pursuit of improvements in patient care outcomes, continuity of care, and cost con tainment, the case manager has become a vital member on interdisciplinary teams and in health care agencies. Telebehavioral health programs, as a relatively new method of delivering behavioral health care, have recently unique structures in place that impact ability to collect outcome data. A military medical center that serves telehealth environment to obtain outcome data for the nurse case manager. This report describes the survey development and the processes created to capture nurse case manager outcomes. Additionally, the surveys and processes developed in this project for measuring outcomes may be useful in other settings and disciplines.

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October December 2014 37 The purposes of this project were to develop nurse case manager impact surveys and determine the processes as determine the feasibility of those processes to gath In this project, the data sources were literature, other stakeholders consisting of providers, command (leader other care team members who partnered in care or con feasible processes to distribute, administer, and collect the surveys and analyze the data that could be obtained opment of the processes was the requirement to main tain anonymity of the participants to mitigate any pos with the participants or staff involved in the conduct of quality improvement application to conduct the project project by the medical centers deputy chief of clinical and outcome of care data is considered an acceptable METHODS The project began when leadership and staff members team, which included the senior nurse scientist and the bers committed to leading the project, with their super visors support. After the literature review, it was clear to the project lead processes and outcome surveys for telehealth at multiple sites. From this information, an action plan and timeline were formulated. To obtain a comprehensive view of the surveys were needed for patients, family members, care tively case managing and directly intervening with the patient or consulting without direct patient interaction. Patient Telebehavioral Health Nurse Case Manager Impact Survey Please Circle Your Answer 1. The Nurse Case Manager helps me get the services I need. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 2. The Nurse Case Manager understands my concerns. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 3. The Nurse Case Manager suggests additional resources, educational programs, information, and/or services to me as needed. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 4. I know how to contact the Nurse Case Manager when I need to. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 5. I am better able to get the services I need because of the Nurse Case Managers help. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 6. I believe the Nurse Case Manager makes a positive impact on my well-being. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 7. I trust the Nurse Case Managers suggestions. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 8. I feel like the Nurse Case Manager cares about me. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 9. I am satisfied with the Nurse Case Managers assistance. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable INSTRUCT I ONS : Please circle the answer that best reflects your agreement with the statement indicated. This survey is confidential and will be collected by the administrative assistant for data collection purposes only. The Nurse Case Manager will have no access to your survey. Thank you for helping us serve you better! Figure 1 Patient impact survey.

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38 http://www.cs.amedd.army.mil/amedd_journal.aspx It was also determined that an action log was needed to Survey Development Methodology Following a rigorous survey development methodology, structed using processes outlined by Waltz et al. 1 The survey development process included: core functional elements establish content validity. There was a 100% consensus developed based on published research, meta-analysis; theory, standards of nursing, social work, case manage tiple standards of practice related to nursing and case management served to identify customary critical core cilitation, and advocacy items. 2-5 Items inquiring about relationship-based care, the therapeutic relationship, and the caring aspects of the nurse-patient relationship were well documented in nursing and behavioral health literature. Finally, items measuring patient education, social change, health promotion, and population health models. The impact surveys were beta tested with pa tients and providers and recommendations incorporated. included were: care coordination, and consultations. Family Telebehavioral Health Nurse Case Manager Impact Survey Impact on my Family Member Please Circle Your Answer 1. The Nurse Case Manager helps my family member get the services he/she needs. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 2. My family member is better able to help himself/herself get needed services because of the Nurse Case Managers help. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 3. I believe the Nurse Case Manager makes a positive impact on my family members well-being. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable Impact on Me Please Circle Your Answer 4. The Nurse Case Manager understands my concerns as a family member. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 5. The Nurse Case Manager suggests additional resources, educational programs, information, and/or services to me as needed to help my family member. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 6. I know how to contact the Nurse Case Manager when I need to. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 7. I trust the Nurse Case Managers suggestions. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 8. I feel like the Nurse Case Manager cares about me. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 9. I am satisfied with the Nurse Case Managers assistance. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable INSTRUCT I ONS : Please circle the answer that best reflects your agreement with the statement indicated. This survey is confidential and will be collected by the administrative assistant for data collection purposes only. The Nurse Case Manager will have no access to your survey. Thank you for helping us serve you better! Figure 2. Family impact survey. EFFECTIVENESS OF TELEBEHAVIORAL HEALTH PROGRAM NURSE CASE MANAGERS (NCM): DATA COLLECTION TOOLS AND THE PROCESS FOR NCM-SENSITIVE OUTCOME MEASURES

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October December 2014 39 tions such as video teleconferencing, telephone, emails, or face-to-face. planning, level of care changes, and diverting from emergency services. tion and emergency actions. ed to adverse drug effects, medication adherence, medication education, medication reconciliation, chologists, psychiatrists, non-telebehavioral health family members. to determine completeness and relevance to practice. Process Development Methodology The project leaders met with small group stakeholder teams to determine the processes needed. This phase needed for each of the surveys used in the collection of outcome data. The following is a description of the involved staff and logistical processes developed unique to each survey. 1. Patient Impact Surveys would be e-mailed to the telepresenters (staff members at remote patient sites Nurse Case Manager as Care Partner Telebehavioral Health Nurse Case Manager Impact Survey Please Circle Your Answer 1. The Nurse Case Manager understands the treatment plan I have in place for the patient. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 2. The Nurse Case Manager suggests additional resources, educational programs or information, and/or services for the patient as needed. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 3. I know how to contact the Nurse Case Manager when I need to. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 4. The Nurse Case Manager is skillful in supporting, educating, and assisting the patient. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 5. The Nurse Case Manager effectively coordinates the patients care with me and other team members (eg, chaplain, family members, other providers). Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 6. The Nurse Case Manager effectively collaborates with me and other team members (eg, chaplain, family members, other providers) about the patients care. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 7. I am better able to get services for the patient because of the Nurse Case Managers assistance. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 8. The Nurse Case Manager adds value to the patients care by providing logistical, social, and/ or emotional support. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 9. The Nurse Case Manager serves as an advocate for getting the resources needed for the patient. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 10. I trust the Nurse Case Managers suggestions. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 11. The Nurse Case Manager makes a positive impact on the patients wellbeing. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 12. I am satisfied with the Nurse Case Managers assistance. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable INSTRUCT I ONS : Please circle the answer that best reflects your agreement with the statement indicated. This survey is confidential and will be collected by the administrative assistant for data collection purposes only. The Nurse Case Manager will have no access to your survey. Thank you for helping us serve you better! Figure 3 Nurse Case Manager as Care Partner impact survey.

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40 http://www.cs.amedd.army.mil/amedd_journal.aspx telepresenters to ensure standardized, noncoercive language which stressed voluntary and anonymous participation. The patient was instructed to return the survey to a designated location after completion. 2. Family Impact Surveys would be offered to family vices such as family education, resources, or support. if the family would be willing to provide feedback e-mail address of the participant to an administra tive assistant. The administrative assistant, using a specially created account with limited access, would send an e-mail with the survey as an attachment. The surveys include standard language about the voluntary, anonymous participation, as well as in names would be shielded from identity by use of recipient who desired to participate would save the e-mail account. The administrative assistant would then save the survey, delete the e-mail, and enter the vey would be assigned a sequential generic number upon receipt. If the recipient did not return the survey within one week, the administrative assistant would send a reminder e-mail. After that, no further contact would be made and the name deleted. tant Impact Survey would be offered based on the provider agreement to receive, complete, and return partnered in care or provided consultation, would re ceive an e-mail detailing the purpose and the volun tary nature of the outcome survey after completion of the consultation or episode of care partnership with Nurse Case Manager as Consultant Telebehavioral Health Nurse Case Manager Impact Survey Please Circle Your Answer 1. The Nurse Case Manager understands my treatment goals. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 2. The Nurse Case Manager helps me understand the ser vices available for Behavioral Health patients. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 3. The Nurse Case Manager suggests helpful resources, edu cational programs, information, and/or services. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 4. The Nurse Case Manager suggests ideas for effective collaboration with other members of the patients team (eg, healthcare providers, social services, and/or family members). Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 5. The Nurse Case Manager responds to my calls and e-mails. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 6. I am better able to get the services my patient needs because of theNurse Case Managers assistance. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 7. I am better able to get services for the patient because of the Nurse Case Managers assistance. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 8. I believe the Nurse Case Managers consultation makes a positive impact on my patients well-being. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 9. I trust the Nurse Case Managers suggestions. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable 10. I am satisfied with the Nurse Case Managers assistance. Strongly Agree Agree Unsure Strongly Disagree Disagree Not Applicable INSTRUCT I ONS : Please circle the answer that best reflects your agreement with the statement indicated. This survey is confidential and will be collected by the administrative assistant for data collection purposes only. The Nurse Case Manager will have no access to your survey. Thank you for helping us serve you better! Figure 4 Nurse Case Manager as Consultant impact survey. EFFECTIVENESS OF TELEBEHAVIORAL HEALTH PROGRAM NURSE CASE MANAGERS (NCM): DATA COLLECTION TOOLS AND THE PROCESS FOR NCM-SENSITIVE OUTCOME MEASURES

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October December 2014 41 The process to identify potential recipients of the survey, deliver the survey, receive and enter returned data would be the same for those care team members would create a list of the names and e-mail addresses, and then e-mail the list to the administrative assis tant on a weekly basis. The administrative assistant would follow the same process described in the Fam the patient, family member, or care partner relating ate categories to track activities. At the end of each administrative assistant who tallied and entered the rized item was listed under the other column, an additional category was created to allow for tracking multiple related instances. Evaluation of Outcome Surveys and Processes Methodology The evaluation of the surveys and processes were con be presented in a future article. qualitative data regarding the processes and surveys. After both qualitative and quantitative data were ana to leadership and other stakeholders. Nurse Case Manager Action Log Part A: Roles, Modality, Continuity of Care Active Case Management Care Coordination Consultation Active Case Management: Perform all NCM functions, assessment, planning, facilitation, care coordination, evaluation, and advocacy. Care Coordination: Perform continuity of care and facilitation activities (phone calls, e-mails etc.); limited patient engagement. Consultation: Provide information, resources, advice, guidance, and/or directions to healthcare providers; no direct patient engagement. Modality VTC: TC: EM: F2F O: VTC video teleconference EM e-mail O other TC telephone call F2F face to face Disposition Safety DCP: LOC: CR: Inpt: DIV: O: ER: DTS/DTO: DCP discharge planning LOC: Level of Care change DIV diverted from ER O: Other CR Crisis Intervention Inpt Arranged Inpt Admit ER Sent to ER DTS/DTO Danger to Self/Others Comments Figure 5. Nurse Case Manager Action Log, Part A

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42 http://www.cs.amedd.army.mil/amedd_journal.aspx RES U LTS The surveys and processes developed were implement ing the feasibility of the processes. Survey Distribution and Completion Patient Impact Survey The surveys were distributed without incident. The Patient Impact Survey completion and submission had challenges relating to logistics which included the physical location of the telepresenter in relation to the with no secure place for patients to leave surveys. All telepresenters indicated the need to provide additional written and verbal information to patients about the out come surveys purpose and process. Additionally, the consensus was that information emphasizing the survey the information sheet. All telepresenters indicated there Nurse Case Manager Action Log Part B: Medication Related Functions, Contacts/Collaborations ADE: ADH: ME: MR: Pharm: RF: Includes evaluating therapeutic/adverse effects, monitoring medication adherence, providing med education, reconciling medications, consulting with Pharmacy, and facilitating medication refills. ADE Adverse Drug Effects ME Medication Education Pharm Pharmacy collaboration ADH Medication Adherence MR Medication Reconciliation ACS: CHAP: CMD: DX: (labs, imaging studies) FAP: Fam: IPMC: Legal: NCM: Patient: PCM: PEBLO/MEB: PSY: PSY MD: Rehab: (PT/OT) SPEC: SW: TBI: WTU: ACS Army Community Services CHAP Chaplain CMD Command DX Labs/Imaging FAP Family Assistance Program Fam Family Member IPMC Integrated Pain Mgmt Clinic Legal JAG/Ombudsman NCM Another NCM Patient Patient PCM Primary Care Manager PEBLO MEB Functions Psy Psychologist PSY MD Psychiatrist Rehab PT/OT/ST SPEC Specialty Care TBI Traumatic Brain Injury WTU Warrior Transition Unit Figure 5 (continued). Nurse Case Manager Action Log, Part B. EFFECTIVENESS OF TELEBEHAVIORAL HEALTH PROGRAM NURSE CASE MANAGERS (NCM): DATA COLLECTION TOOLS AND THE PROCESS FOR NCM-SENSITIVE OUTCOME MEASURES

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October December 2014 43 was little to negligible burden on them and believed it was important to continue collecting outcome data. Family Impact Survey response. There was no further solicitation to provide feedback regarding completion of the surveys. NCM as Care Partner Survey Qualitative data gained from an after action focus group session with 8 providers indicated the survey was clear to distribute or complete. There was concern that without patient identifying information, the providers could not always determine which patient or patient situation they surveys. Also, the providers indicated that assessing iso lated points in ongoing care was sometimes challenging. NCM as Consultant Survey or completion. Action Log Completion needed and time required to complete the action log were ture the information immediately after the intervention. Five of the surveys were completed on the day following suggested inclusion of action log elements into the doc sible solution to reduce the burden of capturing care on a separate paper form. Surveys Data Collection and Entry Patient Impact The telepresenters and administrative assistant reported that sending the completed surveys to the administra tive assistant as a group of attachments in an encrypted e-mail at the end of the week worked well. All indicated that receiving a receipt of the scanned and e-mailed originals once the administrative assistant downloaded, sheet, and sent a receipt to the originating telepresenter. Family Impact Survey Impact Surveys was returned. NCM as Care Partner Survey when the assistants duties and assigned geographic lo cation changed. The tasks related to this project then became additional duties. In addition, delays in distri bution and survey return resulted when the provider list regard to the one week reminder process to complete the mails completed and returned surveys. NCM as Consultant Survey ing to collection of surveys and data entry when the lists of consultants were delayed. This affected the timing of distribution and potential return of surveys. NCM Action Log istrative assistant was relocated. The requirement to scan COMMENT trative assistant yielded vital data to help identify the strengths and limitations of the project and provide fu ture recommendations. Overall the feedback received indicated that the processes put into place worked well. RECOMMEND A TIONS The authors overall recommendation was to continue with the following process changes: Patient Impact Survey Process orientation at the beginning of treatment, clarifying that they may be asked to provide feedback on their encounters to give them a voice in their health care, and provide data for program sustainability.

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44 http://www.cs.amedd.army.mil/amedd_journal.aspx Standardize procedures and language across all telepresenters for the collection and distribution of tribute a reminder slip to the patient to check out with the telepresenter. For future enhancements, rather than paper survey copy, develop a software application for phone, iPad, Facebook, or other medium for immediate survey would necessitate a consent form for nonsecure, un encrypted forms of telecommunications unless a secure encrypted process was available. Care Partner Survey Process the patient with each survey distributed to care partners so it would be clearly known for which the individual providers, was suggested as a solu challenge at this time. Implementation of a periodic summative survey process was suggested as an alternative to an in tions would require minor changes to the survey to following items. Action Log Process important but arduous additional documentation developing an embedded template in the electronic medical record to capture stakeholders interactions collocated with mandatory documentation to allow tion of the number and type of actions taken for the patients case management. General Processes A dedicated assistant is required for outcome deter mination, outcome survey distribution, and data en try. Time must be allotted for these responsibilities. To enable standardized outcome processes, a stan dard operating procedure should be developed for remote sites for staff members who are not organic and points-of-contact. CONCL U SION Timely, relevant, and robust outcome data related to be obtained by following standardized processes and us ing standardized surveys. This article offers processes program located at a military medical facility. IMPLIC A TIONS FOR PR A CTICE clearly called for in case management standards, until now there have been no published standardized outcome processes or measurement surveys, and very little pub veys using standardized survey development processes dards, social change and health promotion theories, and relationship-based care. This project presents surveys and processes which may be of value in other healthcare settings as well. REFERENCES 1. Measurement in Nursing and Health Research 2. Standards of Practice for Case Management Medical Manage ment Guide. Returning Home From Iraq and Afghanistan: Preliminary Assessment of Re adjustment Needs of Veterans, Service Members, and Their Families. 5. A merican Academy of Family Physicians. 6. Relationshipbased Care: A Model for Transforming Practice EFFECTIVENESS OF TELEBEHAVIORAL HEALTH PROGRAM NURSE CASE MANAGERS (NCM): DATA COLLECTION TOOLS AND THE PROCESS FOR NCM-SENSITIVE OUTCOME MEASURES

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October December 2014 45 7. impact of the healing relationships in clinical nurs ing. Alt Ther Health Med 8. management: negotiating care together within a developing relationship. Perspect Psychiatr Care ing alliance in mental health case management. So cial Work Res 10. Nurse as Educator: Principles of Teaching and Learning for Nursing Practice 2008. 11. Health Behav ior and Health Education: Theory, Research, and Practice Sons, Inc; 2002. 12. Health Promotion in Nursing Practice ing health promoting behaviors through telehealth. Nurs Educ Perspect. telehealth and patient empowerment. Popul Health Manag AU THORS The Tripler Army Medical Center is located in Honolulu, Hawaii. It is the only federal tertiary care hospital in the Pacific Basin. It also is the home of the Pacific Regional Medical Command.

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46 http://www.cs.amedd.army.mil/amedd_journal.aspx Cranial electrotherapy stimulation (CES) is a noninva sive, prescriptive medical treatment approved by the Food and Drug Administration for anxiety, insom nia, and depression. About the size of a smart phone, a CES device uses electrodes typically placed on both ear lobes to send a low level (less than 1 mA), pulsed electrical current transcranially through the brain. 1 An EEG analysis of 30 subjects who received one 20 min activity (increased relaxation) and decreases in delta ac tivity (increased alertness) and theta activity (increased ability to focus attention). 2 These changes induce a calm, relaxed, yet alert state. A recent functional magnetic resonance imaging (fMRI) study provides irrefutable proof that CES causes cortical brain deactivation in the midline frontal and parietal regions of the brain after one 20 minute treatment. 3 Many psychiatric and sleep problems are thought to be caused by cortical activation from anxiety or attention disorders. 4,5 Thus, the fMRI study provides additional insight into the mechanism for the effectiveness of CES. Since the early 2000s, Department of Defense (DoD) and Department of Veterans Affairs (VA) practitioners have prescribed CES for the treatment of anxiety, Post traumatic stress disorder (PTSD), insomnia, depression, pain, and headaches. 6,7 CES is classed as a tier II modal ity for pain by The Army Surgeon Generals Pain Man agement Task Force. 8 When CES is used primarily for centralized pain, it also can decrease anxiety, insomnia, and depression, common comorbidities of pain. Tan and colleagues 9 compared service members and veterans preferences for 5 different therapeutic modalities for de creasing stress, anxiety, insomnia, and pain at a veterans outpatient pain management clinic. Participants could choose which device they wanted to use and could use a different device if they chose at future clinic visits. Cra nial electrotherapy stimulation was selected 73% of the time (n=144), while the other 4 stress reducing modali ties were selected from 4% to 11% of the time (n=53). The purpose of this nonprobability, purposive sampling survey was to examine service members and veterans perceptions of the effectiveness and safety of CES for the treatment of anxiety, PTSD, insomnia, and depres sion. It was part of a postmarketing surveillance report for the Food and Drug Administration. SA FETY Cranial electrotherapy stimulation has an excellent safe (EPI) (Mineral Wells, TX) reported, based on a survey Military Service Member and Veteran Self Reports of Efficacy of Cranial Electrotherapy Stimulation for Anxiety, Posttraumatic Stress Disorder, Insomnia, and Depression Daniel L. Kirsch, PhD Jeffrey A. Marksberry, MD Larry R. Price, PhD Katherine T. Platoni, PsyD Francine Nichols, PhD, RN ABSTR A CT Cranial electrotherapy stimulation (CES) is being prescribed for service members and veterans for the treatment of anxi ety, posttraumatic stress disorder (PTSD), insomnia and depression. The purpose of this study was to examine service members and veterans perceptions of the effectiveness and safety of CES treatment. Service members and veterans (N=1,514) who had obtained a CES device through the Department of Defense or Veterans Affairs Medical Center from questionnaires. Data were analyzed using descriptive statistics. Participants reported clinical improvement of 25% or more from using CES for anxiety (66.7%), PTSD (62.5%), insomnia (65.3%) and depression (53.9%). The majority of these participants reported clinical improvement of 50% or more. Respondents also perceived CES to be safe (99.0%). Those individuals who were not taking any prescription medication rated CES more effective than the combined CES and prescription medication group. CES provides service members and veterans with a safe, noninvasive, nondrug, easy to use treatment for anxiety, PTSD, insomnia, and depression that can be used in the clinical setting or self-directed at home. Financial Disclosure

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October December 2014 47 of Alpha-Stim CES users, that during 2007-2011 there was a total of 8,248,920 Alpha-Stim CES treatments (1,982,520 individual users treatments plus 6,266,400 Any side effects that occurred were mild and self-limiting. Reported side literature) are 1% or less. These include dizziness, skin irritation at electrode sites, and headaches. Headaches and dizziness are usually associated with a current set ting too high for the individual. The symptoms normally resolve when the current is decreased. Irritation at the electrode site can be decreased by using alternate sites for placement of electrodes. There have been no seri ous adverse effects reported from using CES during 31 years on the market in the United States. 10 EFFIC A CY performed by Russian scientists in the 1950s and 1960s. These studies focused on the effect of CES on inducing sleep. After the 1966 International Symposia for Electro therapeutic Sleep and Electroanesthesia in Graz, Austria, American scientists began investigating the effectiveness of CES for treating anxiety, insomnia, depression, and substance abuse. Numerous publications on these topics appeared during the 1970s. These early studies were typ ing the research designs used in the time period during the studies were consistently positive, showing CES de creased anxiety, insomnia, and depression. 1 Table 1 Principal Investigator Total (n) Subjects Study Type Findings ( 2008 ) 11 60 P 01 d 0.88 ( 2004 ) 12 74 P 01 scores ( P 001 ( 2001 ) 13 60 P 02 d 0.60 P 05 ( 1999 ) 14 33 P 01 d 0 61 P 01 ( 2008 ) 15 12 General disorder P 01 1.52 P 01 d 0.75 ( 1999 ) 16 197 disorder 0 100 P 05 P 05 Table 2 Principal Investigator Total (n) Subjects Study Type Findings ( 2013 ) 17 46 P 001 d 0.30 ( 2001 ) 13 60 0 10 P 02 d 0 54 ( 2009 ) 18 21 officers P 01 Depression scale ( P 05 ( 2008 ) 15 12 General disorder P 01 d 0.41

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48 http://www.cs.amedd.army.mil/amedd_journal.aspx Over the past 15 years or so, the sophistication of the research designs and the quality of CES research im proved substantially. Four randomized clinical trials anxiety (Table 1). Three of the RCTs, used a double-blind sham controlled design, while one RCT used an investigator-blind de cantly lower scores on state anxiety outcome measures than the sham or control group. Three RCTS on anxi ety included Cohens d effect sizes that ranged from d =-0.60 (moderate) to d =-0.88 (high). Two open clini line to the endpoint of the study, with subjects having lower state anxiety scores at the endpoint of the study. Bystritsky and colleagues reported Cohens d effects sizes for 2 anxiety outcome measures: d =-1.53 on the Hamilton Anxiety Rating Scale (very high) and d =-0.75 (moderate) on the Four-Dimensional Anxiety and De pression Rating Scale. Cranial electrotherapy stimula and depression (Table 2). All studies that investigated the effect of CES used reliable and valid scales for the measurement of outcomes. METHODS The Alpha-Stim CES device with ear clips electrodes (0.5 Hz, 100600 A, 50% duty cycle, biphasic asym metrical rectangular waves) was used in this study. Two electrodes that clip onto the ear lobes are used to send a mild electrical current through the brain. Treatment duration is a minimum of 20 minutes, but may be an hour at least one time daily. PTSD patients sometimes do a one hour CES treatment several times a day. Dur ing acute PTSD episodes, patients may use CES for ex tended periods of time (several hours) until symptoms decrease. While CES treatments should last a minimum of 20 minutes to achieve the desired effect, extended use of CES has no adverse side effects and is well tolerated. duty service members and veterans who obtained an Alpha-Stim CES device through the DoD or VA medical centers from 2006 to 2011 were invited to participate in the web-based survey via email. Email addresses were obtained from prescription information for CES devices All of the potential participants had been taught, using a standardized DoD or VA CES protocol, how to use selfdirected CES at home. Participants either voluntarily chose to respond or not to respond to the questionnaire. Survey Monkey is the professional website ( ) for survey research that was used for this study. Respondents completed the questionnaire on-line from September 1, 2011, to October 1, 2011. Of the 1,514 persons who were invited to participate in the survey, 152 (N) responses to the questionnaire were re ceived, yielding a response rate of 10%. Although re sponse rates vary by the population sampled, a response rate somewhere between 15% and 40% is common for web-based surveys. 19,20 The questionnaire contained 27 questions that covered demographic information, prescription medication use, and current exercise activity, as well as questions asking respondents to rate the effectiveness of CES technology for treating anxiety, PTSD, insomnia, and depression. A single item, 7-point Likert scale, which has established validity in the literature, 21 was used to measure respon dents perceived effectiveness of CES for anxiety, PTSD, insomnia, and depression. A sample question follows: If you are using CES for your PTSD, since starting CES, rate your improvement as: a. Worse (negative change) b. No change (0%) c. Slight improvement (1% to 24%) d. Fair improvement (25% to 49%) e. Moderate improvement (50% to 74%) f. Marked improvement (75% to 99%) g. Complete recovery (100%) RES U LTS Data were analyzed using descriptive statistics. The characteristics of respondents, their use of CES technol ogy, conditions for which they used CES, how often they used CES, and the length of time they had used CES are shown in Table 3. In addition to analysis of improve ment-related questions on anxiety, PTSD, insomnia, and depression, questions were also interpreted in consid eration of respondents use of prescription medication while using CES. There were 152 responses to the ques tionnaire. Seven questionnaires did not include any ef fectiveness and safety data. Thus, the valid sample size was N=145 for the analysis of these questions. Of the 145 persons responding to Do you consider CES safe and effective?, 99% reported that they view CES as safe and effective. Of the 1% of respondents (n=2) report ing CES as unsafe or ineffective, the reasons given were (1) that they were never shown how to use CES properly, and (2) CES was ineffective for their medical condition. MILITARY SERVICE MEMBER AND VETERAN SELF REPORTS OF EFFICACY OF CRANIAL ELECTROTHERAPY STIMULATION FOR ANXIETY, POSTTRAUMATIC STRESS DISORDER, INSOMNIA, AND DEPRESSION

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October December 2014 49 Thirty-one subjects (21.3%) reported that they were not currently using CES for anxiety. One hundred four teen subjects (combined sample tak ing and not taking prescription medi cations regularly) using CES for anx iety responded to, If you are using CES for anxiety, since starting CES, rate your improvement as . Figure 1 shows the results for the total group (N=114), the CES only no medica tion group (n=26), and the CES and medication group (n=88). Fifty-six of the subjects (38.6%) reported not using CES for PTSD. Although PTSD is an anxiety dis order, it was included as a separate variable because of its importance in the treatment of service members and veterans. 22 Eighty-eight subjects (combined sample taking and not taking prescription medication regu larly) using CES for PTSD responded to If you are using CES for PTSD, since starting CES, group (N=88), CES only no medication group (n=18), and CES and medication group (n=70) are shown in Fig ure 2. Forty-six subjects (31.7%) reported that they did not use CES for insomnia. Ninety-eight subjects (combined sample taking and not taking prescription medication regularly) who used CES for insomnia responded to If you are using CES for insomnia, since starting CES, rate your improvement as. (N=98), CES only no medication group (n=21), and CES medication group (n=77) are shown in Figure 3. Depression Fifty-six subjects (38.6%) reported that they were not using CES for depression. Eighty-nine subjects (sub jects combined sample taking and not taking prescrip tion medication regularly) using CES for depression re sponded to If you are using CES for depression, since ings of the total group (N=89), CES only no medication group (n=13), and CES medication group (n=76) are shown in Figure 4. Dworkin and colleagues 23 tant clinical improvement as follows: Improvement of moderate clinical importance is 30% to 49%, and improvement of substantial clinical impor tance, the highest category, is 50% or more. While the criteria were developed to evaluate clini cal trial outcomes on chronic pain, it provides a useful framework for the assessment of clinical improvement in anxiety, PTSD, insomnia, and depression as well. For this study, improvement of moderate clinical impor scale which has been validated for use in measuring CES outcomes used 25% increments for categories. Using a conservative approach, the Slight Improvement (1% to 24%) category on the 2011 Alpha-Stim CES service members and Veterans survey was excluded, leaving the top 4 categories of Fair Improvement (25% to 49%), Moderate Improvement (50% to 74%), Marked Im provement (75% to 99%) and Complete Improvement (100%). Participants reported clinical improvement of 25% or more from using CES for anxiety (66.7%), PTSD (62.5%), insomnia (65.3%), and depression (53.9%). The majority of service members and veterans who report ed improvement of 25% or more had improvement in Characteristics n (%N) Characteristics n (%N) 152 ) ( 145) 109 (72%) 43 (28%) 114 (78%) 152 ) Depression 89 (61%) 19 67 years ( mean= 38 10 ) 98 (67%) 88 (60%) Gender ( 152 ) ( 145 ) Male 114 (75%) Female 33 (22%) Once a day 72 (50%) 5 (3%) 35 (24%) 152 ) 2 3 6 (4%) Yes 125 (82%) 3 4 (3%) 23 (15%) 28 (19%) 4 (2%) 145 ) 152 ) 90 days 19 (13%) 4 9 (6%) Yes 112 (73%) 5 5 (3%) 40 (27%) 6 17 (12%) ( 152 ) 9 5 (3%) 1 year 31 (21%) Yes 116 (76%) 2 years 20 (14%) 31 (20%) 3 years 7 (5%) 5 (3%) 32 (22%)

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50 http://www.cs.amedd.army.mil/amedd_journal.aspx the highest category, substantial clinical importance, (50% or more) on all variables: anxiety, PTSD, insomnia, and depression, as shown in Figure 5. Of the 112 respondents who reported they took at least one prescription medication, 98 provided the name of the drug or condition for which it was taken. The number of prescription medications taken ranged from one to 11, with a mean of 2.6 and a median of 2.0. The types of medications taken are shown in Table 4. Medica tions that are used clinically for anxiety and depression were placed in the anxiety category. 24 Medications used primarily for depression were placed in the depression 1 A 114 P No Change (0%) Slight (1%-24%) Fair (25%-49%) Moderate (50%-74%) Marked (75%-99%) 9.7% 7.7% 32.5% 14.0% 15.4% 19.2% 26.9% 21.6% 10.2% 20.2% 25.0% 23.7% 30.8% 34.1% 9.1% 35 30 25 20 15 10 5 0 40 2 PTSD 88 17.1% 16.7% 14.8% 22.7% 22.9% 22.2% 22.2% 24.3% 23.9% 31.8% 31.4% 33.3% 5.6% 6.8% 4.3% No Change (0%) Slight (1%-24%) Fair (25%-49%) Moderate (50%-74%) Marked (75%-99%) 35 30 25 20 15 10 5 0 P MILITARY SERVICE MEMBER AND VETERAN SELF REPORTS OF EFFICACY OF CRANIAL ELECTROTHERAPY STIMULATION FOR ANXIETY, POSTTRAUMATIC STRESS DISORDER, INSOMNIA, AND DEPRESSION

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October December 2014 51 category. Only those medications catego rized as sedative hypnotics were placed in the insomnia category. Only those drugs aches were included in the migraine head ache category, while all narcotic and other pain medications were included in the pain category, the subject of a separate paper. Several of the most common drugs used to treat anxiety, PTSD, insomnia, depression, pain and Stim service member and civilian surveys as shown in Figure 6. CES data from October 2011 Military Service Member and Veterans study (N=152) and the CES Ci vilian User Survey (N=1,745) August 2011 were used. Pharmaceutical Survey Data were obtained from on-line WebMD user surveys (http://www.WebMD.com/drugs) The Alpha-Stim CES civilian survey was conducted in August 2011 from data collected between July 2006 and July 2011 (http://www. alpha-stim.com ple size from the civilian survey was 1,745 responders from a mail survey of 4,590 (38% useable responses). The WebMD drug survey asked civilians the question: This medication has worked for me? Respondents could choose to answer in one of 5 categories, with 1 being the lowest to 5 being the most effective. The sample size for the drugs selected ranged from N=62 to N=2,238. The CES survey questionnaire asked respondents to rate their improve ing CES. Subjects could choose one of 7 categories: worse (negative change), no improvement (0%), slight improvement (1% to 24%), fair improvement (25% to 49%), moderate improvement (50% to 74%), marked improvement (75% to 99%), and complete recovery (100%). While the questions in the WebMD and CES sur veys were slightly different, all surveys asked questions about effectiveness. The WebMD data were changed to percentages and ranged from 1% to 100%. Two catego ries were excluded from the CES survey as they were not included in the WebMD survey: worse (negative change) and no change (0%). The categories of worse of the responses in all instances (ie, on all questions). The upper 5 categories which ranged from 1% to 100% were used for comparison. The scale was the same, 1% to 100% for the data from all surveys. The comparison of the data from the 2 surveys is both appropriate and struct validity) and the format of item response. 19 COMMENT It is not surprising that the response rate to the survey was not higher. The majority of persons asked to par ticipate in the survey were active duty service members. 45.9% Depression 44.8% 38.7% 27.5% 16.3% 11.2% 9.0% 9.0% 3 98 P 19.5% 1.3% 9.5% 4.8% 4.8% 15.6% 14.3% 21.4% 18.1% 16.3% 18.4% 20.4% 22.0% 23.8% 23.4% 21.4% 42.9% 2.0% No Change (0%) Complete (100%) Slight (1%-24%) Fair (25%-49%) Moderate (50%-74%) Marked (75%-99%) 35 30 25 20 15 10 5 0 40 45 50

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52 http://www.cs.amedd.army.mil/amedd_journal.aspx Many email addresses may not have been valid because the survey covered a 6-year period and some may have moved, were discharged, or may have elected not to re spond to the email if they were no longer using CES. This study supports the ef the treatment of anxiety, PTSD, insomnia, and depression in service members and CES. The effectiveness of CES in a mili tary population was comparable to the effectiveness of drugs commonly used in the treatment of the same conditions in the civilian population. Ninety-nine percent of subjects in this survey considered CES technology to be is that it leaves the user alert and relaxed after treatment, in contrast to drugs that can have adverse side effects and affect service members ability to function on missions that require intense focus and attention. 25 This is particularly true in the combat theater of operations. The information on prescription medica tion use provides a general view of drugs scription medications for anxiety (45.9%), depression 4 89 P 7.7% 13.5% 10.5% 30.1% 25.0% 22.5% 23.0% 17.1% 18.0% 15.4% 26.3% 24.7% 21.0% 21.4% 23.1% 35 30 25 20 15 10 5 0 No Change (0%) Slight (1%-24%) Fair (25%-49%) Moderate (25%-49%) Marked (75%-99%) 20.2% 46.5% 21.6% 43.2% 15.4% 57.7% 66.7%, N=76 64.8%, n =57 73.1%, n =19 60.0%, n =42 72.2%, n =13 62.5%, N=55 59.8%, n =46 85.8%, n =18 65.2%, N=64 52.6%, n =40 60.8%, n =8 54.0%, N=48 23.9% 38.6% 24.3% 35.7% 22.2% 50.0% 20.4% 44.8% 19.5% 23.8% 18.0% 17.1% 36.0% 35.5% 37.8% 40.3% 23.0% 62.0% Depression N=89 N=98 N=88 N=114 5 MILITARY SERVICE MEMBER AND VETERAN SELF REPORTS OF EFFICACY OF CRANIAL ELECTROTHERAPY STIMULATION FOR ANXIETY, POSTTRAUMATIC STRESS DISORDER, INSOMNIA, AND DEPRESSION

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October December 2014 53 (44.8%), pain (38.7%), and insomnia (27.5%) is consistent with the literature. 6,7 The importance of controlling for medi cation type and dosage in future CES studies is a valuable outcome of this sur vey. It would also be helpful to classify the severity of illness of the subjects in future studies. While it appears that med CES technology, it is possible that respon dents taking prescription medication had far more serious symptoms and medical and psychological conditions than the no medication group. The group sizes were unequal. The CES only, no medication group was considerably smaller, ranging from 13 to 26 subjects, in comparison to the CES medication groups that ranged from 53 to 88 subjects. This may account for the differences in scores between the groups. However, the effect of medication appears to be an important confounding of CES. CONCL U SIONS The results of this survey are compelling and provide the foundation for a rigorous placebo controlled RCT that investigates the effectiveness of CES for treating anx iety, PTSD, insomnia, and depression in service mem bers and veterans. In addition, this study also examines This study provides evidence that service members and veterans perceived CES as an effective treatment for anxiety, PTSD, insomnia, and depression. CES can be used either as an adjunct to pharmaceutical therapy or as a standalone therapy, providing service members and veterans with a safe, noninvasive, nonpharmacologic treatment for anxiety, PTSD, insomnia, and depression that can be used in the clinic setting, including the war time theater clinics, or self-directed at home. REFERENCES 1. Kirsch D. The Science Behind Cranial Electro therapy Stimulation Edmonton, Alberta, Canada: Medical Scope Publishing; 2002. 2. Kennerly R. QEEG analysis of cranial electro therapy: a pilot study [abstract]. J Neurother 2004;8(2):112-113. Available at: http://www.stress. org/wp-content/uploads/CES_Research/kennerlyqeeg.pdf. Accessed July 11, 2014. 3. Feusner JD, Madsen S, Moody TD, Bohon C, Hem bacher E, Bookheimer SY, Bystritsky A. Effects of cranial electrotherapy stimulation on resting state brain activity. Brain Behav 2012;2(3):211-220. 4. Yassa MA, Hazlett RL, Stark CE, Hoehn-Saric R. Functional MRI of the amygdala and bed nucleus of the stria terminalis during conditions of uncer tainty in generalized anxiety disorder. J Psychiatr Res, 2012;46(8):1045-1052. 5. Bonnet MH, Arand DL. Hyperarousal and in somnia: state of the science. Sleep Med Rev. 2010;14(1):9-15. 6. Bracciano AG, Chang WP, Kokesh S, Martinez A, Moore K. Cranial electrotherapy stimulation in the treatment of posttraumatic stress disorder. a pilot study of two military veterans. J Neurother 2012;16(1):60-69. 7. cranial electrotherapy stimulation for neuro pathic pain following spinal cord injury. a multi site randomized controlled trial with a secondary 6-month open-label phase. J Spinal Cord Med 2011;34(3):285-296. 8. Pain Management Task Force: Final Report Wash Surgeon General; May 2010. 6 152 1,745 2011 28, 2011 P 70% 67% 83% 56% 78% 84% 68% 81% 84% 80% 85% 90% 30 80 90 50 20 60 10 70 0 40 100 38 ) 38 ) 358 ) 114 ) 462 ) 163 ) 98 ) 1198 ) 2028 ) 311 ) 89 ) Depression

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54 http://www.cs.amedd.army.mil/amedd_journal.aspx 9. Tan G, Dao TK, Smith DL, Robinson A, Jensen MP. Incorporating complementary and alterna tive medicine (CAM) therapies to expand psycho logical services to veterans suffering from chronic pain. Psychol Serv 2010;7(3):148-161 10. Petitioner Presentation to Neurological Devices vices From Class III to Class II. Mineral Wells, TX: Electromedical Products International, Inc; Febru ary 10, 2012. Available at: http://www.alpha-stim. com/wp-content/uploads/EPIs-fda-presentation. pdf. Accessed July 11, 2014. 11. Kim HJ, Kim WY, Lee YS, Chang M, Kim JH, Park YC. The effect of cranial electrotherapy stimula tion on preoperative anxiety and hemodynamic re sponses. Korean J Anesthesiol 2008;55(6):657-661. 12. Cork RC, Wood PM, Norbert C, Shepherd JE, Price L. The effect of cranial electrotherapy stimulation Inter net J Anesthesiol [serial online]. 2004;8(2). Avail able at: http://ispub.com/IJA/8/2/12659. Accessed July 11, 2014. 13. Lichtbroun AS, Raicer MC, Smith RB. The treat stimulation. J Clin Rheumatol 2001;7(2):72-78. 14. Winick RL. Cranial electrotherapy stimulation (CES): a safe and effective low cost means of anxiety control in a dental practice. Gen Dent 1999;47(1):50-55. 15. Bystritsky A, Kerwin L, Feusner J. A pilot study of cranial electrotherapy stimulation for gen eralized anxiety disorder. J Clin Psychiatry 2008;69:412-417. 16. Overcash SJ. Cranial electrotherapy stimulation in patients suffering from acute anxiety disorders. Am J Electromedicine 1999;16(1):49-51. 17. Taylor AG, Anderson JG, Riedel SR, Lewis JE, Kinser PA, Bourguignon C. Cranial electrical stim ulation improves symptoms and functional status Pain Manag Nurs 2013;14(4):327-335. 18. symptoms of depression using cranial electrothera py stimulation (CES): a control experimental study. Correct Psychologist 2009;41(1):9-15. 19. Dillman D. Mail and Internet Surveys 2nd ed. Hoboken, NJ: John Wiley & Sons; 2007. 20. Czaja R, Blair J. Designing Surveys: A Guide to Decisions and Procedures 2nd ed. Thousand Oaks, CA: Pine Forge Press; 2005. 21. Davey HM, Barratt AL, Butow PN, Deeks JJ. A one-item question with a Likert or visual analog scale adequately measured current anxiety. J Clin Epidemiol 2007;60(4):356-360. 22. US Department of Veterans Affairs, National Cen ter for PTSD. Available at: http://www.ptsd.va.gov/. Accessed May 10, 2012. 23. Dworkin RH, Turk DC, Wyrwich KW, et al. Inter preting the clinical importance of treatment out comes in chronic pain clinical trials: IMMPACT recommendations. J Pain 2008;9(2):105-121. 24. Mental Health Indications: What medications are used to treat anxiety disorders? National Insti tute of Mental Health Website; 2008. Available at: http://www.nimh.nih.gov/health/publications/ mental-health-medications/index.shtml. Accessed July 11, 2014. 25. Tilghman A, McGarry B. Medicating the military: use of psychiatric drugs has spiked; concerns surface about suicide, other dangers. Army Times March 17, 2010. Available at: http://www.armytimes.com/ar ticle/20100317/NEWS/3170315/Medi cating-military. Accessed July 11, 2014. AU THORS Dr Kirsch is President, American Institute of Stress, Fort Worth, Texas. Dr Price is Director of Faculty Research and Professor of Psychometrics and Statistics, College of Education and Department of Mathematics, Texas State University, San Marcos, Texas. Dr Nichols is a research consultant and retired Professor, Georgetown University, Washington, DC. Dr Marksberry is Director, Science and Education, Elec tromedical Products International, Inc, Minerals Wells, Texas. When this article was written, COL Platoni was Army Reserve Psychology Consultant to the Chief, US Army Medical Services Corp. Now retired from the Army Reserve, Dr Platoni is in private practice in Centerville, Ohio. MILITARY SERVICE MEMBER AND VETERAN SELF REPORTS OF EFFICACY OF CRANIAL ELECTROTHERAPY STIMULATION FOR ANXIETY, POSTTRAUMATIC STRESS DISORDER, INSOMNIA, AND DEPRESSION

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October December 2014 55 It has been estimated that in recent years up to 15% of casualties in the wars in Afghanistan and Iraq were the result of suicidal behavior and completed suicide. 1 Ac cording to the 2010 Department of Defense Sentinel Event Report (DoDSER), 2 22.42% of Soldiers who died by suicide (n=63) and 44.15% of those who attempted suicide (n=381) had received outpatient behavioral health treatment during the prior month. The former US Army Vice Chief of Staff cited a document produced by the National Institute of Mental Health entitled Op portunities to Improve Interventions to Reduce Sui cidality: Civilian Best Practices for Army Consider ation 3 to illustrate the current lack of suicide-focused, empirically validated clinical treatments. In response, a number of suicide prevention initiatives have been en acted throughout the Army. Suicide prevention efforts within the Army aim in part to reduce suicidal behav iors through education, encouragement of help-seeking behaviors, and destigmatization. 4,5 This is evident in the materials and publications developed by the US Army Center for Health Promotion and Preventive Medicine (now the Army Public Health Command) in conjunc tion with the American Association of Suicidology, and in multimedia publications from the Defense Centers of Excellence. These initiatives largely focus upon the ment early intervention, namely, a referral to behavior al health. In spite of the development of these suicide prevention initiatives, Army service member suicide continues to rise. In 2012, a total of 349 US military suicide deaths were recorded across the branches; the largest portion of these deaths, 182 potential suicides, comprised of members of active duty Army. 6,7 These research to understand suicidal behaviors within the military. Suicide risk may concentrate more in Army Behav ioral Health (BH) patient populations for several of the reasons that make military experience unique when compared to civilian life. When suicidality among mili tary members accompanies behavioral health condi tions associated with sleep disturbances, concentration problems, and physical symptoms that impact on daily functioning, this can lead to reduced occupational per formance, physical conditioning, and combat readiness. Soldiers who are suicidal may also experience somatic concerns and related problems that result in a higher fre quency of medical or sick call visits. This may then con with coworkers and family members, affecting morale and well-being. Special populations within the military community, such as Wounded Warriors, have their own unique set of risks including chronic pain, decreased level of functioning due to injury or other health prob lems, and potential prescription drug abuse. Psychologi cal and physical pains are both likely contributors to suicide. Previous factor analytic research with suicidal inpatients has shown the important psychometric role of Raising the Clinical Standard of Care for Suicidal Soldiers: An Army Process Improvement Initiative Debra Archuleta, PhD Ren M. Lento, MA David A. Jobes, PhD Katherine Brazaitis, MA Lynette Pujol, PhD Bret A. Moore, PsyD Keith Jennings, MA Bruce Crow, PsyD Jennifer Crumlish, PhD ABSTR A CT From 2004 to 2008, the suicide rate among US Army Soldiers increased 80%, reaching a record high in 2008 rent behavioral health practices to identify both effective and ineffective practices, and to adapt services to meet the needs of the Army behavioral health patient population. This paper discusses a process improvement initiative developed in an effort to improve clinical processes for suicide risk mitigation in an Army behavioral health clinic located in the catchment area of the US Army Southern Regional Medical Command.

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56 http://www.cs.amedd.army.mil/amedd_journal.aspx psychological pain in acute suicidal states. 8 In addition, in an analysis of risk factors for suicide in the Army, Retired COL Elspeth Ritchie notes the role of physical pain and disability as a precipitant for suicide, especially among older Service Members with higher rank. 9 Soldiers who experience suicidal behaviors or who com plete suicide have a disproportional effect on military communities. Units are primarily affected by a suicidal Soldier or by the loss of an integral team member which may lead them to experience a range of emotional reac tions such as grief, guilt, and anger. This reduces work performance and contributes to increased vulnerability for a range of health-related problems including suicidal behaviors (ie, contagion effects). 10 The contagion ef fect occurs when one suicide leads to a subsequent sui cide. 10 Factors that may support to the contagion effect have been researched and include documented clusters of suicides in close temporal or geographic proximity, exposure to media coverage of suicides and exposure to suicidal peers. 10 Research has been focused on ado lescents and young adults due their tendency to learn behavior by observing and modeling the behavior of others. 10 This is of particular concern for military lead ership due to the large number of military service mem bers who are young adults under the age of 25. 11 There were indications of possible suicide clusters in the mili tary among Army recruiters in 2008 and in 2009 within a National Guard unit, though these incidents have not been formally studied. 11 Additionally, the death of a Sol dier by suicide often brings increased media and con gressional attention leading to an increase in scrutiny of the chain of command. Finally, the military population is a highly transient population which translates into the high mobility of Soldier suicide risk. This often leads to disjointed treatment services that create challenges in the coordination of care for a Soldier between duty stations, as well as between clinics in a military medical and intervention of suicidality can therefore improve occupational performance and mission effectiveness, while also having a positive effect on the health and wellbeing of a wide spectrum of the military community. This paper discusses a process improvement (PI) initia tive developed to meet the above noted needs and con tribute to Army suicide prevention, as well as raise the clinical standard of care through improved clinical pro cesses for suicide risk mitigation in an Army BH clinic located in the catchment area of the US Army Southern Regional Medical Command. What follows is our stepby-step approach systematically to endeavor to raise the clinical standard of care in an outpatient Army BH clinic. A PROCESS IMPROVEMENT INITI A TIVE Development of a Needs Assessment Report The initial phase of the PI initiative included a thorough and systematic evaluation of existing clinical practices related to suicidal Soldiers and their care. The evalua tion was conducted to understand the unique needs of a military outpatient BH clinic and current clinical prac tices, both effective and ineffective, in order to tailor services to the needs of the Soldiers at risk for suicide. Similar to many Army BH clinics, this was a busy out patient clinic setting with a high volume of complex cases, including Soldiers who were actively suicidal. At the time of the needs assessment, no aggregate data and tracking number of Soldier attempts at suicide, methods of suicide, or completed suicides existed, in part, due to the low incidence of the events. Anecdotal reports in dicated that there may have been 3 or 4 Soldiers seen at the clinic who completed suicide over the past 2 or 3 years. The clinic leadership acknowledged that this information was included in the root cause analysis and the DoDSER which was completed following the death of a Soldier seen in any BH clinic, but not tracked locally It was determined that the procedure in place to track suicidality at this clinic was a minimal paper and pencil self-report screening completed at the intake evaluation, during which the patient was asked only a single question about suicide. When suicidal ideation was endorsed, the clinics standard operating procedures (SOPs) required an assessment of suicidal risk using a local form derived from the Suicide Status Form-II that was then scanned into the electronic medical record. Routinely, no level of risk was assigned to the Soldier. The primary intention of the risk assessment was to assist in assessing safety and need for hospitalization. Although some suicidal pa tients were entered into a database developed by a psy chologist within the BH department called the high inter est patient database and monitored by a treatment team, not all individuals with suicidal ideation were included. Thus, there was no existing system for the tracking of ongoing suicide risk among suicidal patients, and there was no systematic methodology for recording when and if suicide risk had resolved in a patient. Extensive review of the clinics available procedures found guidelines for the hospitalization of a patient in the military hospital and in the community, as well as line of sight procedures for the emergency room for military personnel. There instructions for weapons access or to aid in risk mitiga tion. Each provider passed along information informally to each on how to manage these situations or consulted RAISING THE CLINICAL STANDARD OF CARE FOR SUICIDAL SOLDIERS: AN ARMY PROCESS IMPROVEMENT INITIATIVE

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October December 2014 57 with the clinic chief for guidance. Some providers did periodic checks on the patients by phone, but there was no standardized procedure for this action. As a result of able to all providers. Treatment for suicidal ideation and behaviors generally followed the providers theoretical orientation and most often focused on treatment of depression or coping with situational or relational concerns which may have mini mized the risk posed by other factors such as pain and anxiety. Patients experiencing anxiety or posttraumatic stress-related symptoms were often placed in group treatment due to the limited number of providers avail able for individual treatment because of high workloads. Patients with pain problems were typically referred out side the clinic to a specialty care pain clinic at the hos pital. Suicidal Soldiers were routinely hospitalized for brief inpatient stays at an MTF managed by active-duty personnel. A memorandum of understanding (MOU) was also negotiated with a private psychiatric facility where clinic patients may be hospitalized, seen in a day treatment program, or receive other outpatient services. There was no established or routine use of postvention (a systematic supportive intervention that follows a pa tients death by suicide) to assist clinic staff who were affected by a loss. Overall, the clinics processes for working with suicidal Soldiers at the time of the needs assessment were rela tively typical when compared to other Army MTFs and tings (ie, what reasonably prudent practitioners do with comparable patients in comparable settings). However, cal care that could be provided in such a setting. In or der to provide a more thorough consideration of what might constitute optimal care, a series of sensing ses sions were conducted with clinic staff and Soldiers with current suicidal ideation or a history of ideation or at tempts. The results of those sessions are described in the following sections. Staff Clinical staff indicated that their caseloads were full and challenging. Treatment providers, including psychology technicians (military occupational specialty 68X), de scribed an average of 14 years of practice with an aver estimated the rate of Soldiers with suicidal ideation or behaviors in their current practice as 21%, with a range of 0 to 85%. The lifetime rate of patient completed sui cides ranged from zero to two, with an average number of lifetime patient attempts per provider at slightly over three. Providers estimated that they completed an aver age of 9 hours of continuing medical education on sui cide over the course of their careers. Problems described by clinical staff mostly centered on the volume of complex, high-risk cases and the overall sense of being spread too thin. New civilian clinical staff with little military background experienced chal lenges connected to acclimating to the military culture, including rules, regulations, and military acronyms. Providers noted various challenges in dealing with unit commanders and observed that commanders, for a vari ety of reasons, can implicitly or directly undermine BH treatment. Clinical staff struggled with threats of sui cide that Soldiers used for secondary gain or as a means of avoiding further deployments. Some clinicians per ceived a culture of blame vs being supported or under stood after an adverse event. Clinical consultation was usually done informally with peers and senior clinicians. However, many clinicians expressed a desire for more support and for regularly scheduled formal consulta tion opportunities with subject matter experts. The per ceived delay in medication consultation was also noted as a major challenge to the delivery of effective care. Leadership Clinic leadership recognized the high operational tempo of the clinic environment, the need for more staff sup port, and the development and use of postvention strate gies following a suicide event in the clinic. There also better education about BH in order to supportnot un dermineBH care. Service Members Soldiers were interviewed individually by the exter nal consulting team in the presence of their clinic BH provider. Between October 2009 and August 2010, the overall number of outpatient BH encounters was 4,951. Soldiers were primarily male (69%). Thirty-seven per cent of patients ranged from ages 26-35 years, 29% were in the 36-45 year age group and 22% were in the 18-25 year age group. Due to limitations of the records sys tem, there was no method for accurately tracking demo graphics on race, ethnicity, and marital status. Ranks most often seen by outpatient BH providers were E4 to agnoses for patients were: (1) adjustment reaction, (2) episodic mood disorders, (3) depressive disorder, and (4) anxiety. The modal number of visits fell in the 1 to 5 range, far exceeding the next category of 6 to 10 vis its. There were issues with relatively high no-show rates (leadership estimated up to 33%) among clinic patients.

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58 http://www.cs.amedd.army.mil/amedd_journal.aspx Point of service for entry into the clinic for Soldiers oc curred through walk-ins, referrals by commanders, or transfers from other medical treatment providers. Many Soldiers were in a state of personal and/or professional crisis and were having considerable problems at work issues implicated in their suicidality, including the effect of multiple deployments, posttraumatic stress disorder (PTSD), and traumatic brain injury, as well as problems A major barrier to care for suicidal Soldiers was the perceived lack of support or even the undermining ef fect of their command. A number of the Soldiers inter viewed readily acknowledged that their clinic treatment had been very helpful while others seemed somewhat critical of the larger militarys response to their mental health situation. Perceived strengths of the clinic were the quality of the staff and the excellent care the Soldiers received. The dedication and advocacy of clinical staff on the Soldiers behalf was noted as a particularly helpful aspect of their treatment. Various evidence-based treatments used in the clinic (eg, prolonged exposure for PTSD) were found to be helpful. The perceived major weaknesses of the clinic were described as the staff being over-extended, very long wait times for medication consultation, and Outside Providers Mixed reviews were provided about outsourced care. The MTF inpatient stays were relatively brief and orient ed to short-term stabilization The MTF inpatient staff re ported that there were no treatment or therapies offered. There were very positive reviews of the care provided in the private setting that had established a military-specif ic treatment unit that catered to the culture and needs of active duty Soldiers. The MOU with the private center and the collaborative consultations had created a userfriendly treatment environment about which Soldiers and providers felt quite positive due to the availability of inpatient services and programming. Another private fa cility that did not have an MOU arrangement seemed to standard contemporary psychiatric care (ie, not tailored to the unique needs of active duty Soldiers). RECOMMEND A TIONS FOR THE PROCESS IMPROVEMENT Based on the initial evaluation of clinic practices and focus groups, a number of recommendations were de veloped by the consultation team for consideration to enhance BH-related care of suicidal Soldiers. These included recommendations to establish written suicidescreening tools to identify initial suicidal risk, and track ongoing risk across the course of care and to apply an electronic health record version of the Suicide Status Form (SSF) for the Collaborative Assessment and Man agement of Suicidality (CAMS), which is an evidencebased assessment of suicide risk. Additional suggestions included the use of CAMS-based therapeutic tools to stabilize outpatient care, problem-focused interventions and treatment of suicidal drivers, tracking of clinical out comes, and overall improvement of clinical documenta tion. In addition, creation of a procedure for postvention for adverse events was proposed to support clinical staff and garner lessons learned. Lastly, effectively engaging commanders, family members, and supportive peers in support of clinical care of suicidal Soldiers (which may require separate educational efforts and the cultivation of collaborative working relationships with a Soldiers support structure) was considered as essential to suc cessful remediation of the suicidal risk. Another critical recommendation for a successful sui all clinical providers to attend a weekly telephonic clini cal consultation meeting with the external consultation team members who are expert in the treatment. The ex ternal consultants would eventually withdraw from this consultation meeting once the meeting is clearly estab lished and the use of the intervention has become routine. Such a meeting should be primarily case-focused, input on clinical strategies and related risk management is sues should be encouraged to facilitate adoption of a new evidence-based clinical practice across the clinical staff. We observed that even the most reluctant clinical staff members eventually engaged in the use of the evidencebased approach when they heard about improvements in other providers suicidal patients and saw growth in con even in the face of some very challenging circumstances. A recommendation was also made for the implementa tion phase of the PI initiative, including a series of fol low-up CAMS training sessions for the clinical staff by Dr Jobes and members of the Catholic University Sui cide Prevention Laboratory. These training sessions em phasized the nuts and bolts of using CAMS and used a practical, hands-on approach featuring role-plays, video illustrations, and case examples. The primary learning objectives for training were: use of the SSF for risk as sessment; development of Crisis Response Plans and problem-focused interventions targeting suicidogen ic issues; use of the SSF to track suicide risk over the course of care; update crisis response plans and treat ment plans as needed; and use of CAMS and the SSF to achieve optimal clinical outcomes. RAISING THE CLINICAL STANDARD OF CARE FOR SUICIDAL SOLDIERS: AN ARMY PROCESS IMPROVEMENT INITIATIVE

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October December 2014 59 DEVELOPMENT OF A CLINIC ADVISORY TE A M A well-intended PI effort to raise the clinical standard of care related to suicide risk can be potentially doomed by taking a purely top-down approach. In other words, if the chief of the clinic or the commander of the mili tary treatment facility directs or orders clinical staff to embrace wholesale changes in their clinical practices, resistance in the form of subtle or even overt push-back is likely unavoidable. However, some of the anticipated resistance to changing clinical practices may be moder ated somewhat by abject fears of losing patients to sui cide. In addition, such resistance may be even more con strained by the prospect of malpractice litigation and/or a root cause analysis that attributes a suicide to failures in clinical care. But, even in the face of suicide risk, there are often challenges encountered when changing from familiar clinical practices to a new approach to treat ment. Preparatory actions for the formation of a clinic advisory team can be taken to increase the likelihood of successful implementation. A successful PI initiative may be rooted in the ability of the consulting team to successfully engage key clinic providers as members of an internal advisory team within the overall PI effort. This can not be merely a symbolic gesture. It should be a genuine effort to engage a small group of invested staff members to help shape and tailor the PI efforts to the culture of the clinic. This allows the generation of a bottom-up effort as the advisory team is a key part that come with efforts to improve clinical practices. To visory team should not be too large, perhaps 3 to 5 mem bers depending upon the size of the clinic. Beyond the formation of this internal team, we have also seen the pion who leads the internal team and serves as a point of contact to the external consulting team. Ideally, this champion is someone who has the respect of clinic staff and also has the requisite energy and ability to lead the effort and the work of the advisory team. It is critical that the facility is prepared to make an ongo ing commitment to successfully raising the standard of care through the PI initiative. The clinic advisory team must have strong leadership support and the necessary authority to make systemic changes and exact minimum requirements for success from clinic staff. As previous literature indicates, success or failure in the use of ev behavioral reinforcements for providers to risk changing what they ordinarily do. 12 One of the biggest implications in this regard is that many evidence-based practices are labor intensive and require more front-end engagement, sometimes including longer session durations. An almost certain way to undermine a PI effort is to require busy clinicians to do more on top of more; such an approach will only breed resentment and resistance, dooming the potential success of the PI. Systemic sessions initially, must be pursued so as to reward cli nicians for engaging in an evidence-based form of care. While these providers may see fewer patientswhich is an obvious problem in many over-run systemsthere and matching patients to different kinds of treatments (group vs individual) of different intensities and doses of care in direct relation to the risk that they present. fectively treating the range of suicidal risk. In 2012, the National Action Alliance for Suicide Prevention pub to better accommodate and facilitate the treatment of suicidal risk across treatment settings. 13 SELECTING A N EVIDENCEBA SED APPRO A CH As discussed in previous reviews, 3,14 there have been surprisingly few empirically-supported treatments for suicide risk published in the professional literature. Among the limited options, dialectical behavior thera therapy (CBT) are the leading approaches with the best tary personnel, a newly adapted brief CBT approach is now being studied in randomized clinical trials for suicidal service members in outpatient 15 and inpatient 16 clinical settings. As noted in the review by Schoenbaum and colleagues, 3 other approaches such as Stanley and Browns safety planning intervention 17 and CAMS de veloped by Jobes 18,19 are being studied in Department of Defense (DoD) and Veterans Affairs (VA) settings within rigorous randomized clinical trials. The PI effort described in this article featured the use of CAMS because, as described by Jobes and colleagues, 20 effort to keep suicidal service members out of the hospi tal through the effective development an outpatient sta bilization plan (eg, a crisis response plan or a safety plan) as well as the successful targeting and treatment of key directly and indirectly compel the patient to take their life. It was deemed to have an inherent adaptability that is unique among existing evidence-based approaches. Moreover, this is currently the only published approach that has been used successfully with suicidal active duty service members. 21 In their nonrandomized clinical trial of CAMS vs treatment as usual (TAU) with 55 active

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60 http://www.cs.amedd.army.mil/amedd_journal.aspx duty suicidal Air Force personnel, these investigators observed a strong relationship between CAMS care and use related to emergency department and primary care visits. As described by Jobes in a recent review paper on CAMS, 19 an additional 5 correlational studies have provided uniformly strong support for the effectiveness of CAMS across a variety of settings and populations. A recent, small randomized clinical trial (RCT) provided convincing causal data about the effectiveness of CAMS and overall symptom distress at 12-month follow-up cant increases in hope, patient satisfaction, and reten tion when compared to TAU. 22 Currently, a well-pow ered RCT is underway with suicidal Soldiers in Georgia, and another large RCT is being conducted in Denmark comparing CAMS to dialectical behavior therapy with suicidal outpatients. 19 Given our successful experiences in various PI efforts featuring CAMS, we anticipate the prospective use of CAMS being practiced both widely and effectively with suicidal military members across all service branches. 23 CLINICI A N TR A INING The training process used in the course of this PI initia tive was largely successful but not without challenges. One of the inherent training issues that plague DoD and VA evidence-based professional training is the lack of actual subsequent use of the newly-trained intervention after the training. To address this concern, we sought a 3-phase training approach within the process improve ment effort: 1. Phase I. One full day of didactic CAMS ori entation-training to BH clinical staff across professional disciplines (including psychology technicians). 2. Phase II. Follow-up CAMS role-play training for all clinical providers over a day and half. 3. Phase III. Follow-on consultation calls between key PI members and clinical staff. The following sections detail each phase of train ing and discuss the highlights and challenges that we encountered. Phase I: CAMS Orientation Training A 6-hour PowerPoint-based didactic training session was given to all PI participants from the participating clinic. This orientation training was video-recorded for future use by new providers arriving in the clinic. The goal of this training was to broadly orient the clinicians to help them learn about CAMS, including the theoreti cal foundation and existing empirical support for the approach. This training provided an orientation to the problem of suicide, including the rising rate of suicide cidal behaviors, and the latest research in suicidology. In the course of this training, the providers learned that CAMS is a therapeutic framework, not a new psycho therapy, that emphasizes a certain philosophy of clinical care as well as the clinical use of the suicide status form, a multipurpose assessment, treatment planning, track ing, and outcome tool. Phase II: CAMS Role-play Training This phase consisted of 2 days of training for provid ers approximately one month after Orientation Training. Focus was an introduction to the CAMS suicide status forms which are collaboratively used in all sessions with service members with suicidal behaviors. Role-plays of a hypothetical course of typical CAMS care of 10 to 12 sessions were interspersed with practice in dyads for intakes, safety planning, follow-up sessions, and sui cide resolution sessions using CAMS. Use of the new electronic version of the suicide status form (eSSF) was taught during the second day. Additionally, the SOPs developed by the PI Clinic Advisory Team for integra tion into the clinic and measures for evaluation of the PI were covered. Two separate training sessions were conducted one week apart to accommodate the number of people who required training. Participants of the phase II training were 12 psycholo gists, 7 psychiatrists, 6 social workers, a licensed pro fessional counselor, 5 psychology interns, 2 psychology residents, an advanced practical nurse, a pharmacist, 4 psychology technicians, and a secretary. Prior to the training, participants rated their anxiety working with sess and treat suicidal patients on a 1-5 scale (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly ability to form a strong therapeutic alliance with a pa tient with suicidal concerns (3.9/5), and to successfully assess (3.7/5) and treat (3.6/5) suicidal behaviors. The role-play training sessions were conducted by the external consulting team that included 2 licensed psy chologists and 3 senior doctoral students in clinical psychology. The format for this training experience involved 2 members of the training team performing demonstrations of segments of CAMS over a typical course of CAMS care. One member played a suicidal RAISING THE CLINICAL STANDARD OF CARE FOR SUICIDAL SOLDIERS: AN ARMY PROCESS IMPROVEMENT INITIATIVE

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October December 2014 61 Soldier; the other showed the CAMS-use of the SSF for each segment of care (eg, session 1, a subsequent track After each demonstration role-play, the clinicians in the training sessions were placed in dyads and then asked to role-play the demonstration that was just modeled. Within each training dyad, one partner was designated to role-play a suicidal Soldier-patient that he or she had previously seen, which gave their training partner an experiential chance to learn about using CAMS with a realistic case. With the successful completion of each segment of CAMS, the partners would then switch roles so that each had the chance to experience the clinician role for each training segment. During the role-play ing, members of the external consultation team moved among the dyads to answer questions and make sugges tions if the role-players became stuck or were unclear about certain aspects of the intervention. This role-play of using CAMS. During the training phase, participants completed a 6-question preand postknowledge test to measure their knowledge of CAMS principles and practices. Participants correct scores increased by 1.6 (27%) at posttest. Satisfaction with the implementation training experience was also measured. Most participants were tral. Satisfaction ratings with training averaged greater than 4 (agree) on a 5-point scale for the content and presentation of material, willingness to learn more, and use the material learned in training (4.4/5) and indicated they would recommend other providers participate in CAMS training (4.5/5). Ultimately, the goal for the PI training effort was for all providers to have the orientation and role-play training prior to clinic-wide implementation of CAMS, which oc clinic providers fully oriented and trained in CAMS, the implementation phase would be supported by phase III. Phase III: Follow-on Consultation Calls As noted earlier, the follow-on consultation calls for cli nicians was seen as a critical element to implementation success. The calls between the clinical providers and members of the consultation team began on schedule within weeks of the implementation of CAMS across the clinic. Despite all efforts to thoughtfully orient, train, and prepare providers through the phasic training process, early uptake and use of this intervention was slow and inconsistent among all providers. In our ex perience, there was initial reluctance of many staff members to use the evidence-based treatment for which they had been trained because many reported that they were too busy to introduce a new and complicated approach into their practice. In spite of this feedback, one provider was able to present a new case almost ev ery week and the patients markedly improved. Hearing about this success over time inspired clinicians to give the approach a try. There were various problems that we encountered in the course of the training. Although CAMS was imple mented in military and VA settings prior to this PI initia tive, it had not been integrated into an Army BH clinic. Therefore, the trainers approach to the PI was to keep providers in a busy military clinic. The initial format of training was based on the extensive training experience of one of the authors (D. A. J.) who developed CAMS. timate form of training, but also may have introduced some ambiguity for providers. The biggest problem that plagued each phase of training was related to technology. The training team decided to develop the digital eSSF, with the hope of potential ease of use in administration and the collection of long-term outcome data. However, the beta version of the eSSF to be more cumbersome for providers than expected. It required a multistepped procedure for converting SSF data into a PDF that could then be cut and pasted into the electronic medical record. Providers in the initial training experienced frustration with the system and the transfer of the document, which produced a nega tive perception of the eSSF. Providers comments were the Phase III training. The results of the CAMS roleplay training were somewhat mixed. Much of the roleplay training slowed due to the technology complication which became a major distraction. Ultimately, within the PI effort, the decision was made to scan hard copy versions of the SSF into the electronic medical record due to the many complications associated with the eSSF. The acceptance and routine use of CAMS in the targeted clinic was quite slow from the start and was also some what discouraging. There was both subtle and overt re sistance to using CAMS consistently across clinic pro viders. Providers were encouraged to use the approach, gently noting it was clinic policy to be using the inter vention. However, there were transitions in leadership

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62 http://www.cs.amedd.army.mil/amedd_journal.aspx as well as internal systems issues that perhaps contribut ed to the modest start. For example, personnel changes due to deployment and staff turnover were challenging during the 3-year implementation of the PI. The clinic leadership changed 5 times, causing at least a tempo rary setback each time. Also, participation in the PI was initially mandatory for all providers. However, as leaders changed and reprioritized the PI, a reduction in staff adoption was experienced and implementation was momentum was lost during the training and implemen tation process due to unexpected challenges related to funding the contract, which resulted in the PI being in terrupted for 6 months, thereby delaying the second ori entation training. Reenergizing the PI proved to be chal lenging for the team. Nevertheless, we did eventually see the critical effect of 2 dedicated successive cham pions who led the clinic advisory team and sustained a focus on the use of the intervention. In addition, both department and internal clinic leadership maintained steady support for the use of the intervention. TR A CKING PI OU TCOMES An evaluation plan to assess both the process and out comes of the PI initiative was constructed prior to its implementation. The process evaluation focused on documenting various portions of the PI initiative, in cluding the clinic advisory team and Warrior Resiliency Program team meetings, the Southern Regional Medical Command organization supporting the PI, and consul tation calls. These documents served as due diligence for the processes associated with the PI and reminded individuals of tasks due to the various groups involved. Additionally, the process evaluation was helpful in doc of the PI initiative. An outcome evaluation plan was constructed which in services, and measurable outcomes expected from the PI initiative as shown in the Figure. Components that were to be assessed were CAMS training, the eSSF, consultative support, and the postvention process. The use of CAMS was to be assessed by an increase in the frequency and quality of documentation of suicide risks and treatment course in the electronic medical record. Individual patient outcomes were to be documented by 2 standardized instruments. The Scale for Suicide Ideation (SSI) and the Outcome Questionnaire 45 (OQ-45), were given by the providers at both the beginning and end of treatment to assess CAMS effectiveness. The clinic ad visory team assisted in determining how the instruments would be administered based on measures used in past research studies using CAMS, 20,22 as well as the time to administer and the training required for administration. While other outcome measurements were initially intro duced, they proved to be too complex to complete given multiple personnel changes at the clinic and the organi zation facilitating the PI and the operational tempo of the clinic. The possibility of the active duty psychology technicians administering the measures was explored, however, due to their changing roles/responsibilities and obligations outside the clinic, they were ruled out as an option to relieve some of the time constraints of the providers. Another option explored for administra tion of these measures was to use them during patient triage, but providers reported that they would prefer to administer the measures in order to build rapport and obtain important data related to the service members suicidality. In spite of great care in vetting the SSI and OQ-45 with the Clinic Advisory Team, providers did not feel they had adequate time to provide services and col to the administration of the measures beyond collection of data for the PI, and many reported that they would use them if allotted more time for their intake sessions with the service member. Unfortunately, due to the high workload, this was not feasible. Therefore, due to realitybased constraints, both instruments were dropped from the evaluation plan and a plan for qualitative evaluation through focus groups was developed. At the end of the PI initiative, focus groups were held by a person not involved in its implementation. A total of 11 individuals attended 2 focus groups. Two of the individuals had recently been hired and were trained by a designee in the clinic. Focus group participants were asked about the training, their use of CAMS, the SSF During these focus groups, the majority of individu als (63%) indicated relatively consistent use of the SSF, while 27% used it here and there, but not consistently. When asked about their overall use of CAMS, few indi viduals reported using CAMS regularly according to the original protocol. Participants indicated that the SSF did not work well in triage with high risk patients because of the time needed to perform an intake. A familiar, shorter for individuals who were likely to be hospitalized. Mixed opinions regarding training were expressed in re views. Some individuals who attended the focus group indicated the training was long and too basic for senior clinicians. Most participants indicated the eSSF training time was wasted because it was never implemented. Oth er participants were pleased with training, indicating it was clear and precise and people understood everything RAISING THE CLINICAL STANDARD OF CARE FOR SUICIDAL SOLDIERS: AN ARMY PROCESS IMPROVEMENT INITIATIVE

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October December 2014 63 that was being taught. Participants feedback on the SSF was largely positive. Participants indicated that using the form was good for not getting lost in drama or stories, but helped focus quickly on the drivers of suicidal ide ation. They also commented that collaboration with the patients increased because they signed and dated the form, validating the information and showing them ex actly why they are in treatment. One person said the form was useful beyond the suicidality to speed up treatment. Individuals also gave largely positive feed back on the consultation calls, primarily for meeting an area of unmet need at the clinic. Some appreciated the cases and found suggestions he gave helpful. Others in dicated that it was most valuable to discuss cases with their colleagues since we dont get to do that very often anymore with the amount of work load given. SU ST A INMENT OF PI INITI A TIVE A plan for sustainment of the new process for the use of the CAMS framework was made at the beginning of the PI initiative. Clinic protocols and SOPs were developed for each area of use for CAMS in the clinic including triage, intake session, follow-up visits, termination ses the leadership, providers, and other clinic staff, includ ing the front desk staff, in supporting the use of CAMS within the clinic. The SOPs were intended to provide guidance to current staff as well as new staff, and be and to adapt as needed over time. A model for ongoing training of new staff and refresher training was envi sioned to be completely managed within the clinic by two volunteers or selected clinic staff members. Howev er, because of staff changes and the waxing and waning Process Outcomes Activities Participants What we invest: What we do: Whom we reach: Providers and staff at the Behavioral Health Clinic Dr Jobes and Catholic University of America team Facilitating organization staff Facilitating organization funding CAMS book Needs assessment Sensing sessions CAMS training Risk assessment Treatment Documentation Create electronic version of the SSF Documentation Support Consultative support Postvention process Behavioral health providers Soldiers (all components) Program stakeholders (eg, family members) Effects Short-term Medium-term Long-term What are the expected short-term ef fects and measures? What are the medium-term effects and measures expected one to 2 years out? What are the long-term effects and measures expected 2 to 5 years out? Changes in practice Improved accuracy of risk assessment Increased clarity in treatment planning Resolution of suicidal crisis Decrease no-show rate Increased documentation of risks and treatment course Increased sense of provider support Use and satisfaction with consultation service Decrease in provider anxiety Increased confidence in how leaders handle deaths by suicide Increased competence in assessment and treatment of suicidal behaviors Decreased hospitalization Increased tracking of disposition Increased clinical outcome tracking Decreased perceived organizational barriers Increased perceived provider support Increase quality of care Decreased cost of care Improved professional quality of life The outcome evaluation plan logic model depicting the flow of resources, services, and measurable outcomes expected from the collaborative assessment and management of suicidality (CAMS) PI initiative. Mission: Pilot test and develop a military-specific, evidence-based, best-practice framework for suicide risk assessment, treatment, and documentation

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64 http://www.cs.amedd.army.mil/amedd_journal.aspx support for the PI initiative, the training plan originally developed as a train-the-trainer model, did not material ize. Instead, a clinic staff member involved in imple mentation in the clinic used the videotaped orientation training to informally instruct new employees. LESSONS LE A RNED FOR A PI INITI A TIVE IN A MILIT A RY BEH A VIOR A L HE A LTH CLINIC With strong leadership and sustained focus over time, providers eventually began using CAMS with their sui cidal Soldiers and realizing clinical success. Within 6 months of formal implementation, a robust clinical con sultation meeting evolved where the majority of provid from the constructive and collegial phone meeting with members of the external consultation team. Critically, the explicit and implicit blessing of key, respected staff members seemed to markedly turn the tide from resistance to acceptance for the majority of providers in the clinic to use CAMS or at least be supportive of its use. With regard to tracking patients with suicide risk, ide ations, and/or attempts, clinic leadership instituted the required use of the high-interest patient database for all Soldiers seen within the clinic experiencing suicidal ideation, suicide attempts, or hospitalization. The policy included and tracked in the database. The high-interest patient database, along with the CAMS documentation placed directly in the electronic medical record, provid ed the clinic with a method to track and monitor Soldiers who have any inclinations or concerns related to suicide. The program evaluation was designed to generate sim randomized controlled trial, therefore, evaluation meth Although more systematic evaluation methods were preferred, given the circumstances it was necessary to adapt. The feedback resulted in the creation of an updat ed version of CAMS training for the Army which is cur rently being implemented in another Army BH clinic. As a result of provider feedback, 2-day training consist ing of orientation of CAMS and role-playing training basic competence in delivering CAMS. In terms of its actual clinic use, there were internal ad aptations in the use of CAMS that occurred naturally as the clinic staff and culture became more interested in using the approach. For example, there were cases where clinical social workers (who are assigned to han dle walk-ins) would initially engage a suicidal Soldier in CAMS for a few sessions while waiting for psycho therapy (provided by psychologists) openings in the schedule. When a walk-in who was initially engaged by a CAMS-using clinical social worker began psychother apy sessions, the transition to ongoing CAMS care with the new provider was readily facilitated because both the social worker and psychologist were familiar with treatment. In one case, the Soldier proudly presented the CAMS-guided SSF work that he done with his walkin social worker to his new psychologist psychotherapist, who was of course quite interested and receptive. The process under which all clinic providers worked from the same sheet of music proved to be highly effective for a number of cases within this clinics system of care. Finally, it is interesting to note the success was achieved in a separate Army BH clinic that was added near the end of the CAMS familiarization training Even though members of this clinic staff received only the one-day orientation training (ie, they did not receive the role-play training and were not a part of the follow-on consulta tion calls), they had virtually adopted the use of CAMS by every provider within 6 months following the train ing. This particular clinic had received much less formal focus within the larger PI effort and limited consultation from the Warrior Resiliency Program team, but never theless enthusiastically adopted the CAMS strategy. This apparent success was attributed to strong internal leadership and an internal clinic culture that readily em braced evidence-based practices and worked with sensi tivity to being second guessed in a root cause analysis should a suicide occur. of Soldiers at risk and connecting them with helping resources, primarily Army BH. Although Army Medi cine functions as a single healthcare system, there are few policies that standardize processes for BH provid ers with regard to the clinical management of suicidal the primary patients. As a result, there is a need for knowledge regarding the application of an evidencebased treatment for suicide within individual Army BH clinics. The Process Improvement Initiative discussed in this article provided a unique insight into creating systematic change in a military behavioral health clinic and provided knowledge regarding perspectives of Sol diers and BH providers as well as areas of need. The PI initiative also showed the potential to enhance the clinical standard of care through improved clinical pro cesses for suicide risk mitigation with the intervention of a suicide-focused clinical treatment tailored for the Army population. The use of CAMS offers providers a framework for managing a patients symptoms related RAISING THE CLINICAL STANDARD OF CARE FOR SUICIDAL SOLDIERS: AN ARMY PROCESS IMPROVEMENT INITIATIVE

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October December 2014 65 to the patients suicidal ideations or attempts, a process for documenting the risk and the development of an infrastructure for support with the clinic. Due to the in tricacies encountered during the implementation of this PI initiative, the lessons learned from this project were key in the development of the design for the randomized clinical controlled trial using CAMS implemented at Ft Stewart, Georgia. Future possibilities for the develop ment of PI projects for implementation at other instal lations such as Darnell Army Community hospital at Ft Hood and Walter Reed Army Medical Center have been under consideration as well. Areas of future research include examining the use of the PI to determine if it reduces suicide scores or reduc es the need for curbside consultations with a military population. Real-life constraints limited this PI project from collecting data within these areas. Working with the Air Force, Jobes et al 21 found reductions in emer gency departments and primary care visits were related of the clinic staff to investigate if the adoption of CAMS bolsters the moral of the clinic and/or increases effective for future research. REFERENCES 1. Luxton DD, Osenbach JE, Reger MA, et al. Depart ment of Defense Suicide Event Report (DoDSER) Calendar Year 2011 Annual Report. Tacoma, WA. National Center for Telehealth and Technology; 2012. Available at: http://t2health.dcoe.mil/sites/de pdf. Accessed October 17, 2014. 2. Kinn JT, Luxton DD, Reger MA, Gahm GA, Skopp NA, Bush NE. Department of Defense Suicide Event Report (DoDSER) Calendar Year 2010 An nual Report. Tacoma, WA. National Center for Telehealth and Technology; 2011. 3. Shoenbaum M, Heissen R, Pearson J. Opportuni ties to Improve Interventions to Reduce Suicidal ity: Civilian Best Practices for Army Consid eration. Washington DC: US Dept of Health and Human Services; 2009. 4. Army Health Promotion, Risk Reduction, and Sui cide Prevention Report 2010 Washington, DC: US Dept of the Army; 2010. Available at: http://csf2. army.mil/downloads/HP-RR-SPReport2010.pdf. Accessed August 3, 2013. 5. US Department of Defense. Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury Website. Available at: http://www. Warriors.aspx. Accessed August 2, 2013. 6. Army Releases December 2012 and Calendar Year 2012 Suicide Information [news release]. Washing ton, DC: US Department of Defense; February 1, 2013. Available at: http://www.defense.gov/releas es/release.aspx?releaseid=15797. Accessed August 12, 2013. 7. Chappell W. US militarys suicide rate surpassed combat deaths in 2012. National Public Radio [serial online]; January 14, 2013. Available at: http://www.npr.org/blogs/thetwo-way/2013/01/ 14/169364733/u-s-militarys-suicide-rate-sur passed-combat-deaths-in-2012. Accessed August 12, 2013. 8. Conrad, AK, Jacoby AM, Jobes DA, et al. A psy chometric investigation of the suicide status form II with a psychiatric inpatient sample. Suicide Life Threat Behav 2009;39:307-320. 9. Ritchie EC. Suicide and the United States Army: perspectives from the former psychiatry consultant to the Army Surgeon General. Cerebrum January 2012. Available at: http://dana.org/news/cerebrum/ detail.aspx?id=35150. Accessed August 25, 2014. 10. Insel BJ, Gould MS. Impact of modeling on ado lescent suicidal behavior. Psychiatr Clin North Am 2008;31:293-316. 11. Ramchand R, Acosta J, Burns RM, Jaycox LH, Pernin CG. The War Within: Preventing Suicide on the US Military Santa Monica, CA: RAND Cor poration: 2011. Available at: http://www.rand.org/ pubs/monographs/MG953.html. Accessed October 1, 2014. 12. Jobes DA, Bryan CJ, Neal-Walden TA. Conducting suicide research in naturalistic clinical settings. J Clin Psychol 2009;65:382-395. 13. Covington D, Hogan M, and the Clinical Care & Intervention Task Force. Suicide Care in Systems Framework Washington, DC: National Action Al liance for Suicide Prevention: 2011. Available at: http://actionallianceforsuicideprevention.org/sites/ actionallianceforsuicideprevention.org/files/task forces/ClinicalCareInterventionReport.pdf. Ac cessed August 7, 2013. 14. Psychiatry 2013;76(2):126-131. 15. Rudd MD. Brief cognitive behavioral therapy (BCBT) for suicidality in military populations. Mil Psychol 2012;24:592-603. 16. Ghahramanlou-Holloway M, Cox DW, Greene FN. Post-admission cognitive therapy: a brief intervention for psychiatric inpatients admit ted after a suicide attempt. Cogn Behav Pract 2012;19(2):233-244.

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66 http://www.cs.amedd.army.mil/amedd_journal.aspx 17. Knox KL, Stanley B, Currier GW, Brenner L, Ghahramanlou-Holloway M, Brown G. An emer gency department-based brief intervention for vet erans at risk for suicide (SAFE VET). Am J Public Health 2012;102(suppl 1):S33-S37. 18. Jobes DA. Managing Suicidal Risk: A Collabora tive Approach New York, NY: The Guilford Press; 2006. 19. Jobes DA. The collaborative assessment and man agement of suicidality (CAMS): an evolving evi dence-based clinical approach to suicidal risk. Sui cide Life Threat Behav 2012; 42:640-653. 20. Jobes DA, Comtois K, Brenner L, Gutierrez P. Clinical trial feasibility studies of the collabora tive assessment and management of suicidality (CAMS). In: OConnor RC, Platt S, Gordon J, eds. International Handbook of Suicide Prevention: Research, Policy, & Practice West Sussex, UK: Wiley-Blackwell; 2011:383-400. 21. Jobes DA, Wong SA, Conrad A, Drozd JF, NealWalden T. The collaborative assessment and man agement of suicidality vs treatment as usual: a ret rospective study with suicidal outpatients. Suicide Life Threat Behav 2005;35:483-497. 22. Comtois KA, Jobes DA, OConnor SS, et al. Col laborative assessment and management of suicidal ity (CAMS): feasibility trial for next day appoint ment services. Depress Anxiety 2011;28:963-972. 23. Jobes DA, Lento R, Brazaitis K. An evidencebased clinical approach to suicide prevention in the Department of Defense: the collaborative assess ment and management of suicidality (CAMS). Mil Psychol. 2012;24:604-623. AU THORS Dr Archuleta is with the University of Texas Health Sci ence Center at San Antonio, Texas. Dr Jobes, Mr Jennings, Dr Crumlish, Ms Lento, and Ms Brazaitis are with The Catholic University of America, Washington, DC. Dr Pujol is with the Brooke Army Medical Center, San Antonio Military Medical Campus, San Antonio, Texas. Dr Moore and Dr Crow are with the Warrior Resiliency Program of the Southern Regional Medical Command, Fort Sam Houston, Texas. RAISING THE CLINICAL STANDARD OF CARE FOR SUICIDAL SOLDIERS: AN ARMY PROCESS IMPROVEMENT INITIATIVE

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October December 2014 67 Traumatic brain injury (TBI) is an increasing health problem with approximately 1.4 million people affected annually. 1 Of those affected, nearly 75% are considered to have a mild TBI. 2 Also known as a concussion, mild 3 The Centers for Disease Control and Prevention (CDC) estimated the national cost at nearly $17 billion (10 9 ) each year, with 10% to 15% of patients diagnosed with mild TBI suffering from persistent disabilities. The US Public Health Service estimated 14% to 20% of mili tary service members have sustained TBI since the be ginning of the Iraqi and Afghanistan wars. 4 Of those military service members sustaining TBI from combat, mild TBI is estimated to encompass about 11% of these injuries or about 75% of all head injuries. These per centages are comparable with nationally reported TBI prevalence data for civilians. Based on these statistics, mild TBI has become the signature injury of the 21st century Middle East wars. 4 and referred by their primary care provider to a spe cialist. Communication, collaborative teamwork, and and effective treatment for TBI. 5 Novak and Fairchild 6 with A. Bowles, MD (February 27, 2013), lack of com medical treatment facilities between primary care pro viders and specialists when patients with suspected mild TBI were referred for further evaluation and treatment. Dr Bowles cited poor communication with behavioral health, a difference in the understanding of concussion, and lack of agreement in fundamental philosophies for tary healthcare system. In general, Meester et al 7 cited The Joint Commission (TJC) as also reporting effective communication among healthcare providers as being poor; moreover, TJC en couraged improvement in communication between pro viders to reduce potential errors and improve patient outcomes. The use of a situation, background, assess ment, and recommendation (SBAR) tool may be useful in organizing information and providing cues for com municating what is important between medical provid ers. 8 The SBAR is a communication tool that can be applied to many situations between healthcare profes sionals to facilitate an exchange of needed information. 9 The SBAR generally provides information as to what is happening, pertinent background information about the situation, and a relevant health assessment, and of fers potential solutions for consideration. 9 Furthermore, Mitchell et al 10 developed an assessment tool based on the SBAR format that was validated to identify and im prove the overall quality and educational value. This tool contained 3 successful iterations with internal Mild Traumatic Brain Injury in the Military: Improving the Referral/Consultation Process MAJ Charles Watson, AN, USA ABSTR A CT Background: Objective: To determine if the use of an overprinted communication tool would improve the referral/consultation Design: The consultation/referral process was evaluated following an educational presentation regarding the use of a situation, background, assessment, and recommendation (SBAR) communication form. Data were collected from consultation charts before and after two months of use of the SBAR communication form. Results: The communication tool improved capture of dates of injury, prior treatment, history of testing, patient education, and request for therapy. Conclusion: Findings from this project demonstrated that a communication tool such as the TBI-SBAR would be benecial for use in primary care clinics. This article is the text of a Residency Project presented by MAJ Watson to the Graduate Faculty of the University of Missouri in candidacy for the degree of Doctor of Nursing Practice at the School of Nursing, University of Missouri, Columbia, Mis souri, April 24, 2014.

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68 http://www.cs.amedd.army.mil/amedd_journal.aspx consistency and interassessor reliability improving with each iteration. 10 the military medical facility, particularly when a refer ral is made by the primary care provider to a special tion tool such as an SBAR. The University of Missouri and Brooke Army Medical Center Institutional Review Boards both viewed this as a Quality Improvement proj ect and exempted it from human subjects review. The purpose of this quality improvement project was to determine if using the SBAR tool would improve com munication during the referral process for mild TBI be tween primary care and specialty clinics in one Army medical center. BA CKGRO U ND Traumatic brain injury occurs when an external force or rapid acceleration/deceleration force causes damage to the brain. This can be the result of an indirect force such as a blast exposure or from a direct force such as a blow to the head. 3 Traumatic brain injuries are acute processes with pathophysiological cascades that can be neuroprotective agents administered before or within 15 plementing treatments. 11 The effect of resultant neuro function manifested as impairment in cognitive func tion and/or physical function. 12 Bryan and Hernandez 13 suffering from a mild TBI and a slower reaction time from those who also suffer from headaches and psy chological symptoms as compared to those without any head trauma or illness. In general, mild TBI symptoms usually occur immediately or within days of the event but resolve within 3 months postinjury. 14 These mild symptoms, or the immediate lack thereof, may make it and begin treatment. Additional diagnostic testing may enable primary care doctors to make more informed de cisions when deciding care for patients suffering from any head trauma. For patients undergoing acute neuro imaging as part of their initial evaluation, the computed provide important baseline information. 15 Boake et al 16 reported that the frequency of postconcus sive symptoms (PCS) in patients without obvious brain injury supported the theory that symptoms of PCS may another study, a change or lack of symptoms in indi not to have a correlation with mild TBI. 17 Posttraumatic headaches (PTHA) have also been studied. Bryan and Hernandez 13 reported a longer loss of consciousness (LOC) was associated with increased PTHA severity, whereas, in former studies, longer LOC was associated with a greater severity of brain injury. This suggests that a greater LOC may be more associated with a more se vere TBI versus a mild TBI. The CDC 3 reported better outcomes when a mild TBI was diagnosed early, making it imperative that com munication between primary care and specialty provid been done to standardize the process for communica 18 There are various ways of communicating between nurses, pro viders, and ancillary staff, including verbally, written, and electronically. The SBAR was developed by the military, adapted by the airlines, and used initially in the Kaiser Permanente healthcare system. Evidence shows that SBAR may be applied to communication between providers in almost any healthcare setting. 9 provides important background information, enhances a focused assessment, and offers recommendations for consideration. 9 Renz et al 8 found the implementation of the SBAR coupled with targeted training on its use improves satisfaction with the communication by stan dardizing important required information and providing structure for the communication of this information. The SBAR provides a timely and pertinent communica tion narrative blending nursing and physician communi cation documentation techniques. 19 An SBAR commu nication tool may enhance communication of pertinent information from a primary care provider for referral to a specialist. For example, MacGregor et al 20 reported personnel with symptoms of mild TBI were much more likely to report headaches, memory problems, tinnitus, and dizziness compared to those personnel without head injuries. It is important for that information to be specialists, neurologists, and neuropsychologists as part of a referral. Nurses, physicians, and ancillary healthcare providers are frequently in situations requiring accurate and time ly communication. 19 As the SBAR has been primarily used by nurses, lack of education about SBAR among physicians has resulted in inconsistencies in its imple mentation and sustainability. 21 5 devel oped an instructional guide that included the purpose, objectives, goals, and directions for a simulation experi ence involving the use of an SBAR. Simulation exercis es and structured opportunities offered useful feedback MILD TRAUMATIC BRAIN INJURY IN THE MILITARY: IMPROVING THE REFERRAL/CONSULTATION PROCESS

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October December 2014 69 ence of those who performed recommended exercises. 22 In healthcare settings, Kotter and Cohen 23 recommend ed beginning with the formation of a healthcare team to tion problem between departments. Interventions and 24 Next, the goal of the intervention or outcomes should be established and communicated, the intervention implemented, performance feedback provided, the new process or intervention monitored for tion into standard practice with ongoing monitoring. 23 In summary, it is notable that there are a host of issues at work in TBI, such as postconcussive syndrome, post traumatic headaches, and ineffective communication between primary care providers and specialists. Since patients with mild TBI do better when diagnosed early, any action that leads to quick, effective communication is welcomed. 3 Evidence shows that implementation of the SBAR paired with targeted training on its use im proves communication (rate and effectiveness) by pro viding structure and standardization of the information being communicated. 8 ASSESSMENT OF THE PROBLEM tute for Healthcare Improvement was used for this quali ty improvement project. 25 to the TBI clinic were initially reviewed to determine what information that may be important for the referral consultation was provided consistently or not provided. 1, 2013, and November 30, 2013. A meeting was held provider staff to review this information and determine what information would be most helpful for optimum communication from the primary care provider to the TBI specialist. STR A TEGIES FOR QUA LITY IMPROVEMENT An SBAR tool, presented in the Figure, was created based on peer review from the above mentioned meet by primary care clinics for referrals made to the TBI clinic was directed. An initial education session was held in December 2013 to familiarize physicians, nurse practitioners, and physi mented between January 1, 2014, and March 2, 2014. During that time, a biweekly site visit was conducted to answer questions or concerns that providers had regard ing implementation of the tool. A retrospective chart re view regarding use of the tool and appropriateness of the referral was completed after the implementation period. POST IMPROVEMENT IMPLEMENT A TION RES U LTS Information was collected about the documentation of communication between providers before the SBAR developed by the primary care provider, the reason for the referral, the date of injury, any prior treatment, any history of prior testing, any patient education provided by the primary care clinic, and if a request for therapy by the referring providers (physicians, physician assis tants, and nurse practitioners) was recorded. A referring diagnosis was noted. No referring diagnosis was noted as such. In regards to reasons for referrals, it was noted whether or not there was an actual reason for the referral, and exactly what that reason was. Additionally, any dates of injury, prior treatment, complication with treatment, history of testing, patient education provided by the pri mary care clinic, or request for therapy by the referring provider were all noted only as being present or absent. No detailed mention of these data was needed, only the presence or absence of each element was recorded. The 2 test for independence was used to compare the documentation of communication of important infor The Table details the means and standard deviations Patient education provided by the primary care clinic P =.05 level ( 2 =14.18, d =1). Communication of any patient Results for Pre-SBAR and Post-SBAR Implementation Chart Reviews (N=62) Including Means and Standard Deviations for Each Category Category Pre n Post n Pre mean (SD) Post mean (SD) Diagnosis present 33 25 0.94 (0.24) 0.89 (0.31) Reason for referral 35 28 1 (0) 1 (0) Date of injury 19 21 0.54 (0.51) 0.75 (0.44) Prior treatment 10 13 0.29 (0.46) 0.89 (0.31) History of testing 7 7 0.2 (0.41) 0.25 (0.44) Patient education 0 3 0 (0.11) 0.11 (0.31) Request for therapy 34 28 0.97 (0.17) 1 (0) Statistically significant. Patient education provided by the primary care clinic was more likely to be communicated to the TBI clinic and was statistically significant at the P =.05 level ( 2 =14.18, d =1 ).

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70 http://www.cs.amedd.army.mil/amedd_journal.aspx education given by the primary care provider depends on the use of an SBAR. Despite evidence of improved communication with the other variables, they were not COMMENT This project demonstrated improved documentation and implementation for 5 of the 7 items of important in formation: the date of injury, any prior treatment, any history of testing, any patient education provided by primary care clinics, and a request for therapy by the referring providers (physicians, nurse practitioners, and physician assistants). Based on feedback from the TBI specialists, documentation of patient education given in the primary care clinics was thought to be an important MILD TRAUMATIC BRAIN INJURY IN THE MILITARY: IMPROVING THE REFERRAL/CONSULTATION PROCESS SBAR Patient Transfer Communication Tool: Mild Traumatic Brain Injury Services Report given by: _______________________ Time: ____________ Phone: _________________ Report received by: _______________________ Phone: _________________ S Situation: [ Patient name [ Age/race/gender [ Chief complaint [ Provisional diagnosis [ Reason for referral [ Referring agency B Background: [ Date of injury [ Type of injury [ Previous testing (psychiatric testing, labs, radiology, etc) [ Treatment history (medications, therapy, hospitalization, etc) [ Patient education [ Complications with treatment A Assessment: Mild TBI Symptoms Early [ Headache [ Dizziness or vertigo [ Lack of awareness [ Nausea with/without memory dysfunction [ Vomiting Late [ Persistent low grade headache [ Lightheadedness [ Poor attention/concentration [ Excessive fatigue [ Bright light intolerance [ Loud noise intolerance [ Tinnitus [ Anxiety [ Depression [ Irritability/low frustration tolerance PTSD Symptoms Avoidance [ Emotionally numb [ Avoidance of enjoyable activities [ Hopelessness [ Memory problems [ Concentration problems [ Relationship problems Anxiety and Increased Emotional Arousal [ Irritability [ Overwhelming guilt or shame [ Self destructive behavior [ Sleeping difficulties [ Easily startled or frightened [ Hallucinations R Recommendation If provider has assessed using all of the above mentioned tools and patient meets criteria for mild TBI, then refer patient to TBI clinic and request request for speech therapy or request for additional diagnostic testing to R/O mTBI). If provider has assessed using all of the above mentioned tools and patient does not meet criteria for mild TBI, then return patient to PCP for additional diagnostic workup or refer patient to care based on diagnostic criteria met.

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October December 2014 71 element of information for the TBI clinic. Prior to SBAR implementation, documentation of this information was nonexistent. The implementation of an SBAR demon munication of this information. dates of injuries, whereas 75% captured these dates these requests. It is evident that the use of the SBAR, The SBAR may have served as a guide to improving documentation as well as increasing provider awareness on what is critical for TBI clinic specialist to know. LESSONS LE A RNED Lessons learned from this project include building in time to collect more information from more charts. Since a validated clinical tool for screening of mild TBI was not used, referrals from the primary care provider to the TBI specialist was subjective and may have been dependent on provider training when initiating the re ferral. Current clinical tools used to detect mild TBI are held to subjective reports of symptoms and short cogni tive exercises but offer little objective evidence for clini cal decisions. 26 The diagnosis of mild TBI is challenging due to a variety of symptoms including cognitive, physi cal, and/or behavioral, and may be confused with other medical issues. 27 The presence of comorbid conditions such as posttraumatic stress disorder (PTSD) may have been a confounding factor. Given the existing low detec tion rate and undertreatment of people with PTSD, im plementation of PTSD screening tools in general mental health treatment settings are recommended 28 but were McKenzie 18 categories for communicating important information, furthering the notion that tailoring SBARs to various based on a lack of consensus between departments and providers as to what should be included. IMPLIC A TIONS A ND RECOMMEND A TIONS FOR PR A CTICE This quality improvement project used existing evidence that there are communication problems between pri mary and specialty providers in referring potential TBI patients, selected the SBAR communication format, im plemented it, and measured whether it improved docu mentation of key elements that should be communicated in TBI referrals. The SBAR intervention seemed to im prove the referral/consultation process by identifying key elements of information in the TBI referral. An SBAR tool is recommended for use when communicating be tween the primary care provider and a specialty provider. nication between the primary care clinic and the TBI clinic. Improving communication may have enhanced formation needed by the TBI specialist and allowed for consultation. This was achieved by the reduction in time spent by the TBI specialist contacting the referring pro with the Performance Improvement Research Assess ment Program team enhanced implementation of the process. Involvement of quality improvement experts is recommended when implementing process change be tween departments. CONCL U SION Findings from this project demonstrated that use of a the frequency that key elements were documented be tween 3 primary care clinics and the TBI clinic located within a large Army medical center. Other healthcare particularly between primary care and other specialty services. Enhanced communication may reduce errors and improve patient outcomes. REFERENCES 1. matic brain injury and anxiety sequelae: a review of the literature. Brain Inj 2. Rao V, Bertrand M, Rosenberg P, Makley M, depression after mild traumatic brain injury. J Neu ropsychiatry Clin Neurosci 3. Traumatic Brain Injury page. Centers for Disease Control and Prevention web site [2014]. Available at: http://www.cdc.gov/TraumaticBrainInjury/. Ac cessed July 25, 2014. 4. Helmick K, Parkinson G, Chandler L, Warden D. Mild traumatic brain injury in wartime. Fed Pract 5. tion and patient safety in simulation for mental health nursing education. Issues Ment Health Nurs

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72 http://www.cs.amedd.army.mil/amedd_journal.aspx 6. Novak K, Gordon M. Bedside reporting and SBAR: improving patient communication and satisfaction. J Pediatr Nurs 7. Meester K, Verspuy M, Monsieurs KG, Van Bo munication and reduces unexpected death: a pre and post intervention study. Resuscitation 8. Renz SM, Boltz MP, Wagner LM, Capezuti EA, Lawrence TE. Examining the feasibility and util Geriatr Nurs 9. Thomas C, Bertram E, Johnson D. The SBAR communication technique. Nurse Educ 10. Mitchell EL, Lee DY, Arora S, et al. SBAR M&M: a feasible, reliable, and valid tool to assess the qual ity of surgical morbidity and mortality conference presentations. AM J Surg 11. Kompanje E, Maas A, Hillhorst M, Slieker F, Teas dale G. Ethical considerations on consent proce dures for emergency research in severe and moder ate traumatic brain injury. Acta Neurochir (Wien) Accessed July 25, 2014. 12. Arciniegas D, Anderson C, Topkoff J, McAllister T. Mild traumatic brain injury: a neuropsychiatric approach to diagnosis, evaluation, and treatment. Neuropsychiatr Dis Treat 13. ic head severity among deployed military person nel. Headache 14. Bergman K, Bay E. Mild traumatic brain injury/ concussion: a review for ED nurses. J Emerg Nurs 15. Bigler E. Neuroimaging in mild traumatic brain in jury. Psychol Inj Law 16. Boake C, McCauley S, Levin H, et al. Diagnostic criteria for postconcussional syndrome after mild to moderate traumatic brain injury. J Neuropsychi atry Clin Neurosci 17. Meares S, Shores EA, Taylor AJ, et al. The pro spective course of postconcussion syndrome: the role of mild traumatic brain injury. Neuropsychol ogy 18. idence base for a standardized provider handover structure: using staff nurse descriptions of infor mation needed to deliver competent care. J Contin Educ Nurs 19. Woodhall LJ, Vertacnik L, McLaughlin M. Imple mentation of the SBAR communication technique in a tertiary center. J Emerg Nurs, 20. MacGregor A, Dougherty A, Tang J, Galarneau M. Postconcussive symptom reporting among US combat veterans with mild traumatic brain injury from operation Iraqi freedom. J Head Trauma Re habil 21. Compton J, Copeland K, Flanders S, Cassity C, Spetman M, Xiao Y, Kennerly D. Implementing SBAR across a large multistate hospital health system [abstract]. Jt Comm J Qual Patient Saf 22. Johnson M, Hamilton M, Delaney B, Pennington N. Development of team skills in novice nurses through an athletic coaching model. Teach Learn Nurs 23. Kotter J, Cohen D. The Heart of Change. Real-Life Stories of How People Change Their Organiza tions. Boston, MA: Harvard Business School Press. 2002. 24. Rosswurm MA, Larrabee JH. A model for change Image J Nurs Sch 25. Institute for Healthcare Improvement. Improv Available at: http://www.ihi.org/resources/pages/ tools/plandostudyactworksheet.aspx. Accessed July 25, 2014. 26. Prichep L, Jacquin A, Filipenko J, Dastidar S, Za of traumatic brain injury severity using informed gorithms. IEEE Trans Neural Syst Rehabil Eng 27. Kan E, Ling E, Lu J. Microenvironment changes in mild traumatic brain injury. Brain Res Bull 28. Tiet Q, Schutte K, Leyva Y. Diagnostic accuracy of brief PTSD screening instruments in military veterans. J Subst Abuse Treat AU THOR Health Nurse Practitioner at the San Antonio Military Medical Center and is on the faculty of the Behavioral Health Technician Program at the Medical Education and Training Campus, Joint Base San Antonio Fort Sam Houston, Texas. MILD TRAUMATIC BRAIN INJURY IN THE MILITARY: IMPROVING THE REFERRAL/CONSULTATION PROCESS

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October December 2014 73 The number of inmates with mental health disorders incarcerated in the US prison system has grown into a national public health crisis. The literature reports that 15% to 24% of US inmates have a severe mental ill ness, 1-5 and according to the Bureau of Justice Statistics, over 1 million inmates are diagnosed with at least one mental health condition. 3 tiple factors that have contributed to the growth of this epidemic. 2-4 The availability of new antipsychotic medications start ing in the 1960s made it feasible to manage many psy chiatric disorders on an outpatient basis, leading to the argument formulated by prominent members of the psychiatric community that discharging patients from inpatient hospitals and providing community-based out patient care represented a humane alternative to over crowded and understaffed institutions. 1,2,4,6 As a result, a national movement arose that resulted in the mass closing of public mental health hospitals. 1,2,4,6 However, the new psychiatric paradigm of closing state hospitals and managing psychiatric patients via outpatient clinics and halfway houses was, in most cases, not supported by the necessary resources to provide adequate care for the number of patients released from inpatient fa cilities. 1,2,4,6 Additionally, the health maintenance orga nization (HMO) model evolved into the primary health delivery model in the United States, requiring patients to use network providers covered by health insurance to receive medical care. However, HMO health insurance policies provide more restrictive coverage for individu als with mental health disorders and limit the enrollment of psychotic patients in private hospitals. 1,2,4,6 Finally, civil commitment laws became more restrictive, mak individuals with severe mental illness. 1,2,4,6 The afore mentioned factors have culminated in a revolving-door phenomenon resulting in many individuals with mental health disorders moving continuously between home lessness and the criminal justice system. 1,2,4,6,7 The large numbers of incarcerated individuals with mental health disorders leads to the logical assumption that prison systems should incorporate quality mental health assessment and treatment as a primary compo nent of the inmates rehabilitation process. Hills et al 8 describes the optimal correctional mental health system as a continuum of services which include inpatient and outpatient services, crisis intervention programs, and 24-hour on-call access to mental health services. Mental Health treatment modalities should include individual and group treatment and access to psychotropic medi cations. 8 However, an abundance of literature reports a large disparity in the quality of correctional mental health services provided in US prisons. in both the diagnosis and treatment of inmates with 1,2,4,6-8 For example, Hornung et al 9 surveyed 41 prison systems assessing mental health services offered to prisoners. They found 15 systems had treatment protocols or guidelines for the management of inmates with mental illness, 12 had no protocols, and the remainder did not respond to the question. Additionally, the National Commission on Correctional Health Care conducted an analysis of men tal health care in the US Federal Prison System in 2002. The study concluded that most prisons fail to conform to nationally accepted health care guidelines for mental health screening and treatment. 5 As a result, inmates with mental health disorders are not receiving adequate mental health services during incarceration, resulting in a disproportionate burden of adverse clinical outcomes, social isolation, and ultimately criminal recidivism among this already disadvantaged population. 1,2,4-9 This article discusses the comprehensive mental health services offered to inmates incarcerated at the United States Disciplinary Barracks (USDB) Fort Leavenworth, Kansas and how those services are a critical compo nent to the overall success of the USDB mission. The Directorate of Treatment Programs: Providing Behavioral Health Services at the US Disciplinary Barracks LTC Nathan Keller, MS, USA Laura Whaley, LCSW CPT Ashley Franklin, MS, USA John Lesniak, LCSW Ellen Galloway, PsyD

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74 http://www.cs.amedd.army.mil/amedd_journal.aspx discussion includes the types of mental health disorders experienced by inmates at the USDB and how those dis orders contribute to the risk the inmate poses both in side the facility and to the community at large. We detail the role of the Directorate of Treatment Programs which initiates processes to classify an inmates risk, identify bilitative programs and mental health interventions to mitigate those risks, and increase the likelihood that an inmate will successfully integrate back into the com munity upon release. BA CKGRO U ND The USDB at Fort Leavenworth is the center of correc tional excellence for the US Army. Established in 1874 by Federal law, the USDB is the oldest penal institution in continuous operation in the Federal system and is the only maximum security correctional facility in the De partment of Defense. 10 In 2002, a new state-of-the-art, 515 bed facility became operational with the capability of incarcerating US military prisoners from the Army, Ma rine Corps, Navy, Air Force, and Coast Guard sentenced 10 Since January 2013, in committed by inmates housed at the USDB range from murder, kidnapping, robbery, assault, sexual offenses, and property offenses to drug offenses. Currently, 95% of the inmates incarcerated at the USDB are serving a sentence for a violent or sexual offense.* The USDB mis sion is to conduct correctional and treatment programs that are intended to maintain good order and discipline in the facility and reduce recidivism upon release. The USDB prioritizes educational, vocational, and behavior al health programs that prepare inmates to become selfreliant, trustworthy, and productive members of society. The Directorate of Treatment Programs (DTP) at the USDB is essential in accomplishing this mission. The DTP at the USDB is comprised of a multidisciplinary team which includes one psychiatrist, 3 psychologists, 8 social workers and 15 behavioral health specialists (military occupational specialty 68X) assigned to 3 di visions: Assessment, Rehabilitation, and Mental Health. Collectively, DTP offers a rehabilitation system which institution and society, and provides treatment programs which mitigate that risk. The DTP presents all USDB inmates with the opportunity to participate in a variety of behavioral health programs that will enable them to successfully adjust to a correctional environment and re duce the likelihood that they will reoffend upon release. Historically, inmates have presented with depressive dis orders as the predominant diagnosis at the USDB. How ever, over the last 7 years, a transformation of inmate psychopathology within the institution has occurred, as illustrated in the Figure. The increase in the proportion of inmates diagnosed with posttraumatic stress disorder (PTSD) can be attributed to an increase in the number of inmates with combat experience, currently 53%. Oth erwise, the USDB population mirrors the population of the United States in a shift from mood disorders to anxi ety disorders being the predominant behavioral health concern. 11 The DTP is responsible for assisting all inmates with sition. Inmates adapting to prison can experience dys functional patterns of thinking and acting that make likelihood they will reoffend. 12 Service members who enter prison often present with preexisting behavioral health concerns, including, at a minimum, impaired inmates are able to effectively adapt to the correctional environment, there are some inmates who are more vul likely to act out in self-injurious, violent, or disruptive ways. The majority of USDB inmates respond positively to the standard behavioral health treatment regimen. However, 30% of the USDB inmate population present dance of resources to manage and treat as shown in the Figure. The psychopathology of these inmates increases tive rehabilitation process. Thus, it is critical to rapidly DIRECTORATE OF TREATMENT PROGRAMS: PROVIDING BEHAVIORAL HEALTH SERVICES AT THE US DISCIPLINARY BARRACKS Other PTSD Depression Psychotic Anxiety 2007 10% 15% 20% 47% 8% 72 of 423 (17%) inmates were prescribed psycho tropic medications. 2014 22% 54% 9% 8% 7% 132 of 464 (28%) inmates are prescribed psycho tropic medications. Comparison of Psychopathology Diagnoses in the USDB Population, 2007 and 2014. Source: USDB Inmate Database, June 2007 and June 2014. Source: USDB Inmate Database, June 2014

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October December 2014 75 with the important and complex process of identifying inmate risk and recommending individual rehabilitation treatment plans. DTP ASSESSMENT DIVISION Classifying inmates in accordance to potential risk is risk an inmate poses to himself, other inmates, and the USDB staff. Accurately identifying internal risk is crucial to maintaining the safety and security of the fa cility. The second step is to identify external risk, the risk an inmate poses to the greater community. Accu rately identifying external risk supports recommenda tions on parole, clemency, and conditions of release and improves the safety of the community. The assessment process as a whole fosters appropriate adaptation to the correctional environment and will ultimately increase the potential for inmates to experience a successful tran sition back into society. Assessing a new inmates internal and external risk typi cally begins within 2 hours of the inmates arrival at the USDB. The DTP Assessment Division conducts an ini tial behavioral health triage to ensure the new inmate is not experiencing current suicidal or homicidal ideations, or psychotic symptoms, as well as determining whether he is at above average risk to be a victim or perpetra tor of sexual assault within the facility. Additionally, of mental illness and/or a current psychiatric diagno sis and whether he is currently prescribed psychotropic medications. If any of the above conditions are reported, the Assessment Division immediately implements an appropriate crisis management plan until the reported issues are resolved. Upon completion of the initial triage, new inmates un dergo a 3-week reception process allowing the DTP As sessment Division to conduct an in-depth evaluation of the inmates risk factors and behavioral health needs. A full psychosocial interview is conducted to explore the inmates perception of the circumstances resulting in in across the inmates developmental lifecycle from child hood to the present. In conjunction with the psychosocial interview, psycho logical testing is used to assess the inmate criminologi cally. The DTP Assessment Division administers Rob ert Hares Psychopathy Checklist-Revised (PCL-R). 13 The PCL-R is a diagnostic tool used to rate a persons psychopathic or antisocial tendencies. Psychopaths use charm, deceit, violence, or other methods to ruthlessly prey on others to get what they want, making them ex tremely dangerous in a correctional environment. The PCL-R consists of a 20-item symptom rating scale that gree of psychopathy with that of a prototypical psycho path. Each item is scored 0, 1, or 2 with the overall score ranging from 0 to 40. Any score of 25 or higher meets the criteria for dangerousness. A score of 30 or higher indicates that the individual is a psychopath. Addition ally, the USDB has found a correlation exists between inmates with a PCL-R score of 20 or higher and acts of misconduct and disruptive behavior within the insti tution. Thus, inmates that have a high enough level of psychopathy are assessed as having higher internal risk. In addition to the PCL-R, the DTP Mental Health Divi sion administers a battery of psychological tests during the reception process to assess the inmates internal and external risk. Psychological testing includes the Shi pley-2, a screening measure for intelligence, 14 and the Aggression Questionnaire, which measures the many facets of aggression such as verbal, physical and indi rect aggressive behavior as well as anger and hostility. 15 Also, the Substance Abuse Subtle Screening Inventory 16 and the CAGE substance use questionnaire 17 are ad ministered to determine the likelihood that an inmate suffers from a substance use disorder and are used to make recommendations as to whether the inmate needs substance abuse treatment. This is particularly impor tant when substance use played a role in the inmates ment. Because 53% of the inmates have been deployed to a combat zone,* the PTSD Checklist is administered to identify treatment needs associated with PTSD. 18 Fi nally, the Personality Assessment Inventory (PAI) is administered to get a broad-brush picture of traits and symptoms associated with a variety of psychological disorders, such as psychotic symptoms, personality pa thology, mania, anxiety, depression, somatic complaints, physical aggression, suicidal ideations, as well as gen eral stress and perceived social support. Additionally, the PAI has several validity scales that inform the inter preter whether the inmate is attempting to present him self in an overly positive or negative light. 19 The validity scales assist DTP in determining the likely veracity of the inmates self-report of his problems. The data collected through the interviews and psycho logical testing is further used by the DTP Assessment Division to determine the inmates appropriate custody Source: USDB Inmate Database, June 2014

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76 http://www.cs.amedd.army.mil/amedd_journal.aspx cal formula. The risk factors are calculated into custody points that determine the custody grade of each inmate. Custody grades within the USDB consist of Maximum Custody (MAX), Medium Custody (MED), Minimum Inside Only, Minimum Custody, and Trusty Custody. which gives them the opportunity to integrate into the facility, learn about the inmate subculture, and adjust through reduction in custody points (decay of disciplin ary points, time served, and completion of treatment). By the end of the reception process the DTP Assess ment Division has created a formal risk assessment, an initial treatment plan, and a Risk Assessment Manage inmates internal and external risks. The initial treat and rehabilitation needs and recommends interventions to meet those needs. Additionally, the RAMP outlines possible custody elevation dates, initial and future job assignments, and tentative dates to start the formal reha bilitation groups. Before leaving reception, the inmates meet with their temporary case manager to review their RAMP. The inmates will also be assigned a permanent case manager from DTP rehabilitation division who will assist them in successfully navigating the rehabilitation process. DTP REH A BILIT A TION DIVISION Upon completion of the reception process, inmates as signed to a custody level other than MAX are elevated to the general population housing unit. At this time, inmates meet with their assigned DTP Rehabilitation Division case manager to begin their long-term reha bilitation process. Inmates are assigned case managers based on their behavioral health needs. If an inmate has problems, he will be assigned to a credentialed provider for treatment; all other inmates will be managed by a be havioral health specialist. The role of the case manager is to coordinate treatment plans, provide counseling for maries for various armed services parole and clemency boards. Although behavioral health treatment is a criti cal part of the rehabilitation process, all individual and group treatment remains voluntary and inmates have the option to stop treatment at any time or decline par ticipation altogether. The theoretical underpinnings for the majority of be havioral health interventions provided at the USDB are derived from Cognitive Behavior Therapy (CBT) and administered in a group setting. Inmates participate in a variety of evidence-based CBT treatment groups facilitated by behavioral health specialists and creden tialed providers. Treatment groups are delineated on the RAMP and purposefully sequenced starting with a general cognitive skills group followed by anger man agement. These 2 groups are designed to improve the develop CBT and emotions management skills which then form a foundation for the treatment groups that fol low. After these 2 groups, if necessary, the inmate will be offered formal substance abuse treatment. Finally, after the general groups are completed, the inmate is treatment. This treatment sequence allows the inmates to participate in treatment over the duration of their sen tence and sets up a process where the later groups build on the skills developed in the earlier groups. 20 a cognitive skill-building group that is the foundation include (1) improvement in thinking skills, particularly problem-solving and decision-making, (2) developing pro-social behavior that is not dependent on external controls, and (3) improving interpersonal skills in prob lem-solving, and viewing frustration as a problem-solv ing task rather than a personal threat. The next group is Anger Management. 21 This CBT-based group enhances the inmates ability to recognize underlying motivations for anger, develop their ability to examine their own be havior in response to anger, recognize cognitive errors that contribute to anger, and cultivate thinking and be haviors designed to handle anger appropriately. of substance abuse problems have the Chemical Abuse and Addictions Program (CAAP) (The Change Com panies, Carson City, NV) on their RAMP. The level of substance abuse treatment provided is dependent upon the severity of the inmates substance abuse problem. The CAAP-Didactic is a structured program designed to meet the needs of those inmates who do not have an extensive history of substance abuse. CAAP-Intensive consists of a year-long treatment program facilitated by credentialed providers for inmates with a substantial history of substance abuse. CAAP-Intensive is based on the philosophy that recovery is a life-long process re quiring full commitment, practice, and life-style chang es. In addition to CAAP, a 12-step based, voluntary DIRECTORATE OF TREATMENT PROGRAMS: PROVIDING BEHAVIORAL HEALTH SERVICES AT THE US DISCIPLINARY BARRACKS

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October December 2014 77 self-help group is offered twice a month to any inmate with substance abuse issues. The content of the selfhelp program is developed by the inmates, supervised by behavioral health staff, and supported by community volunteers who bring the message of recovery to those incarcerated. Once an inmate has successfully completed all previous treatment groups on his RAMP, he is eligible to partici Inmates are screened for these groups by credentialed providers to determine the appropriateness of the inmate for the group. Group enrollment requires that the inmate accept some responsibility for having committed the of fenses for which he was convicted. Furthermore, the inmate must demonstrate a desire and commitment to offenses and be willing to make the changes necessary to reduce the likelihood of reoffending upon release. the USDB are Assaultive Offenders Group (AO) and Sex Offenders Treatment Group. The AO 20 is designed for inmates incarcerated for vio lent and assaultive behaviors. The AO group enables in mates to identify the values, thoughts, behaviors, and attitudes that contributed to their assaultive behavior. It encourages a change to a violence-free lifestyle and helps the inmate develop skills to effectively problemsolve, appropriately manage emotions, and successfully The Sex Offender Treatment Group (SOT) is the most comprehensive treatment group offered at the USDB. Currently, 75% of the inmates incarcerated at the USDB the past 25 years, sex offender treatment provided at the USDB has evolved, incorporating research and treat ment protocols from the broader sex offender treatment literature. The USDB sex offender treatment program currently uses the Self-Regulation/Good Lives Model 22 as the primary method of sex offender treatment. The Self-Regulation/Good Lives Model assumes that sex offenders use sex offending in order to meet important needs. The purpose of treatment under this model, then, is to assist each inmate in identifying (1) what needs are most important to him, (2) which needs he was attempting to meet through his sexually offensive be havior, and (3) how he can meet those needs through healthier and more socially-appropriate behavior. The Self-Regulation/Good Lives Model is a dramatic shift in phasize important approach goals rather than focusing solely on what the inmate must avoid. This focus on ap proach goals is far more motivating to inmates and gives them hope for a full and offense-free lifestyle. Group treatment educates inmates on recognizing how their thoughts, behaviors, and emotions led to their offenses. It then teaches inmates how to develop and implement healthy skills and coping mechanisms to manage their and attain their personal life goals. Effectively treating sex offenders requires an accurate assessment process to identify all of the factors that con tribute to the inmates urges to offend, as well as intense therapy to enable the inmate to identify realistic strate gies to reduce those urges. Inmates undergo a compre hensive assessment process prior to enrollment in SOT. The assessment tools utilized include the STATIC-99R, STABLE 2007, penile plethysmograph (PPG), and sexu al history polygraph. These assessments combined pres treatment targets for change through the group process. The STATIC-99R 23 is an actuarial measure that uses de mographic and historical factors (such as age and past that cannot be changed or affected by treatment. The outcome of the measure is a numerical value that places the inmate into a risk category (low, moderate-low, moderate-high, or high) that has been shown in the lit erature to provide an overall moderate degree of pre dictive accuracy. The STABLE-2007 24 is a structured interview that measures 13 dynamic factors shown in the literature to be related to risk of recidivism. The out come of this measure provides a numerical value that also places the inmate into a risk category (low, moder ate, or high). These factors are important to measure as they can be changed with treatment over time. Thus, the STABLE-2007 provides group facilitators with valu able treatment targets that, if appropriately addressed, can reduce the inmates risk of recidivism. Once both assessments are completed, the results are combined to whether the inmate is directed into the low-moderate risk or moderate-high/high risk SOT group. This over all risk category also provides a research-based percent age risk of sexual or violent recidivism over 1, 3, or 5 year periods postrelease. Additionally, the PPG is ad ministered to measure the inmates arousal to auditory and visual stimuli depicting normal sexual encounters as well as deviant (coercive or age-inappropriate) sex ual encounters, through the measurement of change in Source: USDB Inmate Database, June 2014

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78 http://www.cs.amedd.army.mil/amedd_journal.aspx penile tumescence. The empirically-based outcome of the instrument is a numerical deviance differential that provides a risk category (low, moderate, or high), indicating whether the inmate has a greater, equal, or lower level of sexual arousal to children versus adults. This is a critical risk indicator because sexual deviance has routinely been shown in the literature to be among the most potent indicators of recidivism risk. 25-27 The PPG results are used to determine whether an inmate should complete the Deviant Arousal Reduction module of treatment, which uses covert sensitization and mas turbatory satiation to help manage and reduce arousal to deviant stimuli. Finally, all inmates are required to take a sexual history rapher, in order to be eligible for the SOT group. The polygraph interview covers the inmates sexual history across his entire lifespan. The purpose of the polygraph is to obtain information that is pertinent to the inmates treatment. For instance, often inmates who are incarcer ated for the sexual abuse of one child will acknowledge other sexually deviant behavior (excessive pornography use, bestiality, etc) or additional victims that demonstrate a pattern of sexual behavior problems that must be ad dressed in treatment. Furthermore, while not foolproof, the polygraph provides the facilitator with an indication of the inmates veracity surrounding his sexual behavior. This alone can provide the facilitator with insight into ar eas that need further inquiry over the course of treatment. Inmates assessed as moderate-low/low risk (based on the combined STATIC-99R/STABLE-2007 score) will par ticipate in a group in which factors such as relationship skills, cognitive restructuring, management of emotions, and development of risk management plans are the pri mary focus of treatment. Inmates who are assessed as moderate-high/high risk for re-offending participate in a more intensive group treatment program due to the increased number of needs, beliefs, and attitudes the in mates have that contribute to their offending. Treatment comprises both psychoeducational components (emo tions management, cognitive restructuring, relationship skills, and deviant arousal reduction) and an intensive dynamic therapy group which addresses entrenched schemas and belief systems that support sexual offend ing, development of offense chains, motivation for treat ment, and the development of a good life/comprehensive risk management plan for their release. Upon completion of the inmates required treatment, the inmate will be placed in a sex offender maintenance group that meets based upon their risk level to reoffend. The maintenance group helps to keep the inmates focused on achieving their life goals without offending, as well as preparing further for release into the community. DTP MENT A L HE A LTH DIVISION In addition to rehabilitation, some inmates need indepth treatment to address mental illness or personality disorders. The credentialed professionals from the DTP Mental Health Division are responsible for in-depth psy chological assessment of inmates who pose diagnostic challenges and management problems within the facil ity. Referral questions often require additional testing to aid in differential diagnoses and recommendations for treatment planning. The DTP Mental Health Division credentialed provid ers maintain an individual caseload of up to 12 inmates, focusing on the most severely mentally ill or personal ity disordered, as these inmates historically require the most resources in terms of time and systemic manage ment. To facilitate successful management of these inmates, the DTP Mental Health Division insures the development of Inmate Management Plans for the most seriously mentally ill/behaviorally disordered inmates, and provides consultation for the other professionals and behavioral health specialists when they are treating an inmate with particularly challenging mental illness or severe personality disorder. Because 53% of the USDB inmates have a history of combat deployments,* there are a high number with PTSD. The DTP Mental Health Division has implement ed a Cognitive Processing Therapy (CPT) group, 28 an evidence-based PTSD treatment program that focuses on helping inmates identify stuck points in their think ing and distorted beliefs that stem from their traumatic experiences. The inmates then go through a number of sequenced exercises designed to challenge and shift those distorted beliefs to more reality-based and healthy beliefs. The DTP Mental Health Division is also responsible for the case management of inmates in the Special Housing Unit (SHU). Sixty-four percent of the inmates housed in the SHU have been diagnosed and are receiving pharmacological treatment for an anxiety disorder, as opposed to 11% of the inmates housed in the general population. Additionally, 92% of the inmates housed in the SHU, as opposed to 21% of the inmates in gen eral population, have been diagnosed and are receiving pharmacological treatment for a behavioral health disor der.* Most inmates housed in the SHU are there due to DIRECTORATE OF TREATMENT PROGRAMS: PROVIDING BEHAVIORAL HEALTH SERVICES AT THE US DISCIPLINARY BARRACKS Source: USDB Inmate Database, June 2014

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October December 2014 79 behavior to the requirements of the facility. It appears that there is a relationship between sustaining a major mental illness and an increased likelihood of commit ting disciplinary infractions. As a result, the inmates in the SHU require specialized behavioral health interven tions that target both behavioral health issues and adap Because many of the inmates who end up in the SHU have common problems, such as anger and emotion and anxiety and personality disorder traits, an SHU group was implemented to allow treatment to be pro vided to a larger target group as well as for inmates to peers. Group topics are focused on stress management, anger and emotion management, problem-solving, and communication skills. Relevant movies are occasionally shown after the discussion of a topic to permit a less personal, thus less threatening, exploration of the topic. A more personal exploration of the topic is addressed in follow-on sessions. This sequence encourages participa tion and allows a less defensive response to the material. While not formally investigated as of this writing, the SHU group appears to reduce the number of problems between staff and inmates in the SHU. The DTP Mental Health Division facilitates all aspects of inmate psychiatric care. On average, 30% of the USDB inmate population require psychopharmacological in tervention.* The DTP Mental Health Division provides organizational and administrative support to the on-site psychiatrist and to the psychiatrist providing telepsychi atry services. It also works closely with the pharmacy and medication nurses to insure seamless access to and accurate administration of all psychotropic medication. CONCL U SION The USDB mission is to conduct correctional and treat ment programs to foster maintenance of good order and discipline in the facility and reduce recidivism upon release. The DTP staff faces a myriad of challenges in working within the correctional environment. First, in addition to situational and personal factors that drive inmates to commit the offenses for which they are con comorbid behavioral health problems. These additional problems pose unique challenges to treatment and risk remediation that must be addressed. Furthermore, the factors inherent in the USDB correctional environment such as separation from support systems, lack of con trol over daily routines, lack of privacy, and insecurity about postincarceration employment and relationships DTPs CBT focus and logical sequencing of treatment has enabled it to develop programs that provide a con sistent therapeutic language and address both behavioral health and rehabilitation needs. The DTP staff also takes a systemic approach in ad dressing safety and risk within the institution, providing crisis intervention and de-escalation services to serve the inmates and support the correctional staff. They also work towards reducing the stigma and misunder standing of inmates with behavioral health disorders through education, thus improving how cadre interact with behaviorally challenged inmates. Additionally, the DTP provides command consultation to USDB staff at all levels, advising on the appropriate management of the USDB has implemented policies and procedures that promote effective management of inmates with behav ioral health conditions which has increased the safety and security of the facility. Although there is research on a variety of cognitive behavior-based treatments, including many of the pro grams DTP uses, future research could focus on exam treatment outcome research for the cognitive behavior groups developed at the USDB which are not researched, manual-guided treatment programs. Finally, a relation ship between serious mental illness and disciplinary re ports has been noted. However, no direction of a causal relationship or whether there is another substantial vari examining the relationship between mental illness and disciplinary infractions may permit us to more effec tively treat inmates with a mental illness while simulta neously increasing the safety and security of the facility. The USDBs motto is Our MissionYour Future. The mates; it is invested in ensuring that each inmate has been given an opportunity to develop the skills neces sary to reduce the likelihood that they will reoffend upon release. The DTPs extensive portfolio of services makes it an integral part of that mission. REFERENCES 1. Baillargeon J, Penn JV, Knight K, Harzke AJ, Bail largeon G, Becker EA. Risk of reincarceration among prisoners with co-occurring severe mental illness and substance use disorders. Adm Policy Men Health 2010;37(4);367-374. Source: USDB Inmate Database, June 2014

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80 http://www.cs.amedd.army.mil/amedd_journal.aspx 2. Baillargeon J, Binswanger I, Penn J, Williams B, Murra, O. Psychiatric disorders and repeat incar cerations: the revolving prison door. Am J Psychia try 2009;166(1):103-109. 3. James DJ, Glaze LE. Mental Health Problems of Prison and Jail Inmates Washington, DC: US Dept Justice Statistics; 2006. 4. Kinsler PJ, Saxman A. Traumatized offenders: dont look now, but your jails also your mental health center. J Trauma Dissociation 2007;8(2):81-95. 5. The Health Status Of Soon-To-Be-Released In mates: A Report To Congress Chicago, IL: Nation al Commission on Correctional Health Care; 2002. 6. Lamb HR, Bachrach LL. Some perspec tives on deinstitutionalization. Psychiatr Serv 2001;52(8):1039-1045. 7. Hoge SK. Providing transition and outpatient services to the mentally ill released from cor Pub lic Health Behind Bars New York, NY: Springer Science+Business Media; 2007:461-477. 8. Hills H, Siegfried C, Ickowitz A. Effective Prison Mental Health Services: Guidelines to Expand and Improve Treatment Washington, DC: National In stitute of Corrections, US Dept of Justice; 2004. Available at: https://s3.amazonaws.com/static.nicic. gov/Library/018604.pdf. Accessed August 11, 2014. 9. Health care for soon-to-be-released inmates: a sur vey of state prison systems. In: The Health Status Of Soon-To-Be-Released Inmates: A Report To Congress, Volume 2 Chicago, IL: National Com mission on Correctional Health Care; 2002:1-11. 10. Grande P. United States Disciplinary Barracks Charleston, SC: Arcadia Publishing; 2009. 11. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry 2005;62(6):617-627. 12. Haney C. The psychological impact of incarcera tion: Implications for post-prison adjustment. In: Travis T, Waul M, eds. Prisoners Once Removed: The Impact of Incarceration and Reentry on Chil dren, Families, and Communities Washington, DC: The Urban Institute Press; 2003:33-66. 13. Hare RD, Neumann CS. Psychopathy New York, NY: Oxford University Press; 2009. 14. Shipley WC, Gruber CP, Martin TA, Klein AM. Shipley-2 Torrance, CA: WPS Publishing; 2009. 15. Buss AH, Warren WL. Aggression Questionnaire Manual Torrance, CA: WPS Publishing; 2000. 16. Miller FG, Roberts J, Brooks MK, Lazowski LE. Adult SASSI-3 Users Guide Springville, IN: The SASSI Institute; 2003. 17. Ewing JA. Detecting Alcoholism: the CAGE ques tionnaire. JAMA 1984;252(14):1905-1907. 18. Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, Keane TM. Clinician-administered PTSD scale for DSM-5 (CAP-5). US Dept of Veter ans Affairs Website; 2014. Available at: http://www. ptsd.va.gov/professional/assessment/adult-int/caps. asp. Accessed August 12, 2014. 19. Hopwood CJ, Morey LC, Rogers R, Sewell K. Ma lingering on the Personality Assessment inventory: J Pers Assess 2007;88(1):43-48. 20. Porporino FJ, Fabiano EA. Theory Manual for Reasoning and Rehabilitation (Revised). Ottawa, Canada: T3 Associates; 2000. 21. Reilly PM, Shopshire MS. Anger Management for Substance Abuse and Mental Health Clients: A Cognitive Behavioral Therapy Manual Washing ton, DC: Center for Substance Abuse Treatment, US Dept of Health and Human Services; 2002. 22. Yates PM, Prescott DF. Building a Better Life: A Good Lives and Self-Regulation Workbook Bran don, VT: Safer Society Press; 2011. 23. Phenix A, Helmus L, Hanson RK. STATIC-99R Evaluators Workbook. Static 99 Clearinghouse [internet]; 2009. Available at: http://www.static99. org. Accessed August 11, 2014. 24. Hanson RK, Harris AJ, Scott T, Helmus L. Assess ing the Risk of Sexual Offenders on Community Su pervision: The Dynamic Supervision Project 200705 Ottawa, Canada: Public Safety Canada; 2007. 25. Hanson RK, Morton-Bourgon K. The Accuracy of Recidivism Risk Assessments for Sexual Offenders: A Meta-Analysis Ottawa, Canada: Public Safety and Emergency Preparedness Canada; 2007. 26. Beech AR, Fisher DD, Thornton D. Risk as sessment of sex offenders. Prof Psychol Res Pr 2003;34(4):339-352. 27. Olver ME, Wong SC. Psychopathy, sexual devi ance, and recidivism among sex offenders. Sex Abuse 2006;18(1):65-82. 28. Resick PA, Monson CM, Chard K. Cognitive Pro cessing Therapy Washington, DC: US Dept of Vet erans Affairs; 2007. AU THORS LTC Keller is the Director of Treatment Programs, USDB, Fort Leavenworth, Kansas. CPT Franklin is a Clinical Psychologist, Directorate of Treatment Programs, Fort Leavenworth, Kansas. Dr Galloway is Chief, Mental Health Division, Director ate of Treatment Programs, Fort Leavenworth, Kansas. Ms Whaley is Chief, Rehabilitation Division, Director ate of Treatment Programs, Fort Leavenworth, Kansas. Mr Lesniak is Chief, Assessment Division, Directorate of Treatment Programs, Fort Leavenworth, Kansas. DIRECTORATE OF TREATMENT PROGRAMS: PROVIDING BEHAVIORAL HEALTH SERVICES AT THE US DISCIPLINARY BARRACKS

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October December 2014 81 To date, over 2.5 million service members have deployed in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Of these, approximately 1.9 million are parents, with 48% having served at least 2 tours in Iraq and/or Afghanistan, affecting over 2 mil lion children. 1,2 Additionally, despite increases since the 1970s in the percentage of women who serve, the mili tary is still overwhelmingly male (84%), that is, the ma jority of military parents are fathers. The adverse effects of combat deployments on families have been supported by research. 3,4 Several studies re port higher rates of depression, anxiety, overall stress, and decreased family cohesion when the parent is de ployed in a combat zone. 3,5 Service members also report higher rates of family stress and lower rates of partner cohesion. In one study, up to 20% of deployed service members indicated that they planned separating or di vorcing their spouse upon return from deployment. 6 Sol diers with posttraumatic stress disorder have even high er rates of post-deployment adjustment problems with their partner. 7 Limited literature suggests adverse effects of parental military deployment on children and adolescents. As more research emerges from the current Overseas Con tingency Operations (formerly Global War on Terror), studies show higher rates of behavior problems and decreased social and emotional functioning in children of all ages. 8-11 In one study of military families with a deployed parent, Lester et al found that 33% of schoolaged children were at high risk for psychosocial mor bidity. 10 Similarly, adolescents reported higher rates 13 Additionally, these children were also at risk for higher rates of physi cal abuse following periods of deployment. 14,15 Recent literature suggests that drug and alcohol use are higher among children of deployed military personnel. 16 Several studies suggest that military children have in creased rates of internalizing and externalizing behav iors when their parent deploy. 4,17 Furthermore, children have reported higher rates of sadness during the par ents deployment. 18,19 Lastly, children with preexisting psychopathology or coming from poorly-functioning The Effects of Military Deployment on Early Child Development Dana R. Nguyen, MD Juliana Ee, PhD Cristbal S. Berry-Cabn, PhD Kyle Hoedebecke, MD ABSTR A CT Purpose: The purpose of this observational, point prevalence study is to determine if parental deployment af fects the cognitive, social and emotional development of preschool age children in the military family. Methods: Demographic information was collected and an age-appropriate Ages and Stages Questionnaire (ASQ-3) and Ages and Stages Social-Emotional Inventory (ASQ:SE) were administered. The primary outcome measure was the failure rates on the developmental instruments. Results: to those in the nondeployed group. Children of deployed parents were at least twice as often to fail the ASQ-3 or ASQ:SE developmental screen compared to children whose parents did not deploy. 30.5% of children in the deployed group failed the ASQ-3 screen while 12.5% of children who did not have a deployed parent failed ( P =.009). On the ASQ:SE developmental screen, 16.8% of children who had a parent deploy failed versus 5.4% of children who did not have a parent deploy ( P =.031). Conclusions: This study suggests that parental deployment is related to adverse risk for developmental delays in children in military families. The psychological burden on military children could be life-long or require

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82 http://www.cs.amedd.army.mil/amedd_journal.aspx predeployment families may also be more vulnerable to the effects of deployment. 20,21 The effect of deployment on children under the age of 5 years has been little studied. Several studies suggest that young childrens reactions to parental deployment differ by a number of individual (temperament, age, and developmental stage) and family factors (the length of deployment, family composition, total time of service borhood in which the family lives, relocation, and other family stressors). 22 In general, childrens reactions and adjustment to parental deployment are largely based on their age and developmental stage. 23-25 Simultane ously, childrens reactions to parental deployment show a strong linkage with family functioning during deploy ment, that is, the nondeployed parents responses in particular. 19 Literature on military deployment-related family sepa ration indicates that younger children, compared with older children, are more vulnerable to the effects of the separation. 18,19 A study of Army families found that chil dren ages 0 to 5, compared to older children, coped least well with deployment-related parental absence. 26 Unable to express their feelings and experiences easily in words, children under the age of 5 tend to express their feelings about parental deployment in externalizing behaviors (eg, aggression, hyperactivity, and problematic behav iors), rather than internalizing behaviors (eg, depressive symptoms, withdrawal, and anxiety). 17,18 Young children also exhibit changes in moods, attention seeking, sad ness, reduced appetite, and sleep problems. 17,27 Recent rine Corps families with children enrolled in an on-post daycare center showed that children aged 3 to 5 with a deployed parent exhibited higher rates of behavioral symptoms compared to children without a deployed par ent. 28 Controlling for socioeconomic variables, Barker and Berrys study showed that young children with a deployed parent experienced behavioral problems. 22 While some studies have shown increased behavioral symptoms in children with deployed parents, the data have limitations. Risk assessment for preschool age children is crucial since important psychological forma tion and development are forged during these preschool years. Because 40% of military children fall into this age category, failure to assess the consequences of mili tary parent deployment on young children could prove disastrous. The purpose of this study is to determine if parental deployment affects the cognitive, social, and emotional development of preschool age children in the family. METHODS The sample consisted of 151 children of active duty ser vice members households between the ages of 6 and 65 months stationed on Fort Bragg. A convenience sample of parents was selected among children presenting for routine appointments in a family medicine clinic. Only one preschool age child per family was surveyed. If more than one child in the family met the inclusion cri teria, a random number generator was used to pick the child evaluated. All parents signed a written consent prior to data collection. Three data collection instruments were used: a demo propriate Ages and Stages Social-Emotional Inventory (ASQ:SE). 29,30 Along with basic family demographic information, the study survey assessed several military the length of deployments, and whether a parent was cur rently or recently deployed. If a parent deployed to a com bat military operation during the subject childs lifetime, the subject was categorized in the Deployed Parent. If neither parent had deployed to a combat operation during the child subjects lifetime, the subject was placed in the Nondeployed Parent data group. The demographic sur vey also asked which parent deployed (mother, father, or both parents). Finally, parents were asked to self-report if they currently have depression or anxiety. The ASQ-3 and the ASQ:SE are widely used parentalreported assessment tools with established psychomet ric properties. 29,30 The ASQ-3 consists of a 10-minute questionnaire completed by parents. Answers to screen ing questions are assigned points that are then summed motor, problem solving, and personal-social. Scores be neath the cutoff points indicate a need for further assess child is developmentally appropriate. Each ASQ-3 developmental area is associated with a number score. The absolute score for each category can be up to 60, but the cutoff for values of concern var ies for each age surveyed. The absolute score was re corded as a data point, and the qualitative rating was recorded in order to compare all children as a whole. For the ASQ-3, the qualitative rating is pass, at-risk, or fail, based on the subjects score compared to the cutoff value. This qualitative value was converted into pass or fail (combining at-risk and fail into one category for this study). THE EFFECTS OF MILITARY DEPLOYMENT ON EARLY CHILD DEVELOPMENT

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October December 2014 83 The ASQ:SE is also completed by the parent. The out come variables measured by the ASQ:SE include selfregulation, compliance, communication, adaptive be haviors, autonomy, affect, and interaction with people. One number score is determined for the ASQ:SE. In addition to the number score, a qualitative rating is also given. There is no at-risk category for the ASQ:SE. Therefore, the rating of this study was recorded as either pass or fail. Statistical analyses were conducted using PASW Sta tistics 18 (IBM Corporation, Armonk, NY). All values were statistically analyzed using frequency distributions with calculations of means and standard deviations (SD). Continuous variables were assessed for normality of dis tribution and compared using 2-tailed t tests. Categorical variables were compared using the Fishers Exact Test. P value less than or equal to 0.05. In order to detect the difference in failed developmental screens as a result of deployment (Cohens Kappa=0.6), that is, to have 80% power to re ject the null hypothesis with type I error of 5%, a sample of 50 participants was required for each group if 80% of children passed both tests. Therefore, our sample This research protocol was approved by the Wom ack Army Medical Center Institutional Review Board and the Clinical Investigation Regulatory Army Medical Research and Materiel Command. RES U LTS consented for the study and completed all parts of the questionnaire packet. Basic demographic data are presented in Table 1. Parent and child character istics are comparable between deployment groups. enlisted ranks. More parents in the deployed group reported having depression or anxiety currently 17.9%, P=. 24). Average length of parental deployment was 10.4 months (range=1-36 months). The groups also had a comparable distribution for childrens gender and race. A slight variance existed between the mean age of children (32.7 months for the deployed group and 21.6 months for the nondeployed group). for children in the deployed group compared to those in the nondeployed group (Table 2). Children who had a parent deploy during their lifetime failed the ASQ-3 30.3% of children who had a deployed parent failed the ASQ-3, while 12.5% of children who did not have a de ployed parent failed ( P=. 009). Failure rates for the 5 different subcomponents of the cant differences were found between groups for the areas of gross motor skills ( P=. 008). Scores for the personal-social skills ( P=. and problem solving had similar trends for each group. On the ASQ:SE developmental screen: 16.8% of chil dren who had a parent deploy failed versus 5.4% of chil dren who did not have a parent deploy ( P=. 031). The effect of the length of total months of parent de ployment during a childs lifetime is presented in the Figure. In our study, the 95 children in the deployed parent group were placed into one of 3 categories: 1 to 11 total months, 12 to 23 total months, and 24 to 36 to tal months. While there appears to be a trend for higher Table 1 Child and Parent Characteristics by Deployment Status. Child Characteristics Deployed Parent (N=95) Nondeployed Parent (N=56) Age, mean months (SD, range) 32.7 (16.1, 7-65) 21.6 (14.3, 6-60) Male 45 (47.4%) 29 (51.8%) Race/Ethnicity White 59 (62.1%) 38 (67.9%) Black 13 (13.7%) 10 (17.9%) Hispanic 13 (13.7%) 5 (8.9%) Asian 4 (4.2%) 1 (1.8%) Native American 3 (3.2%) 2 (3.6%) Unknown 3 (3.2%) 0 (0.0%) Parent Characteristics P value Length of deployment mean months (SD) 10.4 (6.81) n/a Enlisted rank 73 (76.8%) 35 (62.5%) .23 Anxious/depressed 26 (27.4%) 10 (17.9%) .12 Table 2 Analysis of Screening Outcomes by Parent Deployment Status. Outcome Deployed (N=95) Nondeployed (N=56) P value ASQ-3 Fail Overall 29 (30.5%) 7 (12.5%) .009 Communication 6 (6.3%) 3 (5.4%) .557 Gross Motor 10 (10.5%) 0 (0.0%) .008 Fine Motor 17 (17.9%) 5 (8.9%) .100 Problem Solving 7 (7.4%) 1 (1.8%) .133 Personal-Social 9 (9.5%) 1 (1.8%) .061 ASQ:SE Fail 16 (16.8%) 3 (5.4%) .031

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84 http://www.cs.amedd.army.mil/amedd_journal.aspx rates of failed developmental screens with longer time away from the child, these results were not statistically P>. 05). Other variables were recorded on the demographic sheet, however, the number of subjects present in these subcat egories was not robust enough for data analysis. These variables included current deployment status of a par ent, recent return of a parent from a deployment, and whether the mother or father had deployed. COMMENT There are few studies that suggest that parental wartime deployment has adverse effects on preschool age chil dren. Our study suggests that preschool age children with a deployed parent during their lifetime more of ten have higher rates of adverse developmental screens compared to those military children who did not have a parent deploy. Our data show that a larger number of these children failed the ASQ-3 developmental screen. Our data also show that children of deployed parents fail the ASQ:SE 3 times as often. Our trends in failure rates are above the expected failure rates for these screening tools. An anticipated failure rate for the ASQ-3 in the general population is between 10% and 15%. A 12.5% failure rate in the nondeployed group is similar to the expected rate of the general popu lation. In contrast, the deployed group has a 30.5% failure rate for the ASQ3. Higher failure rates are also found in the deployed group for the ASQ:SE. Given the fact that children in both groups live in a military household, one could possibly deduce from these of a parent does have an impact on the emotional and overall developmental status of young military children. The absence of a parent during a childs important developmental years is most likely to have adverse effects on the childs interpersonal behaviors. This hypothesis is support ed by the ASQ:SE fail rates that were higher among children with deployed parents. Additionally, these chil dren had higher failure rates on the personal-social subcomponent of the ASQ-3. The fact that the gross motor subcomponent scores were statisti cally different between both groups of children is not readily explained. Previous studies have shown that children were at risk for higher rates of physical abuse following periods of deployment. 15,16 One could hypothesize that a link ex ists between the increased risk of child maltreatment or neglect in a household with a deployed parent and the delayed gross motor development on the screening tools in our study. Further assessment is needed to delineate this possible relationship. One previous study demonstrated a pattern between the length of parent deployment and increased mental health diagnoses. 31 In our study, a trend appears to exist between length of parent deployment and frequency of failing a developmental screen. As shown in the Figure, the overall failure rate of children for both the ASQ-3 and the ASQ:SE increases with each deployment length of time. However, the differences in failure rates be research in this area is warranted. Our study has several limitations. First, we acknowl edge that the ASQ-3 and the ASQ:SE are screening tools and do not confer a diagnosis of developmental de lay. However, rates of abnormal developmental screens mental delays in these children. Other more comprehen sive screening instruments exist, but they are costly and lengthier to administer in the primary care setting. THE EFFECTS OF MILITARY DEPLOYMENT ON EARLY CHILD DEVELOPMENT ASQ:SE P =.24 ASQ-3 P =.23 Percentage of Failed ASQ Screens Total Months of Parent Deployment Analysis of ASQ screening outcomes relative to length of parent deployment.

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October December 2014 85 We also recognize that even though our subjects are all under 65 months old, multiple developmental stages ex ist within the age range studied (6 to 65 months). Infants and toddlers experience deployment differently than preschool age children. Thus, conclusions regarding age range among children with different developmental stages may not take into consideration possible inter vening variables. Lastly, we did not control for self-reported parental depression or anxiety. Our demographic data suggest a trend of higher frequency of anxiety or depression in families that have had a deployed service member. While we expect that increasing sample size would not affect the overall results of our study, enrolling more subjects may allow us to better control for parental anxi ety or depression. Operational deployments affect all military families. The lasting effects on family members remain largely unknown. This study suggests that parent deployment is related to adverse risk for developmental delays in children. These adverse outcomes could be mitigated by early detection of developmental delay and aggres sive screening techniques. Additionally, the psychologi cal burden on children could have lasting effects that behavioral health professionals to work with military utes to the growing body of evidence of the enormous toll paid by military families. ACKNO W LEDGMENTS The authors acknowledge Dr Javier Vazquez-Ortiz for his assistance in administering the survey. The authors also acknowledge University of North Carolina Chapel Hill Faculty Development Fellowship faculty for their support and guidance for the conceptualization of this project. REFERENCES 1. Baiocchi D. Measuring Army deployments to Iraq and Afghanistan. Santa Monica, CA: RAND Cor pubs/research_reports/RR145.html. Accessed July 8, 2014. 2. Report on the Impact of Deployment of Members of the Armed Forces on Their Dependent Children able at: http://www.militaryonesource.mil/12038/ MOS/Reports/Report_to_Congress_on_Impact_ of_Deployment_on_Military_Children.pdf. Ac cessed July 8, 2014. 3. Blount BW, Curry A, Lubin GI. Family separations in the military. Mil Med 4. Kelley ML. The effects of military-induced sepa ration on family factors and child behavior. Am J Orthopsychiat 5. Haas DM, Pazdernik LA. Partner deployment and stress in pregnant women. J Reprod Med 6. Mental Health Advisory Team (MHAT) VI: Op eration Iraqi Freedom 07-09 Washington, DC: gov/search/product.aspx?ABBR=PB2010104249. Accessed July 8, 2014. 7. Gewirtz AH, Polusny MA, DeGarmo DS, Khaylis A, Erbes CR. Posttraumatic stress symptoms among National Guard soldiers deployed to Iraq: associa tions with parenting behaviors and couple adjust ment. J Consult Clin Psychol 8. Barker LH, Berry KD. Developmental issues im pacting military families with young children during single and multiple deployments. Mil Med 9. Chandra A, Martin LT, Hawkins SA, Richardson A. The impact of parental deployment on child social and emotional functioning: perspectives of school staff. J Adolesc Health 10. Lester P, Peterson K, Reeves J, et al. The long war and parental combat deployment: effects on military children and at-home spouses. J Am Acad Child Adolesc Psychiatry 11. Aranda MC, Middleton LS, Flake E, Davis BE. Psychosocial screening in children with wartimedeployed parents. Mil Med 12. Flake EM, Davis BE, Johnson PL, Middleton LS. The psychosocial effects of deployment on military children. J Dev Behav Pediatr 13. Chandra A, Lara-Cinisomo S, Jaycox LH, et al. Children on the homefront: The experience of children from military families. Pediatrics 14. Gibbs DA, Martin SL, Kupper LL, Johnson RE. Child maltreatment in enlisted soldiers fami lies during combat-related deployments. JAMA 15. Rentz ED, Marshall SW, Loomis D, Casteel C, Martin SL, Gibbs DA. Effect of deployment on the occurrence of child maltreatment in mili tary and nonmilitary families. Am J Epidemiol 16. Acion L, Ramirez MR, Jorge RE, Arndt S. In creased risk of alcohol and drug use among chil dren from deployed military families. Addiction

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86 http://www.cs.amedd.army.mil/amedd_journal.aspx 17. Kelley ML, Hock E, Smith KM, Jarvis MS, Bon ney JF, Gaffney MA. Internalizing and externaliz ing behavior of children with enlisted Navy moth ers experiencing military-induced separation. J Am Acad Child Adolesc Psychiatry 18. Jensen PS, Martin D, Watanabe H. Childrens re sponse to parental separation during Operation Desert Storm. J Am Acad Child Adolesc Psychiatry 19. Watanabe HK, Jensen PS. Young childrens adapta tion to a military lifestyle. In: Martin JA, Rosen LN, Sparacino LR, eds. The Military Family: A Prac tice Guide for Human Service Providers Westport, 20. Lincoln A, Swift E, Shorteno-Fraser M. Psycho logical adjustment and treatment of children and families with parents deployed in military combat. J Clin Psychol 21. Cozza SJ, Guimond JM, McKibben JB, et al. Com bat-injured service members and their families: the relationship of child distress and spouse-perceived family distress and disruption. J Trauma Stress 22. Barker LH, Berry KD. Developmental issues im pacting military families with young children during single and multiple deployments. Mil Med 23. Amen DG, Jellen L, Merves E, Lee RE. Mini mizing the impact of deployment separation on military children: stages, current preventive ef forts, and system recommendations. Mil Med 24. Lester P, Peterson K, Reeves J, et al. The long war and parental combat deployment: effects on military children and at-home spouses. J Am Acad Child Adolesc Psychiatry 25. Murray L. Helping children cope with separation during war. J Spec Pediatr Nurs 26. Orthner DK, Rose R. Adjustment Among Army Children to Deployment Separations. Washing ton, DC: Army Research Institute for the Behav www.army.mil/fmwrc/docs/saf5childreportoct05. pdf. Accessed July 8, 2014. 27. Roberts D, McGulre B, Engell D. Childrens reac ings from a survey of Army families. Mil Med 28. Chartrand MM, Frank DA, White LF, Shope TR. Effect of parents wartime deployment on the be havior of young children in military families. Arch Pediatr Adolesc Med 29. Squires J, Bricker D. Ages & Stages Question naires: A Parent-Completed Child Monitoring Sys tem. Baltimore, MD: Paul H. Brookes Publishing 30. Squires J, Potter L, Bricker D. The ASQ Users Guide for the Ages & Stages Questionnaires: A Parent-Completed Child Monitoring System. Bal AU THORS Dr Nguyen, Dr Ee, and Dr Hoedebecke are with the De partment of Family Medicine, Womack Army Medical Center, Fort Bragg, North Carolina. Dr Berry-Caban is with the Clinical Investigation Ser vice, Womack Army Medical Center, Fort Bragg, North Carolina. THE EFFECTS OF MILITARY DEPLOYMENT ON EARLY CHILD DEVELOPMENT

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October December 2014 87 Being overweight or obese is one of the leading causes of preventable deaths in the United States. Approximately 400,000 people die per year of diseases related to being overweight or obese. 1 associated with hypertension; type 2 diabetes; stroke; gallbladder disease; osteoarthritis; endometrial, breast, prostate, or colon cancer; and respiratory problems. 2,3 Given the enormity of the issue, there is pressure to use The Army Surgeon General stated: mobilize the political will to invest in the long-term good stewards of the resources that we are given. 4 Being overweight or obese can translate into costly med ical care. The military spends $1.1 billion (10 9 ) a year to treat overweight or obese health-related problems of ser vice members, retirees, and their families. 5 Measures can be taken to prevent being overweight or obese. There fore, strategies must be developed to assist the Army spouse population in learning the skills necessary to make more informed choices and increasing awareness of the resources that are available to assist them. Being spouses are emotionally burdened with deployments. The duration of the current war in Afghanistan and re cent war in Iraq has taken its toll on US Army spouses. 6 The high operational tempo of repeated combat deploy ments, unexpected extended deployments, short dwell times, and a dangerously unpredictable war zone that includes the potential for combat-related casualties are all sources of uncertainty and stress for Army spouses. 7 The stressors of the war became apparent with elevated rates of psychological distress (eg, posttraumatic stress disorder, depressive symptomology) in returning Sol diers. 8 Consequently, priorities were established by the US Army Medical Department to assess, identify, and treat the needs of Soldiers and their families. 8 A key concept in the Army Medicine 2020 Campaign Plan is The Performance Triad that addresses the sleep, activity, and nutrition of Army personnel and their families. The strategy begins with identication of the variables that may impact an individuals ability to sleep, engage in activity, and consume proper nutrition, fol lowed by teaching awareness and methods of changing behaviors that result in choosing healthy options. 9 The Performance Triad may be an effective method to con tribute to the transformation of Army medicine from a reactive to proactive preventative public health focus. The philosophy extends beyond the active duty Soldier The Effect of Deployment, Distress, and Perceived Social Support on Army Spouses Weight Status LTC Tammy L. Fish, MS, USA Melissa H. Bellin, PhD Donna Harrington, PhD Terry V. Shaw, PhD ABSTR A CT This study examined the relationship between deployment status, psychological distress, perceived social support, age, rank, and gender with Army spouses (N=1863) weight status. We posited that spouses of deployed Soldiers have a higher body mass index (BMI) than spouses of nondeployed Soldiers; spouses with higher psychological distress scores have a higher BMI than those with lower distress scores; and spouses with low social support scores have higher BMIs than those with higher social support scores. Method: Secondary analysis of data from the 2008 Active Duty Spouse Survey was used to examine the relationship between weight status (health versus overweight or obese) and Army spouses deployment status, demographic charac teristics, psychological distress, and perceived social support. Results: Deployment status and weight status were not related ( P female spouses to be overweight or obese. Psychological distress increased in direct correlation with increased age, and as perceived social support decreased, the incidents of being overweight or obese increased. Conclusions: Findings suggest several risk factors are associated with being overweight or obese: male spouse, noncom social support scores. The risk factors support the use of the Army Surgeon Generals Performance Triad of sleep, activ ity, and nutrition as a tool to assist Army personnel and Department of the Army civilians in teaching spouses awareness and methods of changing behaviors that may result in choosing healthy options.

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88 http://www.cs.amedd.army.mil/amedd_journal.aspx to also emphasize the well-being of military spouses. A primary example of this commitment is The Army Family Covenant, the Armys pledge to take care of the Soldiers families signed by the Armys Public Health Command and the Chief of Staff of the Army. 10,11 How ever, research on the physical health and psychological well-being of military spouses is limited in scope. The relationship between stress and weight among mili and Operation Desert Storm (1991-1995) with Navy spouses. One of many shared physical symptoms among military spouses with deployed spouses was eating dis orders. 12 Navy spouses also reported weight loss when their husbands were at sea for long periods of time. 13,14 However, another study revealed that Navy wives weight loss and gain were equivalent regardless of the Sailors deployment status. 15 Although these studies of fered important initial insights into the relationship be tween service-related stress and weight, they occurred prior to the obesity epidemic in the US, which has mark edly increased since 1980 across all demographics and among the military population as well. 10,16 Recent epidemiology data indicate 1 in 5 Army active duty spouses are overweight, and one-third are obese compared to one-third overweight and one-third obese in the civilian sector. 10 gest that although Army spouses may have fewer inci dents than the general population for unhealthy weight status, more than half are at risk for weight related health problems. Several demographic factors are related to in creased risk of being overweight or obese. Research sug gests that as adults grow older, their BMI increases. 17 Fur ther, as men increase in age, their BMI scores increase at a rate higher than womens BMI scores increase for the same age. 18 In the civilian sector, obesity rates increased for all socioeconomic status groups and education levels from the middle of the 1990s until 2007. 19 It is well established that spouses of deployed Soldiers experience stress, but it is not known whether stress elevates the incidents among Army spouses for being overweight or obese. 20,21 Analysis of the civilian sector yielded inconsistent results for the relationship between events, such as long-term illness of themselves or chil problematic adult children are at greater risk of gain ing weight and obesity. 22 However, research has failed to cult, and obesity among women. 23 A systematic review of the literature concerning Army spouses concluded that spouses with poor coping skills are predisposed to physical health problems and recommended further study of the effect of stress associated with separation on military spouses health and well-being. 24 Associa tions among psychological symptoms (eg, depression, anxiety) and weight status are similarly inconsistent. sity and depression among women. 25 A systematic re view revealed that US studies consistently showed a re lationship between obesity and depression with women, meaning that there are higher odds that an obese woman may become depressed. 26 Conducted simultaneously, a systematic review and meta-analysis revealed a moder ate level of evidence for a positive association between 27 Although social support theory suggests that individu als with a social support system are healthier, no studies Army spouses perceived social support and being overweight or obese. 28 In the civilian population, it was found that perceived social support protects against obe sity among men but not for women, suggesting the need to examine this relationship further. 29 ARMY SPO U SES concern in the general public. Attention to correlates of weight status among Army spouses is particularly im portant because the spouses have the unique stressors of military, adapting in foreign countries, decreased social support from the family of origin, and family separations due to combat and noncombat related tours. 30 The unique challenges that military spouses face as a result of their Soldier deploying to a combat zone include constant fear for the safety of the Soldier, managing the household and children solo, and coping with loneliness. 31 Army spouses whose Soldiers are deployed to a combat zone are at risk of negative mental and physical health moderate to severe emotional problems that negatively affected other areas in their life. 20 the Army spouses surveyed met the DSM-IV* criteria for generalized anxiety. More than one-tenth of Army spouses whose Soldiers were deployed at the time of the survey had depressive symptoms, which is double the rate of the civilian community in the US adult population. 20,32 When spouses lack social support, they report increased loneliness. Spouses faced with extended deployments and unexpected extensions may struggle with mental THE EFFECT OF DEPLOYMENT, DISTRESS, AND PERCEIVED SOCIAL SUPPORT ON ARMY SPOUSES WEIGHT STATUS *Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

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October December 2014 89 health problems and loneliness compared to spouses whose Soldiers deployment is not extended. 20,33-35 Researchers hypothesized that poor coping is associated with physical health problems, which may be related to being overweight or obese. 3,12 Additional researchers supported the hypothesis and found an association be tween an Army spouses ability to cope and health prob lems. 12,36,37 Spouses with effective coping skills such as the ability to solve problems were less likely to have physical health problems. In summary, we do not know if there is an association between Soldiers deployment status and Army spouses weight status, but in the earlier studies, 13,14 spouses of Sailors either lost or maintained their weight when the Sailor was at sea. Spouses of deployed Soldiers experi ence stress and are more likely to be diagnosed with de pression than spouses of nondeployed Soldiers. 20,21 In the civilian population, depression and anxiety are related to increases in weight, and weight increases in concert with increasing age. 17,25-27 It is unclear whether there is an association between social support and weight status. The purpose of this study is to examine Army spouses weight status (eg, BMI, healthy weight, overweight, or obese) in relation to their Soldiers deployment status along with the variables of rank and education, psycho logical distress, and perceived social support. It is hy pothesized that Army spouses chronic stress of deploy ment may be related to being overweight or obese. Hav ing an understanding of the variables associated with an Army spouses overweight or obese status may assist in program planning and treatment of problematic weight and behavioral health issues. METHOD Data Source Permission was granted by the Department of Defense (DoD) to use the 2008 Active Duty Spouses Survey (ADSS) for the secondary data analyses used in this study. The data for this study are from the 2008 ADSS development by the Human Resources Strategic Assess ment Program and Defense Manpower Data Centers Secretary of Defense for Personnel and Readiness. The purpose of the survey was described to its participants as an opportunity to voice their concerns on issues that affect them and their families with the goal of improv ing personnel policies, programs, and practices. 38 The 2008 ADSS has 95 questions across 9 sections: 1. Background information 2. Permanent change of station moves 3. Spouses deployment status 4. 5. 6. Financial well-being of the family 7. Health and well-being of the spouse 8. Feelings about military life 9. The spouses use of Military One-Source A sample of 49,368 spouses was collected from active duty databases (Army, Air Force, Marine Corps, Navy, and Coast Guard), and 13,423 spouses responded (a 28% response rate from the DoD military spouses). Spouses no longer married to the service member, widowed, or whose spouse was no longer active duty were excluded solely of Army spouses. Because all identities were re moved from the data, the University of Maryland, Balti more, Institutional Review Board reviewed and approved Study Sample The target population for this study (N=1863) consists of male and female legally married spouses of US Army active duty Soldiers below the rank of general who have ity of the sample was female (90%); the average age of the spouses was 26 (SD=5.73). Race was distributed into 2 categories: non-Hispanic white (67%) and minor ity (33%). Almost one-third of the sample was from the active duty Army Soldiers are married, which is almost the same as the marriage percentage (56%) for the ser vices combined (Air Force, Army, Marine Corps, and Navy). In this sample, the average age of married enlist ed Soldiers (30.3 years) is lower than the average age of (65.6%). Spouses who were underweight (<1%) were not included in this study. Study Measures The survey measures demographic characteristics through self-response categories of gender, race, age, rank, education, and deployment status (not deployed, deployed but not to a combat zone, and deployed to a from home for more than 30 days. Psychological Distress. The Kessler Scale (K6) was used in the survey. It is designed to assess whether a men tal illness is present and its severity. The questions are similar to those used to assess symptoms of anxiety and

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90 http://www.cs.amedd.army.mil/amedd_journal.aspx depression. 39 Six questions inquire of the participants feelings over the last 4 weeks: ( a ) so sad that nothing could cheer you up, ( b ) nervous, ( c d ) hopelessness, ( e ) that everything was an effort, and ( f ) worthless. The 6 items are individually answered using a 5-point Likert scale ranging from 0 to 4 (none of the time, little of the time, some of the time, most of the time, all of the time). The scoring for the K6 is the total of the 6 items with scores ranging from 0 to 24. Scores of 0 to 7 indicate no diagnoses, 8 to 12 moderate mental illness, and scores above 12 indicate a severe mental illness. 38,40 The K6 has a strong Cronbachs (.89) in the current study and in Kesslers psychological distress scale. 32 Social Support. A 10-item perceived social support scale was used in the 2008 ADSS. The scale indicates the degree to which spouses have a network of friends and family, other than their spouse, who can provide com panionship, assistance, and other types of support. A higher score on the scale indicates greater perceived sup port. 38 The questions ask how likely is it that a friend, neighbor, or relative other than their spouse would: ( a ) listen to you if you needed to talk, ( b ) help with your daily chores if you were sick, ( c ) lend you tools or equipment if you needed them, ( d ) help you with physically de manding chores, ( e ) look after your belongings (house, pets, etc.) when you travel, ( f ) loan you $25 or more, ( g ) give you a ride if you need it, and ( h ) tell you about community resources. The answer to the 10 questions are averaged so each respondent has a total score on the perceived social support scale with a higher average score meaning more per ceived support and lower mean ing less perceived support. Cron bachs for the 10 perceived so cial support items was .94 in this study. Weight Status. The survey asks the respondents their height with out shoes and their weight. The re spondents BMI was calculated as (weight in pounds 703) / (height in inches squared). In addition to the continuous BMI measure, BMI was also categorized as 3 : Healthy: 18.5 kg/m 2 to 24.9 kg/m 2 Overweight: 25.0 kg/m 2 to 29.9 kg/m 2 Obese: 30 kg/m 2 or higher Data Analysis The primary study hypothesis is that spouses of US Army Soldiers who are deployed (whether to a combat zone or other environment) have higher BMIs than spouses of Soldiers who are not deployed. One-way analyses of variance (ANOVAs) were conducted to examine the dif ference in the average BMIs for the 3 groups of inter est: (1) Soldiers not deployed, (2) deployed but not to a combat zone, and (3) deployed to a combat zone. For 2 analysis was used to examine whether there is of interest when compared to the categories of having a healthy weight and being overweight or obese. RES U LTS Table 1 shows the basic demo graphics of the Army spouses from this survey (N=1863). The en (90%) with non-Hispanic white (67%) representing the highest percentage in the race category. The ages of the spouses were equally dispersed among the 5 age categories. The high est percentage of the spouses has age in the ranks W1 through W5 (10%). Forty-two percent of the Army spouses have some college and the smallest percentage rep resents no college (13%). Only 8% of the Army spouses report that their Soldier has been de ployed away from home but not to a combat zone. Forty-six per cent report that their Soldier has never deployed. Comparison of Healthy and Overweight or Obese Army Spouses There were several differences between Army spouses with THE EFFECT OF DEPLOYMENT, DISTRESS, AND PERCEIVED SOCIAL SUPPORT ON ARMY SPOUSES WEIGHT STATUS Table 1 Demographics of the Army Spouses Characteristic n (%N) Gender (N=1861) Male 183 (9.8) Female 1678 (90.1) Race (N=1851) Non-Hispanic white 1248 (67.0) Total minority 603 (32.4) Age (N=1858) <26 368 (19.8) 26-30 394 (21.1) 31-35 385 (20.7) 36-40 344 (18.5) >40 367 (19.7) Rank (N=1862) E1-E4 465 (25.0) E5-E9 549 (29.5) W1-W5 199 (10.7) O1-O3 312 (16.7) O4O6 337 (18.1) Education (N=1853) No college 252 (13.5) Some college 789 (42.4) 4 year degree 534 (28.7) Professional degree 278 (14.9) Deployment Status (N=1842) No deployment 865 (46.4) Deployed but not to a combat zone 153 (8.2) Deployed to a combat zone 824 (44.2) NOTE: N of each subgroup does not equal total study sample population of 1863 due to missing data.

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October December 2014 91 healthy weights and those who were over weight or obese (see Tables 2 and 3). Male female spouses to be overweight or obese (75% versus 47%) ( P <.005). More than half of the minority spouses are in the overweight or obese category compared to less than half of the non-Hispanic white spouses ( P <.005). Spouses with Soldiers in the enlisted ranks overweight or obese category compared to O6 ( P <.001). Spouses with no or some col lege were more likely to be in the overweight or obese category compared to spouses with a 4-year or professional degree ( P <.005). Com pared to those with weights in the healthy range, spouses who were overweight or obese were older, had higher psychological distress scores, and reported less perceived social support. Of the variables examined, only de to weight status. One-way ANOVAs were conducted to com pare the BMIs, age, education, K6, and per ceived social support of Army spouses in the 3 deployment groups (Table 4). Age, educa lated to deployment status. Spouses in the no (approximately 2 years older) than spouses in either deployment group; spouses in the 2 ferent in age. Table 5 presents the Tukey post hoc comparisons. Spouses in the no deploy ment group on average had higher levels of education than spouses in either deployment group; spouses in the 2 deployment groups were not sig than spouses in either deployment group; spouses in the ent K6 scores. BMI scores and perceived social support 2 analysis was used to examine whether the spouses in the 3 deployment statuses have different rates of be ing in the healthy or overweight or obese category and COMMENT The purpose of this study was to examine Army spous es weight status (eg, BMI, healthy weight, overweight, or obese) in relation to their Soldiers deployment status along with the variables of rank, education, psychologi cal distress, and perceived social support. Results fail to Table 2. Descriptive Variables Comparing Healthy to Overweight/Obese Categorical Variable Weight Healthy n (%N) Overweight/ Obese n (%N) 2 P Gender 49.74 <.005 Male (N=183) 46 (25.1) 137 (74.9) Female (N=1678) 864 (52.6) 778 (47.4) Race 14.29 <.005 Non-Hispanic white (N=1226) 646 (52.7) 580 (47.3) Total minority (N=590) 255 (43.2) 335 (56.8) Age 14.60 .006 <26 (N=354) 198 (55.9) 156 (44.1) 26-30 (N=389) 206 (53.0) 183 (47.0) 31-35 (N=376) 184 (48.9) 192 (51.1) 36-40 (N=338) 163 (48.2) 175 (51.8) >40 (N=365) 156 (42.7) 209 (57.3) Rank 29.99 <.005 E1-E4 (N=451) 209 (46.3) 242 (53.7) E5-E9 (N=544) 234 (43.0) 310 (57.0) W1-W5 (N=194) 97 (50.0) 97 (50.0) O1-O3 (N=306) 171 (55.9) 135 (44.1) O4O6 (N=331) 198 (59.8) 133 (40.2) Education 36.41 <.005 No college (N=245) 117 (47.8) 128 (52.5) Some college (N=774) 329 (42.5) 445 (57.5) 4 yr degree (N=526) 309 (58.7) 217 (41.3) Professional degree (N=272) 149 (54.8) 123 (45.2) Deployment Status 4.67 .097 No deployment (N=849) 406 (47.8) 443 (52.2) Deploy, no combat zone (N=149) 68 (45.6) 81 (54.4) Deploy to combat zone (N=808) 424 (52.5) 384 (47.5) K6 Scale 18.83 <.005 No mental illness (N=1221) 651 (53.3) 570 (46.7) Moderate mental illness (N=358) 158 (44.1) 200 (55.9) Severe mental illness (N=197) 78 (39.6) 119 (60.4) K6 Scale indicates Psychological Distress Subscale: 1-5=no mental illness; 6-12=moderate mental illness; >13=severe mental illness Table 3. Continuous Variables Comparing Healthy to Over weight/Obese (N=1863) Continuous Variables Weight Healthy Mean (SD) Overweight/Obese Mean (SD) t P Age 32.7 (8.2) 34.3 (8.4) -4.07 <.0005 K6 Scale 5.4 (5.0) 6.4 (5.3) -4.01 <.0005 Social Support 3.9 (1.1) 3.7 (1.2) 4.40 <.0005 K6 Scale indicates Psychological Distress Subscale: 1-5=no mental illness; 6-12=moderate mental illness; >13=severe mental illness Social Support indicates subscale for perception of likelihood of support: very unlikely=1; unlikely=2; neither likely nor unlikely=3; likely=4; very likely=5

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92 http://www.cs.amedd.army.mil/amedd_journal.aspx deployment status and spouse weight status. However, spouses weight status was related to gender, rank, psy chological distress, and perceived social support. Spe increased psychological distress, and lower perceived social support were related to increased incidence of be ing overweight or obese. The percentage (60%) of Army spouses who are over weight or obese is lower than what has been reported for the civilian population in which 68% of adults over 20 are overweight or obese. 41 However, an unexpected to be overweight or obese compared to females. This men in the United States are more likely to be overweight or obese in comparison to wom en. 17 Further, in the civilian sector in the last increased compared to that of women. 18 How ever, the weight differences between men and women in the Army are notably higher (25%) than the civilian sectors difference of 10%. 17 or obese compared to spouses of Soldiers in the higher ranks (O1 through O6). Because rank is directly associated with income, it is possible that spouses of Soldiers in enlisted accessing high quality foods such as whole grain, lean meats, and fresh fruits and vegetables. They may also rely on fast food options that are often perceived as more economical and convenient. Previous research has tied socioeconomic status to diet quality, with lower socio economic status associated with greater consumption of 42-44 Psychological stress was also associated with weight status, with spouses who endorsed greater distress also reporting higher BMI. The physiological pathway in which stress may predispose an individual to obesity is well documented. Individuals experiencing acute or chronic stress have been found to have elevated glu cocorticoids related to hypothalamic-pituitary-adrenal axis simulation that may increase eating behaviors, and, in turn, elevate BMI. 45,46 Consistent with other studies, can increase when the Soldier is deployed. 34,47 between perceived social support and BMI; participants who had higher social support scores were less likely to be overweight or obese. Social support is especially im to the military way of life, and are often separated from their Soldier. 48,49 The protective effect of social support may work directly on weight status by providing oppor tunities for shared physical activity and may also offer a buffer for psychological distress. 50 Spouses perceptions of social support affects Soldiers decisions to continue serving their country, and Airmen who perceive that spouses cope effectively with the military lifestyle. 47,51 Men differ from women in their use of social support and the supports effectiveness in decreasing stress. 52 THE EFFECT OF DEPLOYMENT, DISTRESS, AND PERCEIVED SOCIAL SUPPORT ON ARMY SPOUSES WEIGHT STATUS Table 4. Comparing Deployment and Weight Status of Army Spouses Continuous Variable Deployment Status Past 12 Months No Deployment Mean (SD) Deployment to Combat Zone? No Mean (SD) Yes Mean (SD) F P BMI 26.17 (5.47) 26.12 (6.08) 26.11 (5.94) 0.02 .977 Age 34.8 (8.46) 32.7 (8.62) 32 (7.84) 23.2 <.005 Education 2.52 (0.91) 2.33 (0.88) 2.40 (0.89) 5.01 .007 K6 Scale 5.16 (4.70) 6.43 (5.47) 6.49 (5.49) 14.68 <.005 Social Support 3.75 (1.15) 3.82 (1.09) 3.80 (1.13) 0.62 .537 BMI indicates body mass index. Assigned Education values: no college=1; some college=2; 4-year degree=3; graduate degree=4 K6 Scale indicates Psychological Distress Subscale: 1-5=no mental illness; 6-12=moderate mental illness; >13=severe mental illness Social Support indicates subscale for perception of likelihood of support: very unlikely=1; unlikely=2; neither likely nor unlikely=3; likely=4; very likely=5 Table 5. Tukey Post Hoc Test on Deployment Status Categorical Variable Deployment Status P Age not deployed deployed not combat .012 deployed combat <.005 deployed not combat not deployed .012 deployed combat .666 deployed combat not deployed <.005 deployed not combat .666 Spouse Education not deployed deployed not combat .042 deployed combat .024 deployed not combat not deployed .042 deployed combat .607 deployed combat not deployed .024 deployed not combat .607 K6 Scale not deployed deployed not combat .016 deployed combat <.005 deployed not combat not deployed .016 deployed combat .989 deployed combat not deployed <.005 deployed not combat .989

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October December 2014 93 Implications Future Research. The results of this study provide a di rection for building programs that maximize protective factors and address risk factors associated with spouse weight status. Because this study only included data through 2008, it is important to conduct follow-up re search to fully capture the long-term effects of deploy ments, especially in light of the ongoing operations re sofar as the US military population has never served as long or had as many repeated deployments to combat zones. The literature shows that Soldiers with multiple ment problems compared to those with only one deploy ment. 8,53 Soldiers with at least 2 deployments have higher less than 2 deployments. 8,53 The experience of multiple deployments over 13 years may also have substantial instead of 7 years may offer a more comprehensive pic ture of the interrelationships among deployment, stress, social support, and weight status. Policy and Practice. We have enhanced understanding of how psychological distress and perceived social sup port are associated with being overweight or obese and the higher incidents of overweight among male spouses. health through the Performance Triad; they may also improve the ability of primary care providers and Army units to enhance the treatment and programs provided for spouses. For example, Army units could tailor a so cial support program to have physical activities, such as basketball leagues, that may attract the male spouses. Morale, Welfare, and Recreation support services could make a concerted effort that focuses on engaging male spouses to participate in their sponsored activities such providers could also channel educational material about the relationships of stress, social support, and healthy lifestyle choic es to spouses of Soldiers who are prepar ing to deploy. programs such as the Army Wellness Cen ters (AWC) and Comprehensive Soldier Fitness (CSF) program. For example, the fact that three-quarters of male spouses are overweight or obese may also be criti cal information for the AWC as they could design programs geared towards reaching out to male spouses. As another example, the AWC could provide networking opportunities to increase perceived social support for families living outside the United States where they may be removed from their families of ori they structure their programs that address their 5 di mensions of strength: physical, emotional, family, social, and spiritual. CONCL U SION The results of this study fail to support a relationship between deployment and weight status among Army spouses during the period 2001 through 2008. However, by identifying several key risks (older age, lower rank, male gender, psychological distress) and protective mechanisms such as social support associated with spouse weight status. Moreover, this study contributes to The Army Surgeon Generals Performance Triad strat egy of recognizing and intervening on factors that cre ate challenges with sleep, activity, and nutrition. It also offers suggestions to shape policy and clinical practice to enhance care for Army spouses. Additionally, study results may help shape clinical practice in primary care settings by encouraging providers to routinely screen associated with being overweight or obese, and help link at-risk groups to programs and resources. Collectively, these steps could help advance The Army Surgeon Gen erals Performance Triad initiative. REFERENCES 1. Robbins AS, Chao SY, Baumgartner N, Runyan CN, Oordt MS, Fonseca VP. A low-intensity inter vention to prevent weight gain in active duty Air Force members. Mil Med. 2006;171(6):556-561. 2. Gantt CJ, Neely JA, Villafana IA, Chun CS, Ghara baghli SM. Analysis of weight and associated health val medical center. Mil Med. 2008;173(5):434-440. Table 6. Comparing Deployment Status of Spouse with Being Overweight/ Obese Categorical Variable Deployment Status No Yes Not Combat Zone Combat Zone n (%N) n (%N) n (%N) 2 P Healthy weight (N=898) 406 (47.8) 68 (45.6) 424 (52.3) 4.34 .114 Unhealthy weight 5.03 .081 Overweight (N=528) 269 (60.7) 51 (63.0) 208 (53.7) Obese (N=383) 174 (39.3) 30 (37.0) 179 (46.3) Deployment status during the last year.

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94 http://www.cs.amedd.army.mil/amedd_journal.aspx 3. Karasu SR, Karasu TB. The Gravity of Weight: A Clinical Guide to Weight Loss and Maintenance Arlington, VA: American Psychiatric Publications; 2010. 4. Horoho PD, Brock DA. Army medicine strategy: the road ahead. Paper presented at: 2012 Perfor mance Triad Nutrition Action Plan Workshop; Sep tember 2012; US Army Public Health Command; Aberdeen Proving Ground, MD. 5. Dall TM, Zhang Y, Chen YJ, et al. Cost associ ated with being overweight and with obesity, high alcohol consumption, and tobacco use within the rolled population. Am J Health Promot 2007;22 (2):120-139. 6. Manos G. The case for treating depression in mili tary spouses. J Fam Psychol. 2011;25(4):488-496. 7. Sheppard SC, Malatras JW, Israel AC. The impact of deployment on U.S. military families. Am Psy chol. 2010;66(1):65-72. 8. Tanielian TL, Jaycox LH, eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery Santa Monica, CA: Rand Corporation; 2008. Avail able at: http://www.rand.org/pubs/monographs/ MG720.html. Accessed August 4, 2014. 9. Kukral L. Performance triad to change focus of Army medicine. US Army Website. September 27, 2012. Available at: http://www.army.mil/ar ticle/88044/. Accessed May 1, 2013. 10. Kennan JO. Nutrition Plan. Presentation at 2012 Performance Triad Nutrition Action Plan Work shop. September 2012; US Army Public Health Command; Aberdeen Proving Ground, MD. 11. McLeroy C. Army family covenant: keeping prom ises. Soldiers. 2008;63(6):22. 12. Blount BW, Curry A, Lubin GI. Family separations in the military. Mil Med. 1992;157(2):76-80. 13. Snyder AI. Periodic marital separation and physical illness. Am J Orthopsychiatry 1978;48(4):637-643. 14. lowe DH, Segal MW. The Impact of Deployment Separation on Army Families. Washington, DC: Walter Reed Army Institute of Research; August 1984. Report WRAIR NP-84-6. Available at: http:// www.dtic.mil/dtic/tr/fulltext/u2/a146595.pdf. Ac cessed August 5, 2014. 15. Nice DS. The course of depressive affect in Navy wives during family separation. Mil Med. 1983;148(4):341-343. 16. Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The epidemiology of obesity. Gastroenterol. 2007;132:2087-2102. 17. Wang Y, Beydoun MA. The obesity epidemic in the United Statesgender, age, socioeconomic, racial/ ethnic, and geographic characteristics: A systemat ic review and meta-regression analysis. Epidemiol Rev. 2007; 29: 6-28. 18. Flegal KM, Carroll MD, Kit BK, Ogden CL. Preva lence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. 2012;307(5):491-497. 19. Ogden C, Lamb M, Carroll M, Flegal K. Obesity and socioeconomic status in adults: United States, 2005-2008 NCHS Data Brief. 2010;50:1-8. 20. lence of mental health problems, treatment need, and barriers to care among primary care-seeking spouses of military service members involved in Iraq and Afghanistan deployments. Mil Med. 2008;173(11):1051-1056. 21. Gottman JM, Gottman JS, Atkins CL. The compre nent. Am Psychol. 2011;66(1):52-57. 22. ohr P, Rod NH. Psychosocial risk factors in weight changes and risk of obesity: The Copenhagen City Heart Study. Eur J Epidemiol. 2012;27(2):119-130. 23. rated health in family planning clinic patients. BMC Fam Prac. 2004;5(11):1-8. 24. Blakely G, Hennessy C, Chung MC, Skirton H. A systematic review of the impact of foreign postings on accompanying spouses of military personnel. Nurs Health Sci. 2012;14:121-132. 25. De Wit L, Luppino F, van Straten A, Penninx B, meta-analysis of community-based studies. Psy chiatry Res. 2009;17:230-235,26. 26. sion: Systematic review of epidemiological studies. Int J Obes. 2008;32:881-889. 27. Gariepy G, Nitka, D, Schmitz N. The association between obesity and anxiety disorders in the popu lation: A systematic review and meta-analysis. Int J Obes. 201;34:407-419. 28. House JS, Landis KR, Umberson D. Social relation ships and health. Science 1988;241(4865):540-545. 29. Obesity and health-related quality of life: Does so cial support moderate existing associations? Br J Health Psychiatry. 2009;14:717-734. 30. Burrell LM, Adams AA, Durand DB, Castro CA. The impact military lifestyle demands on wellbeing, Army, and family outcomes. Armed Forces Soc. 2006;33(1):43-58. 31. Warner CH, Appenzeller GN, Warner CM, Grieger T. Psychological effects of deployments on military families. Psychiatr Ann. 2009;39(2):56-63. THE EFFECT OF DEPLOYMENT, DISTRESS, AND PERCEIVED SOCIAL SUPPORT ON ARMY SPOUSES WEIGHT STATUS

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October December 2014 95 32. 32.Kessler RC, Barker PR, Colpe LJ, et al. Screen ing for serious mental illness in the general popula tion. Arch Gen Psychiatry. 2003;60(2):184-189. 33. Hill R. Families Under Stress: Adjustment to the Crises of War Separation and Reunion New York, NY: Harper & Brothers; 1949. 34. use of mental health services among U.S. Army wives. N Engl J Med. 2010; 362(2): 101-109. 35. SteelFisher GK, Zaslavsky AM, Blendon RJ. Health-related impact of deployment extensions on spouses of active duty army personnel. Mil Med. 2008;173(3):221-229. 36. Stress ful experiences, coping strategies, and predictors of health-related outcomes among wives of de ployed military servicemen. Armed Forces Soc. 2010;36(2):351-373. 37. Padden DL, Connors RA, Agazio JG. Stress, coping, and well-being in military spouses dur ing deployment separation. West J Nurs Res. 2011;33(2):247-267. 38. Defense Manpower Data Center. 2008 Survey of active duty spouses: Tabulations of Respons es Washington, DC: US Dept of Defense; 2008. DMDC Report No. 2008-041. Available at: http:// prhome.defense.gov/Portals/52/Documents/RFM/ MCFP/docs/2008%20Military%20Spouse%20 Survey.pdf. Accessed August 5, 2014. 39. Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, Kessler RC. Improving the K6 short scale to predict serious emotional disturbance in ado lescents in the USA. Int J Methods Psychiatr Res 2010;19(suppl 1):23-35. 40. Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences Psychol Med. 2002;32(6):959-976. 41. Ogden CL. Disparities in obesity prevalence in the United States: black women at risk. Am J Clin Nutr. 2009;89(4):1001-1002. 42. Darmon N, Drewnowski A. Does social class predict diet quality? Am J Clin Nutr. 2008;87(5):1107-1117. 43. Lallukka T, Laaksonen M, Rahkonen O, Roos socio-economic circum stances and healthy food habits. Eur J Clin Nutr. 2007;61:701-710. 44. Turrell G, Hewitt B, Patterson C, Oldenburg B. Measuring socio-economic position in dietary re search: is choice of social-economic indicator im portant? Public Health Nutr. 2003;6(2):191-200. 45. system. Physiol Behav. 2007;91(4):449-458. 46. Warne JP. Shaping the stress response: interplay of palatable food choices, glucocorticoids, insu lin and abdominal obesity. Mol Cell Endocrinol. 2009;300(1-2):137-146. 47. Depressive symptoms among US military spouses during deployment: the protective effect of positive emotions. Armed Forces Soc 2012;38(3):373-390. 48. Bowen GL, Mancini JA, Martin JA, Ware WB, Nelson JP. Promoting the adaptation of military families: an empirical test of a community practice model. Fam Relat. 2003;52(1):33-44. 49. Pittman JF, Kerpelman JL, McFadyen JM. Internal and external adaptation in Army families: lessons from Operations Desert Shield and Desert Storm. Fam Relat. 2004;53(3):249-260. 50. Watt RG, Heilmann A, Sabbah W, et al. Social relationships and health related behaviors among older US adults. BMC Public Health [serial online]. 2014;14(533). Available at: http://www.biomedcen tral.com/content/pdf/1471-2458-14-533.pdf. Ac cessed August 5, 2014. 51. work factors on marital tension: evidence from the interface of greedy institutions. Hum Relat 1994;47(2):183-209. 52. Bellman S, Forster N, Still L, Cooper CL. Gen der differences in the use of social support as a moderator of occupational stress. Stress Health 2003;19(1):45-58. 53. Adler A, Huffman AH, Bliese PD, Castro CA. The impact of deployment length and experiences on the well-being of male and female soldiers. J Oc cup Health Psychol. 2005;10(2):121-137. AU THORS LTC Fish is Clinical Assistant Professor, Army-Fayette ville State University Master of Social Work Program, Army Medical Department Center and School, Joint Base San Antonio Fort Sam Houston, Texas. Dr Harrington is Professor and Associate Dean for Doc land School of Social Work, Baltimore, Maryland. Dr Bellin is an Associate Professor, University of Mary land School of Social Work, Baltimore, Maryland. Dr Shaw is an Associate Professor, University of Mary land School of Social Work, Baltimore, Maryland.

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96 http://www.cs.amedd.army.mil/amedd_journal.aspx Until relatively recently, many cultures viewed wife beating as an acceptable part of marriage. 1 Even though violence in relationships is not condoned in the United States, one in 4 women will experience a form of domestic abuse in their lifetime. 2 While men comprise 85% of the domestic violence arrests, women also per petrate violence towards their partners. 3 Three million children witness domestic violence every year. 2 Most healthcare professionals agree that domestic violence is far-reaching and has effects on families, communi including situational couple violence (SCV), intimate partner terrorism, and violent resistance. 4 The most common form of violence between couples is SCV. 4 This type of violence is commonly called batter ing, which involves a partner physically attacking an other. It can either be an isolated incident or reoccur ring, potentially a particularly dangerous situation since physical attacks often increase in severity. Intimate partner terrorism involves an individual who terrorizes by using coercion to control the partner through a com bination of violence and other tactics including threats, intimidation, or psychological abuse. This form of abuse is believed to be less frequent than SCV but still affects 2 million women in the United States. Violent resistance occurs when the victim of intimate partner terrorism 4 Resistance can be especially dangerous if the female obtains a weapon and attacks the male out of fear. All 3 types of violence can be dangerous, in some cases life threatening, thus requiring timely and effec tive intervention. The Department of Defense created the Family Advoca cy Program (FAP) to treat victims and offenders of fam to involve SCV. Service members are under a great deal of public scrutiny since many individuals believe that the stress of military life can lead to family abuse. 5 The Army has been involved in an almost 13-year period members and their families. The many stressors associ ated with military service may impede healthy family functioning. 6 Nearly 18% of married Soldiers report in ments. 7 Operation Iraqi Freedom deployments are often correlated to decreased marital satisfaction, increased divorce intentions, and an increase in self-reported spousal abuse. 8 military deployments also increase marital dissatisfac tion, divorce rates, and decrease the emotional health of partners. 9 Assessing a FAP referral, which in many cases is a com plex endeavor, begins with an intake interview that in cludes a biopsychosocial assessment and determining the details of the allegedly abusive incident. Establishing safety is of paramount importance. The standard proto col involves completing the Spouse Abuse Risk Assess ment, Spouse Abuse Manual Assessment Worksheet, and Safety Plan to address the presenting circumstances. ditional assessment tool that can quickly assess the level of danger in a SVC situation and identify individuals that may be vulnerable to future incidents. The Korem 10 current FAP assessment procedures. THE KOREM PROFILING SYSTEM The KPS examines the method in which an individual communicates and the process they use to make deci sions. 10 Properly application of the system requires a clinician to determine the degree of assertiveness de livered in an individuals communication and the emo tion expressed in their messages. Examining a persons Applying the Korem Profiling System to Domestic Violence CPT Victor Johnson, MS, USA Chandra Brown, LMSW ABSTR A CT Soldiers involved in domestic violence are a focus of concern for the US Army. The Family Advocacy Program is designed to prevent and intervene to mitigate future violence. Some of the Family Advocacy Program assess ment tools are limited in their ability to identify contributing factors of situational couple violence. This article of situational couple violence and provide appropriate interventions to prevent future incidents.

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October December 2014 97 decision making process, seen as a performance trait, the decisions they make and whether their thought pro cesses tend to be conventional. Assessing these charac teristics is helpful to understanding a persons typical style in communicating and performing. When com bined, these 2 basic traits form a broad picture of the characteristic manner in which a person relates to others and responds to environmental demands. Communication Traits A social worker can use the KPS to explore the break down in the communication. First, the social worker should evaluate if the client is assertive when they talk. The social worker should evaluate if the individual is mostly assertive or mostly nonassertive and place a point on a graph as illustrated in Figure 1. Next, the social worker evaluates if an individual uses a lot of emotion or controls their emotions when communicating. A point is placed on the graph as shown on Figure 1. Plotting 2 different traits forms what is called a type which is represented by each quadrant. 10 Individuals who are in typical with their respective professions. The 2 person alities that control their emotions are the Accountant and Sergeant. For instance, the Accountant is nonas sertive and controls emotions. This type of individual maintains emotional composure and nonassertively makes inquires like an investigator or detailer. While the Accountant can be easy-going, analytical, and ef simistic, and critical of others. The Sergeant, a designa tion coined by Korem which can also be called a leader or commander, is more typical in the military and gives orders while controlling emotion. While a Sergeant is ented, this trait has the dark side of being overbearing, egotistical, impatient, and unsympathetic. 10 The 2 types that express emotion are the Artist and Salesman. The Artist has traits typical of a counselor or sensor in the sense of a person who communicates nonassertively while using emotion. An Artist is typi cally agreeable, creative, compassionate, and loyal, however, this trait has the dark side of being critical, moody, unsure, and naive. The last personality type is the Salesman who can also be seen as a communicator or presenter since they convey emotion and enthusiasm, selling their product while using assertion. This trait has the upside of being optimistic, passionate, friendly, and selling, unfocused, and short-fused. 10 Interactions among Traits Each quadrant in Figure 1 has a position that is often communication trait. Sergeants are more likely to con trol their emotions and be assertive in their communi cation. In complete contrast is an Artist who expresses emotion while lacking assertiveness in communication. Individuals that have communication patterns that are complete opposites, which would be represented by a their communication. 10 A social worker armed with this knowledge can quickly assess the dysfunctional com munication pattern and explain it to the couple suffering from SCV. Korems assertion that the method of communication 11 who posited that in dividuals who are communicating in different love lan are similar. The KPS argues that individuals who control emotions and are nonassertive, such as the Accountant, expresses emotions and is assertive. The same opinion applies for the Sergeant and Artist. 10 Armed with a fast communication assessment tool, a so cial worker can quickly provide important information and recommendations to a couple suffering from SCV. Individuals with certain communication traits require unique methods for effectively engaging in conversa tion. For example, one should be more directive when addressing a nonassertive person to control miscommu nication. Further, be slightly less assertive when asking a nonassertive person a question or making a statement to make the message less threatening. When address ing an assertive or control individual, who is typically blunt, use direct communication. 10 Control and expres sive individuals often require someone to show emotion Figure 1 Communication Axis. (Courtesy of Dan Korem.) NO N ASSERTIVE ASSERTIVE CO N TROL EXPRESS Accountant Salesman Sergeant Artist Plot 1 Plot 2

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98 http://www.cs.amedd.army.mil/amedd_journal.aspx nication that is without emotion when obtaining factual information from expressive individuals. 10 Decision Making Social workers devise safety plans in every assess ment to ensure the welfare of their clients. Tools such as the Spouse Abuse Manual Assessment Worksheet and Spouse Abuse Risk Assessment have limitations in their ability to protect an individual in the long run. The KPS addresses this problem by analyzing the method by which an individual makes decisions. Figure 2 is used to evaluate an individuals emotional approach and pre dictability in decision making. A social worker should fear when making decisions. It should be determined if the individual is slightly fearful, cautious, or has a high degree of fear. The social worker would then make a horizontal plot as illustrated in Figure 2. Next, the social worker can examine whether the individual makes con ventional or unconventional decisions. A conventional person makes predictable decisions and often thinks inside of the box. In contrast, an unconventional per son is often unpredictable and thinks outside of the the vertical axis of the graph as shown in Figure 2. 10 Understanding the Performance Quadrants The 2 conventional types are the Loyalist and Man ager. The Loyalist is typically obedient and a team player, and can be also viewed as a supporter or sustain er. While Loyalists are manageable, reliable, and precise, they have the downside of being uncreative, indecisive, and unwilling to take responsibility for their actions. The Manager type are typically leaders who tend to fol low the rules and follow orders. While Managers are organized, goal oriented, logical, and self-assured, they have a dark side of being bureau and micromanaging. A Manager also relies on experience versus creativity to solve problems. In contrast with these conventional traits are unconventional types of individuals. 10 The 3 unconventional types are the Random Actor, Cautious Innovator, and Innovator. Indi viduals of the Random Actor type are usually troubled and operate out of paranoia or fear. While Random Actors are imaginative and creative, they can be dangerous, deceptive, moody, and lack empathy. These individuals also seek protec Cautious Innovators are creative types of individuals similar to designers or software developers, but do not take risks. Individuals with these traits are loyal, freethinking, and creative, however they can be aimless, ir responsible, insecure, and unwilling to take responsibil ity for their actions. The last unconventional type that type of individual is willing to take risks and challenge a system. While this trait has the strength of being selfassured, creative, decisive, and adapts to change, it can have the downside of being forgetful, reckless, unreli able, and irresponsible. 10 Interactions Among Types The 2 different methods of assessing the decision-mak ing traits of an individual forms quadrants that reveal certain personality types. The Manager is both a pre The complete opposite type is the Loyalist who makes decisions out of fear, but is predictable. Naturally the Manager can get along with the Loyalist who will follow suit. A slightly fearful individual who is unconventional is the Cautious Innovator. This individual has some fear 10 Last is the Random Actor who is both fearful and unconventional. Random Actors and Innovators initially get along well in relationships. Eventually Innovators become annoyed and weary of the Random Actors paranoia. This personality type can be the most dangerous since Random Actors make choices based on paranoia. These types of individuals often engage in random acts of violence and harm in nocents. Examples of Random Actors include John Mu hammad, the Beltway Sniper, and Mark Kools who killed members of his chain of command with a hand grenade in Kuwait. 12 These individuals have the traits of the Intimate Terrorist that Leone et al describe as an individual who op erates on fear. 13 Not all Random Actors are dangerous as explained below. An individual who lacks violent traits should not warrant as much concern. 12 A social worker armed with this knowledge can quickly assess how dangerous a partner may be Loyalist Random Actor Manager Innovator CO N VE N TIO N AL UNC O N VE N TIO N AL FEAR CO NF IDE N T Plot 1 Cautious Innovator Plot 2 Figure 2. Performance Axis. (Courtesy of Dan Korem.) APPLYING THE KOREM PROFILING SYSTEM TO DOMESTIC VIOLENCE

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October December 2014 99 rate traits. One is the hammer, which is the Random Actor who uses unconventional traits for creative and 12 This type of individual is typi cally not violent. In contrast is the gun, the Random Actor who is waiting to explode. There are usually 2 cri teria for the gun type of Random Actor to explode. First, the gun needs bullets, which can be a bad relationship or a history of being bullied. The second criteria is the trig ger, the event that pushed the individual over the edge such as a partner ending a relationship. 12 This type of individual can cause a great deal of harm to a partner. The social worker conducting the assessment should look for a history of violence throughout the interview to determine if the individual is a hammer or a gun. A social worker should examine a more thorough safety plan with a Random Actor demonstrating the gun trait. Application to Family Advocacy Physically aggressive couples tend to lack appropriate communication skills. 14 There are a number of factors couples. Researchers have found that wives who tend to be physically aggressive can be easily provoked by their spouses offensive or defensive statements. 15 A so cial worker who understands how each communication ents attention in order to select an appropriate interven tion. More importantly, the social worker can teach and coach their clients to communicate more smoothly with other communication types which allows them to pre vent frustration during conversations that can ultimately lead to violence. Limitations The KPS is not without its weaknesses. Inexperienced individuals using the system may take a snapshot at a point in time and misread a person. Individuals that are presenting to FAP are often attempting to conceal their actual communication traits from the social worker to protect their careers. Korem argued that watching an individual in a stressful situation or the use of confron tation can cause the person to present their true traits. 12 Korem argues to use a quick safety check to verify a vidual using his system should look at the total person and not a particular incident when an individual may act out of character. 10 Couples experiencing SCV are prime examples of individuals who may not necessarily be violent individuals. A situation in which the couple sim of applying the system is mistaking communication for action. Korem stressed the importance of separating the two. Adolph Hitler is an example of an individual who ing decisions based on fear and paranoia. 12 CONCL U SION Using the KPS as a screening tool along with other mandated techniques allows providers to quickly assess potential communication issues with an individual. The KPS is in no way designed to replace assessment tools approved by the Army Medical Command which are critical in safety planning and determining therapeutic interventions. The KPS also allows providers to go be yond an individuals personal communication presenta problematic in the future. In the case of working with ful trait in clients that may require an intervention that a conventional biopsychosocial assessment may miss. While Korem posits law enforcement and businesses works, 10 the behavioral health community should evalu work. The KPS is a promising system for incorporation into the FAP. A pilot study should be conducted to mea sure its true effectiveness for addressing situations of domestic violence. ACKNO W LEDGEMENT The authors thank Dan Korem for his mentorship, advice, ditionally, the authors thank Sandy Korem for her guid ance and assistance in preparing this article. REFERENCES 1. Salber PR, Taliaferro E. The Physicians Guide to Domestic Violence: How to Ask the Right Ques tions and Recognize Abuse....Another Way to Save a Life. Volcano, CA: Volcano Press; 1995. 2. Safe Horizon. Domestic Violence: Statistics & domestic-violence-statistics--facts-195.html?gclid =CMGS9ZnQl70CFenm7AodAU0AHw. Accessed March 15, 2014. 3. Rennison CM. Intimate Partner Violence, 19932001 [internet]. Washington DC: US Dept of Jus 4. Ooms T. A Sociologists Perspective on Do mestic Violence: A Conversation with Michael Johnson, Ph.D. Interview conducted at Center for Law and Social Policy and National Confer ence of States Legislatures conference: Building

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100 http://www.cs.amedd.army.mil/amedd_journal.aspx Bridges: Marriage, Fatherhood, and Domestic Vi olence; May 1-3, 2006; Racine, WI. Available at: 5. Thompson M. The living room war. Time. 1994;143:48-51. Cited by: Robichaux JR, McCarroll, JE. Family maltreatment and military deployment. In: Lenhart MK, ed-in-chief; Ritchie EC, senior ed. Combat and Operational Behavioral Health Fort Sam Houston, TX: Borden Institute; 2011:535-542. 6. Martin SL, Gibbs DA, Johnson RE, et al. Male sol dier family violence offender: spouse and child of fender compared to child offenders. Violence Vict. 2009;24(4):458-468. 7. Gibbs D, Clinton-Sherrod M, Johnson R. Interper married soldiers following return from deployment. Mil Med 2012:177(10):1178-1183. 8. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006:295(9),1023-1032. 9. B, Morrissey J, Engel C. Deployment and the use of mental health services among U.S. Army wives. New Engl J Med 2010;362(2):101-109. Cit ed by: Lewis M, Lamson A, Leseuer B. Health dynamics of military and veteran couples: a bio psychorelational overview. Contemp Fam Ther 2012:34:259-276. 10. Korem D. Right the First Time Expanded Second Edition. Richardson, TX: International Focus Press; 2012. 11. Chapman G. The 5 Love Languages. Chicago, IL: 12. Korem D. Rage of the Random Actor Richardson, TX: International Focus Press; 2005. 13. Leone J, Johnson M, Cohan C. Victim help seeking: differences between intimate terror ism and situational couple violence. Fam Relat. 2007;56(5):427-439. 14. Burman B, Margolin G, John R. Americas angriest home videos: behavioral contingencies observed J Con sult Clin Psychol 1993;61:28-39. Cited by: Ronan G, Dreer L, Dollard K, Ronan D. Violent couples: coping and communication skills. J Fam Violence. 2004;19(2):131-137. 15. Ronan G, Dreer L, Dollard K, Ronan D. Violent couples: coping and communication skills. J Fam Violence. 2004;19(2):131-137. AU THORS CPT Johnson is a Social Work Intern at the Carl R. Dar nall Army Medical Center, Fort Hood, Texas. Ms Brown is with the Family Advocacy Program, Carl R. Darnall Army Medical Center, Fort Hood, Texas. Articles published in the Army Medical Department Journal are indexed in MEDLINE, the National Library of Medicines (NLMs) bibliographic database of life sciences and biomedical information. Inclusion in the MEDLINE database ensures that citations to AMEDD Journal to researchers during searches for relevant information using any of several bibliographic search tools, including the NLMs PubMed service. APPLYING THE KOREM PROFILING SYSTEM TO DOMESTIC VIOLENCE

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October December 2014 101 Students with active-duty military experience repre sent a unique population on the college campus. Over 945,000 students in the United States use education ben 1 In tion program reports that over 400,000 current service Program and are enrolled in higher education pro grams. 2 as the Post 9-11 GI Bill, has made higher education an may be an especially attractive option in coming years; deployments to combat zones may decrease and the traditional students, which can both enrich the veteran during transition and retention. This suggests the need to better understand how student veterans perceive their transition to and experience in higher education. port academic success, the challenges they experienced ideal resources aimed at supporting the student veteran. THE ST U DENT VETER A N A ND THE COLLEGE EXPERIENCE 4 5 and student veteran academic success compared to their nonveteran counterparts 6 rather than on their transition to the college environment and subsequent experience. However, several recent studies have explored the tran students, 7 and 2 studies explored the transitional expe ments or other active military service. 7 and a reluc mio and colleagues 7 prevalent among the veteran participants in their study, ence seemed to have equipped student veterans with a in more traditional college students which resulted in diminishing class participation. 7-9 Mental and physical health concerns were also noted as contributing to the 7,9 Understanding the Student Veterans College Experience: An Exploratory Study ABSTR A CT Objective: Students with active duty military experience are a unique and growing population on college cam ence in higher education. Method: Results: Conclusion:

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102 http://www.cs.amedd.army.mil/amedd_journal.aspx status and attempt to understand them. et al 10 students compared to that reported by civilian students. dent veterans. nity than traditional college students. 11 thoroughly examined, 12 surveys have shown that non traditional students, a group to which most student vet college, and that being a student veteran is negatively 14 14 ian and veteran student groups in relation to academic relevant support provided by college campuses would be use to improve their college experience and retention. ST U DY METHODOLOGY This mixed-methods exploratory study used a purposive tion. To participate in the study, respondents had to be who had served in any military branch on an active duty board, an introductory email was sent via the universi the study. Invitations to participate were sent within one mation so that an individual interview could be sched uled. Twelve students responded to the study invitation pleted interviews, which was assessed to be adequate 15 2011. Qualitative data were gathered using semistruc tured individual interviews 15 tion to the student role and throughout their college expe choose not to participate in social and academic support Participants received an instructional letter at the begin UNDERSTANDING THE STUDENT VETERANS COLLEGE EXPERIENCE: AN EXPLORATORY STUDY

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October December 2014 103 titative data were gathered prior to and during the in study room on campus with one exception, one respon dent completed the interview by phone. Investigators re as an incentive. DA T A AN A LYSIS interviewers and read repeatedly and independently by tive analysis was used during these readings. 16 Once the and determined major themes together. The resulting categorized emerging themes well exceeded the mini berman. 17 Quantitative data gathered in this study were researchers independently noted saturation with the data as themes were repeated consistently throughout data collection, and new cases resulted in little variance. 19 In addition, the 2 investigators who interviewed partici pants have extensive military experience, including com bat deployment, and have been immersed in the military milieu and enrolled as student veterans. Quantitative RES U LTS Demographics were enrolled in graduate programs. They had a mean the participants were deployed to a combat zone while on each participant reported that they were in good academ were employed and one was serving in a military reserve lationships and only one reported having children. ployment status in this study sample were comparable to 20,21 Qualitative Findings associated with the undergraduate and graduate student veterans in established support programs. Perceived Strengths considered assets in a college environment. The unani Self-Discipline were strong assets in an academic setting. They shared

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104 http://www.cs.amedd.army.mil/amedd_journal.aspx one participant stated: Leadership and Teamwork they assumed in the military. Interviewees described New Perspectives and Different/Valuable Experiences Student veterans repeatedly mentioned their ability to responsibilities and experiences in their pasts allowed them to have insights and perspectives about material out military experience. These experiences also pro degree: Losing my brother [in combat] helped put things into want to be [in college], to have the opportunity to do that reason. Other veterans discussed how their time in the service helped prepare them to manage stress. Participants described how the stress they endured in the military lenges in the military, one interviewee said: ments in the military. Perceived Challenges Three predominant perceived challenges were prevalent Social Interactions Student veterans unanimously expressed frustration over social interactions with other students. One par ticipant said: Socially connecting with other [undergraduate] students students. Participants described how, in military environments, unit members oen share a close bond as they spend large amounts of time together in high-stress situations. Adjusting to the absence of that bond was described as dicult by some of the participants. One student vet eran expressed these sentiments by saying: they have to do. that being older than most students, in addition to hav necting socially challenging. Financial Stress stress added an additional burden to being a student enced by student civilians, this concern is tied to a tran UNDERSTANDING THE STUDENT VETERANS COLLEGE EXPERIENCE: AN EXPLORATORY STUDY

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October December 2014 105 Culture/Role Adjustments ership or management roles in the military to assume they had to be intentional about interacting with others appropriately. For instance, multiple study participants described how in military circles it may be appropriate gressive in college. One participant said: The biggest [challenge] is learning how to become a have to act more cordial toward others. Ideal Support The predominant themes that emerged when describing something. were to contact me and provide social help, especially cial support and stated: isolated and alone. Reasons for Low Participation in Existing Programs Some people get out and want nothing to do with the time to participate. Participants also mentioned that, visible and actively promoted to encourage participation. Quantitative Responses regarding topics that corresponded with the qualitative available to student veterans, they rated themselves as were consistent with the themes generated in qualitative veterans are presented in the Table. COMMENT time management, which were generated when explor social connections and interactions with other students

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106 http://www.cs.amedd.army.mil/amedd_journal.aspx research by Livingston et al who discussed how student rated themselves higher on all quantitative items in this conservative responses. The predominant qualitative themes described by this to be compatible with those discussed in previous stud ies involving veterans attending college. 7,9,10,14 Previous cused on them being a disadvantaged population with prevalent mental health issues, 22 derstand their experiences. Support services also appear dent veterans. Theoretical models such as that proposed by Tinto purport that engagement and integration in the tion pus. 14 Gilardi and Gugielmetti their civilian counterparts when provided appropriate support. 24 establishing relevant support services. study support these actions to encourage engagement could be made to existing transition programs bridging these 2 environments. One veteran in this study, who nent service members preparing to leave a deployment providing counseling and guidance during this transi 25 the nontraditional experience using a systems perspec tive and suggested that the community into which these encompass both the university campus and their mili UNDERSTANDING THE STUDENT VETERANS COLLEGE EXPERIENCE: AN EXPLORATORY STUDY Veteran Students Perceptions of Comfort in Seeking Support and Resource Awareness. Item Response mean (SD) ( N= 10 ) To what extent are you comfortable seeking social support? 6.5 (2.8) To what extent do you think other students with military experience are comfortable seeking social support? 4.9 (0.9) To what extent are you comfortable with seeking academic support? 7.4 (2.2) To what extent do you think other students with mili tary experience are comfortable seeking academic support? 5.9 (1.3) To what extent do you think that you are aware of the resources and programs available to students with military experience? 6.9 (2.3) To what extent do you think other students with military experience are aware of the resources and programs available to them? 5.2 (1.9) To what extent are you comfortable being affili ated with groups created specifically for student veterans? 7.4 (2.8) To what extent do you think other students with military experience are comfortable being affili ated with groups created specifically for student veterans? 6.5 (1.8) *Data generated from Likert scale responses: 1 (minimal comfort/awareness) to 10 (maximum comfort/awareness)

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October December 2014 107 their unit command was important to them when pursu ing their education. ter understand established and existing resources that nontraditional students, including student veterans, in tion. program, 26 may also serve to improve the campus com students with military experience. In sum, the strengths participants perceived they brought to their education to help them excel in their academic on classroom material, and the ability to manage stress. 27 when inter strengths student veterans bring to academic environ veterans by helping other personnel on college cam challenges. LIMIT A TIONS A ND FU T U RE DIRECTIONS insights and consistent themes emerged in their inter et al, may be required to reach out to and increase response is presented in this study to better understand the demo Student veterans represent a diverse population consist sue career advancement through their college endeavors. student veterans can excel in academic environments, just as they did in their military service. REFERENCES 1. 2. partnerships, opportunities, and programs to en 2009;126:61-69. 4. veterans. 5. diers. 6. era and educational attainment.

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108 http://www.cs.amedd.army.mil/amedd_journal.aspx 7. 2014. 9. ments. 10. 11. nontraditional and traditional students in terms tors, and coping strategies. 12. ditional students: engagement styles and impact on attrition. 14. college outcomes among student veterans. 15. Kvale S. Publications; 1996. 16. Bel 17. cedures. 19. Qualitative data analysis and in best practice. 20. 21. 22. 2010. 24. Ed [serial online] student-veterans-do-better-peers-when-given-sup 25. derstanding the social and academic integration 26. [disserta 27. AU THORS UNDERSTANDING THE STUDENT VETERANS COLLEGE EXPERIENCE: AN EXPLORATORY STUDY

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October December 2014 109 The US military and Veterans Health Administration (VHA) regularly conduct outreach with the hope of engaging those who need it in effective treatment. The need for active mental health outreach is apparent. Esti mates place the prevalence of posttraumatic stress dis order (PTSD) among returning Veterans between 10% and 20%. 1,2 Despite these high rates, treatment utiliza tion rates among returning Veterans remain low with only half of those who indicate mental health problems seeking help from the military or VHA. 3 According to the most recent VHA health care utilization report, roughly 55% of all separated Veterans of Operation En during Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans used VHA health care. Of those, 53.3% carried a mental health diagnosis. 4 The response to this unmet need for mental health treat ment includes regular screening both in the VHA and Department of Defense (DoD), both of which provide active screening to detect the presence of potential men tal health symptoms and guide referral to appropriate services. 5,6 Screening gathers important information for providers and researchers alike. Identifying Veter ing with appropriate treatments can prevent long-term 7 These screening tools also provide important data for epidemiological studies of treatment utilization and need. 8 The VHA currently uses the 4-item Primary Care PTSD Screen (PC-PTSD) to identify Veterans who may have PTSD. 9,10 Primary care providers then use this informa tion to guide referrals for mental health treatment. When compared with the Clinician Administered PTSD Scale (CAPS), the screen has the ability to correctly identify 78% of PTSD cases. 9 While research demonstrates that the PC-PTSD screen can accurately predict a PTSD diagnosis, research has not demonstrated whether the screen is useful for pre dicting treatment use. Within the VHA, regular screen ing provides a means of referring Veterans for treatment. In one study, 38% of Veterans who screened positive on the PC-PTSD screen (by answering yes to any 2 of the 4 questions) completed a mental health followup visit within 90 days. 11 Screening instruments in nonVA or civilian primary care settings are more likely to capture those with more severe diagnoses of PTSD, 12 which means screens may not aid in identifying indi symptoms become worse. Research has also shown that Mental Health Outreach and Screening Among Returning Veterans: Are We Asking the Right Questions? Katharine Bloeser, MSW Kelly K. McCarron, PsyD Benjamin Batorsky, MPH Matthew J. Reinhard, PsyD Stacey J. Pollack, PhD Richard Amdur, PhD ABSTR A CT This study looked at predictors of mental health treatment utilization in a unique cohort of recently separated Veterans coming to the Department of Veterans Affairs (VA) (N=152). This convenience sample voluntarily completed questionnaires, which included mental health screening tools, during an outreach event at a large urban VA Medical Center. Researchers reviewed computerized medical records of these consenting partici stress disorder screening results, functional impairment, and treatment-seeking. Certain functional impair ments increase the odds of participation in VA mental health care. These include problems with school and/or (OR=3.0), irritability/anger (OR=3.4), isolation (OR=3.8), drug use (OR=5.7), and problems with social sup port (OR=7.0). This study concluded that asking about symptoms alone may not capture the breadth and nature

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110 http://www.cs.amedd.army.mil/amedd_journal.aspx age plays a factor in the effectiveness of the PC-PTSD screen in referring Veterans for treatment. One study showed that Veterans aged 30 to 44 years are 57% less likely than Veterans aged 18 to 29 years to attend any mental health visits after screening positive on the PCPTSD screen. Older veterans, over the age of 75, are the least likely to attend a follow up appointment. 13 One reason for concern about VHA screening measures predicting treatment use might be that screening fo cuses on symptoms rather than on functioning in daily life. The concern is that screening procedures may un derestimate the impact of subthreshold symptoms, thus deterring seeking help before problems get worse. 14 general functioning and adjustment to civilian life, in dependent of diagnosis, 15 and it is often these functional impairments that are foremost among their concerns. 16 Researchers at the VHA Puget Sound 17 found that OEF/ OIF Veterans with PTSD were no more likely than Vet erans with subthreshold PTSD (as measured by the Post traumatic Stress Disorder ChecklistMilitary Version) body of literature that also points to examination of dis tress that does not necessarily meet diagnostic thresh olds yet still merit intervention. 18,19 ties, or problems related to everyday life, may provide a glimpse into these subthreshold conditions. This study sought to uncover the relationship between screening for functional impairments and mental health care engagement among a cohort of new VHA enroll ees. This study was designed to answer 3 main research questions: 1. What types of functional impairments do ser vice members and Veterans report? 2. What associations exist between problem pre sentation and eventual VHA treatment-seeking? 3. Can screening for functional impairment better predict VHA mental health treatment-seeking than screening for PTSD symptoms alone? METHODS Following approval from a Veterans Administration Medical Center Committee on Human Subjects and the Research and Development Committee, questionnaires were distributed to Veterans during a Welcome Home event. This event was held by the VHA at a sports sta dium in a suburb of a major US city in the summer of 2010 for Veterans who recently returned from deploy ment. This event offered Veterans the opportunity to learn more about and enroll in the VHA. It targeted a group of Veterans who may or may not decide to seek VHA care. The authors often work in a clinical capacity at these events, offering screening and support. The use fulness of such events, beyond enrollment numbers, had not yet been examined in a research capacity. Researchers provided a full description of the study both verbally and in writing. Participants provided written informed consent and completed questionnaires that in cluded clinical screening tools and questions about mili tary history, perceived stigma, and attitudes toward the VHA. At this time, Veterans also provided consent for a review of their medical records. Demographic questions like age, gender, and housing status were also included. In December 2011, researchers reviewed computerized medical records of consenting participants to record treatment utilization data. This information was coded according to standard criteria and entered into the data set. Of note, the race/ethnicity variable was taken from chart reviews of VHA records. Questionnaire The questionnaire included the PC-PTSD Screen 5 ; the yes/no version of the 2-item Patient Health Question naire (PHQ-2) 20 to assess for possible depression; the Cut down, Annoyed, Guilty, and Eye-opener (CAGE) 21 (AUDIT-C) 22 to assess for alcohol abuse; and the VHAs traumatic brain injury (TBI) screening tool. 23 The TBI screening tool consists of items that ask about mecha nism of head injury as well as immediate and long term postconcussive symptoms. Two other assessments were created. While not vali dated measures, these questions were adapted from the literature and clinical observation to asses for perceived barriers to care 24 25 The func tional impairment questions asked Veterans on a 4-point Likert scale (None=1, Severe=4) to rank their level of health, sleep, and home life. Electronic Health Records In addition to data collected by questionnaire, a brief chart review for each subject was conducted with avail able records to determine VHA health care use. Data collected in these chart reviews included percentage of connection due to mental health diagnoses), race and ethnicity, and VHA health care use. These included data points for all VHA medical encounters (eg, specialist MENTAL HEALTH OUTREACH AND SCREENING AMONG RETURNING VETERANS: ARE WE ASKING THE RIGHT QUESTIONS?

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October December 2014 111 referrals, primary care appointments), receipt of VHA mental health treatment, and mental health diagnoses (ie, depression, PTSD, Bipolar, Anxiety and/or other). in a mental health clinic by a psychiatrist, psychologist, social worker, registered nurse, or nurse practitioner. Statistical Analyses Associations between categorical variables were exam ined using 2 tests for association. Logistic regression was used to examine prediction models with utilization as the dependent variable. Data were analyzed using SAS Version 9.2 (SAS Institute Inc, Cary, NC) with P multiple comparisons as this is considered a pilot study with initial results presenting important questions to guide future research. Full P values are provided to as sist with interpretation. The study is powered to detect a medium effect size (Cohens d=0.5) for bivariate as sociations and for multiple regression. Sample The sample included consenting service members and Veterans who attended the event. For some, the event was their only contact with the VHA system of care. Others had used VHA health care services. Inclusion criteria stipulated that participants had to be an OEF/ OIF active duty service member or an OEF/OIF veteran. At the event, 152 questionnaires were completed. Re search assistants then conducted chart reviews using VHA computerized records on the 88 participants with Figure. Questionnaires that were partially completed or did not have the Veterans name or other identifying information were included in the dataset. Chart reviews were not performed for questionnaires that either did the VHA electronic medical record system (n=19). The as shown in Table 1. This consisted of participants who had a chart review completed (n=88) and those who did not (n=64). No clinical data on treatment use could be provided for those Veterans who did not have a chart review completed. RES U LTS Subjects es between Veterans with and without chart reviews. There were more women in the group without a chart review ( 2 =9.3, P who did not have chart reviews responded that they had children compared with 20% of those with chart review data ( 2 =8.0, P =.02). Results of Screening, Report of Functional Impairment, and VHA Treatment-Seeking Of the total sample (N=152), 28.9% of Veterans screened positive for PTSD (endorsed 2 or more PTSD symptoms), 34.0% screened positive for depression, and 35.4% screened positive on the CAGE. A large num ber of Veterans chose not to respond to the AUDIT-C (n=56). Of the 96 who did respond, 35.4% screened pos itive. Many Veterans also left the TBI screen blank, of the 72 who did respond, 36.1% screened positive. Vet erans reported problems with numerous functional dif with drug use (2.0%), social support (6.7%), physical work (19.8%), relationships (21.7%), road rage or driving (27.0%), irritability/anger (34.3%), and sleep (34.9%). Bivariate analyses were used to determine associations between problem presentation and eventual VHA treat ment-seeking. A 2 test for association was used to deter mine the relationship between conditions reported and receipt of any VHA treatment (ie, mental health and/or medical treatment) (Table 2). The population described in Table 2 consists only of those Veterans who had a chart review completed (n=88). Results indicate that one-half of those Veterans (n=44) eventually sought VHA health care after the event. Analyses showed that stable hous ing, PC-PTSD screen responses, AUDIT-C responses, TBI screen responses, the CAGE, and PHQ-2 were not associated with VHA treatment-seeking. Twenty per cent of participants who sought VHA medical and/or Processing of participants questionnaires and chart reviews. Questionnaires completed at event N= 152 Name and last 4 digits of SSN illegible n = 45 Name and last 4 digits of SSN legible n = 107 Unable to locate in system n = 19 Chart review conducted n = 88

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112 http://www.cs.amedd.army.mil/amedd_journal.aspx mental health treatment reported mod (a functional impairment that is not assessed in diagnostic screening tools). This is in comparison to 9% among those who did not seek VHA treat ment ( 2 =11.1920, P =.0107). Simi larly, the majority of those who did not receive VHA treatment (90.9%) did not self-report any problems with social supports. Those who sought VHA treatment were more likely to report problems related to social sup port ( 2 =11.3002, P =.0035). No other functional impairments were statisti VHA treatment. Results of Screening, Report of Functional Impairment, and VHA Mental Health Treatment-Seeking A total of 23 Veterans sought mental health treatment following the Wel come Home event. Bivariate analyses using a second 2 test were conducted to determine factors associated with VHA mental health treatment. Certain functional impairments increase the odds of participation in VHA mental health care (Table 3). These include problems with irritability/anger (odds ratio (OR)=2.5, P =.0333), school and/ or work (OR=3.5, P culty with sleep (OR=4.8, P =.0283), physical health problems (OR=10.9, P support (OR=11.3, P =.0008). Veter ans who reported 3 or more functional impairments were 3 times more likely to engage in mental health treatment (OR=3.1, P =.0254). There was no as sociation between screening positive on the PC-PTSD or PHQ-2 screens and participation in mental health treatment. selected for inclusion in a series of logistic regressions. These regressions were used to calculate odds ratios and functional impairment and mental health treatment after controlling for a positive PC-PTSD screen and a positive PHQ-2 screen (Table 4). After controlling for a positive school or work (OR=3.5, P =.0239), irritability or anger (OR=3.2, P =.0339), social support (OR=11.8, P =.0049), physical health (OR=12.9, P =.0050), or sleep (OR=3.1, P =.0333) were more likely to seek mental health treat ment. After controlling for a positive PHQ-2 screen, (OR=3.3, P =.0425), social support (OR=10.9, P =.0059), or physical health (OR=10.4, P =.0087) were more likely to seek mental health treatment. COMMENT Once enrolled in the VHA, seeking treatment for a men MENTAL HEALTH OUTREACH AND SCREENING AMONG RETURNING VETERANS: ARE WE ASKING THE RIGHT QUESTIONS? Table 1 Demographic Characteristics of Sample: VA Chart Review Versus No VA Chart Review Chart Review Completed (n=88) Number (%n) Chart Review not Completed (n=64) Number (%n) 2 P value Age, years <=25 26-30 31-35 36+ Missing 8 (42.1%) 7(36.8%) 1 (5.3%) 3 (15.8%) 0 45 (51.1%) 31 (35.2%) 7 (8.0%) 5 (5.7%) 45 2.5554 .4654 Gender Female Male Missing 1 (1.1%) 87 (98.9%) 0 3 (15.8%) 16 (84.2%) 45 9.324 .0023 Race White Unanswered/Unknown African American Other (Multiple or Asian) 54 (61.4%) 23 (26.1%) 7 (8.0%) 4 (4.5%) Not available (chart reviewed for race variable) Ethnicity Hispanic/Latino Not Hispanic/Latino Unanswered/Unknown 8 (9.1%) 56 (63.6%) 24 (27.4%) Not available (chart reviewed for ethnicity variable) Marital Status Married Remarried Divorced Separated Never Married Missing 35 (39.8%) 0 (0%) 3 (3.4%) 3 (3.4%) 47 (53.4%) 0 27 (42.2%) 1 (1.6%) 3 (4.7%) 1 (1.6%) 31 (48.4%) 1 2.2365 .6923 Children Yes Missing 18 (20.5%) 0 25 (39.7%) 1 6.6646 .0098 Service Status Enlisted Officer Missing 74 (86.1%) 12 (14.0%) 2 56 (93.3%) 4 (6.7%) 4 1.9232 .1655 Branch Army Marine Corps Navy Missing 1 (1.1%) 87 (98.9%) 0 (0%) 0 3 (4.7%) 58 (90.6%) 2 (3.1%) 1 4.792 .091 Rank E-3 E-4 E-5 E-6 E-7+ Missing 13 (17.3%) 31 (41.3%) 26 (34.7%) 3 (4.0%) 2 (2.7%) 13 6 (11.3%) 17 (32.1%) 23 (43.4%) 5 (9.4%) 2 (3.8%) 11 3.673 .452 Deploy ments 0 1 2 3 4 5 Missing 2 (2.6%) 25 (32.5%) 40 (52.0%) 9 (11.7%) 1 (1.3%) 0 (0%) 11 0 (0%) 21 (39.6%) 27 (50.9%) 4 (7.6%) 0 (0%) 1 (1.9%) 11 4.5165 .4777

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October December 2014 113 Table 2. Functional Impairment, Diagnosis and Prediction of Any VHA Treatment Total Sample (N=152) Number (%N) VHA Treatment Number Who Received Any VHA Treatment (n=44) Number (%n) Number Who Did Not Receive Any VHA Treatment (n=44) Number (%n) 2 P value PTSD Screen Positive Negative 43 (28.9%) 106 (71.1%) 15 (34.1%) 29 (65.9%) 10 (76.7%) 33 (76.7%) 1.2467 .2642 PTSD Screen Responses Nightmares Avoidance Hypervigilance Numbing 39 (25.7%) 37 (24.7%) 46 (30.5%) 44 (29.1%) 13 (29.6%) 11 (25.0%) 16 (36.4%) 14 (31.8%) 9 (20.9%) 8 (18.6%) 13 (30.2%) 11 (25.6%) 0.8544 0.5211 0.3679 0.4131 .3553 .4704 .5442 .5204 AUDIT-C Positive Negative 62 (64.6%) 34 (35.4%) 31 (73.8%) 11 (26.2%) 22 (61.1%) 14 (38.9%) 1.4356 .2309 TBI Positive Negative 26 (36.1%) 46 (63.9%) 7 (38.9%) 11(61.1%) 8 (47.1%) 9 (52.9%) 0.2383 .6254 CAGE Positive Negative 51 (35.4%) 93 (64.6%) 17 (40.5%) 25 (59.5%) 15 (37.5%) 25 (62.5%) 0.0763 .7824 Depression Positive Negative 51 (34.0%) 99 (66.0%) 17 (38.6%) 27 (61.4%) 13 (30.2%) 30 (69.8%) 0.6798 .4096 Functional Difficulties Road rage/driving None Mild Moderate Severe 70 (46.1%) 41 (27.0%) 32 (21.1%) 9 (5.9%) 17 (38.6%) 13 (29.5%) 12 (27.3%) 2 (4.5%) 20 (45.5%) 14 (31.8%) 9 (20.5%) 1 (2.3%) 1.042 .7910 School/education/ work None Mild Moderate Severe 89 (58.6%) 32 (21.2%) 25 (16.5%) 5 (3.3%) 26 (59.1%) 8 (18.2%) 8 (18.2%) 2 (4.5%) 25 (56.8%) 10 (22.7%) 8 (18.2%) 1 (2.3%) 0.5752 .9021 Relationships None Mild Moderate Severe 76 (50.0%) 43 (28.3%) 26 (17.1%) 7 (4.6%) 20 (45.5%) 10 (22.7%) 11 (25.0%) 3 (6.8%) 25 (56.8%) 13 (29.5%) 5 (11.4%) 1 (2.3%) 4.1969 .2410 Finances None Mild Moderate Severe 86 (56.7%) 37 (24.3%) 23 (15.1%) 5 (3.3%) 23 (52.3%) 13 (29.5%) 6 (13.6%) 2 (4.5%) 25 (56.8%) 12 (27.3%) 5 (11.4%) 2 (4.5%) 0.2142 .9753 Irritability/anger None Mild Moderate Severe 57 (37.5%) 43 (28.3%) 32 (21.1%) 20 (13.2%) 13 (29.5%) 13 (29.5%) 10 (22.7%) 8 (18.2%) 18 (40.9%) 14 (31.8%) 10 (22.7%) 2 (4.5%) 4.4435 .2174 Isolation None Mild Moderate Severe 81 (54.4%) 43 (28.9%) 19 (12.8%) 6 (4.0%) 16 (36.4%) 19 (43.2%) 7 (15.9%) 2 (4.5%) 31 (70.5%) 8 (18.2%) 3 (6.8%) 1 (2.3%) 11.1920 .0107 Physical fights None Mild Moderate Severe 112 (76.7%) 28 (18.4%) 12 (7.9%) 0 27 (61.4%) 13 (29.5%) 4 (9.1%) 0 34 (77.3%) 8 (18.2%) 2 (4.5%) 0 2.6604 .2644 Drug use None Mild Moderate Severe 140 (92.1%) 9 (5.9%) 2 (1.3%) 1 (0.7%) 38 (86.4%) 5 (11.4%) 1 (2.3%) 0 42 (95.5%) 1 (2.3%) 1 (2.3%) 0 2.8667 .2385 Social support None Mild Moderate Severe 119 (79.9%) 20 (13.4%) 10 (6.7%) 0 27 (64.3%) 7 (16.7%) 8 (19.0%) 0 40 (90.9%) 4 (9.1%) 0 0 11.3002 .0035 Physical health None Mild Moderate Severe 96 (63.2%) 43 (28.3%) 9 (5.9%) 4 (2.6%) 23 (52.3%) 14 (31.8%) 5 (11.4%) 2 (4.5%) 29 (65.9%) 14 (31.8%) 0 1 (2.3%) 6.0256 .1104 Table 2 continued on the next page. Includes mental health treatment.

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114 http://www.cs.amedd.army.mil/amedd_journal.aspx school/education or work, irritability or anger, so cial supports, physical health, and sleep. Surprisingly, screening positive for PTSD, alcohol abuse, TBI, or de pression are not associated with seeking treatment for mental health care. After controlling for screening posi tive for PTSD or depression, functional impairments predicted engagement in mental health treatment. In our study, those Veterans with children were less likely to have a chart review completed, indicating that this sam ple may be biased towards Veterans without children. This study joins a body of literature that points to the importance of social support in the treatment and iden portant factor in recovery from and prevention of symp toms of PTSD for Vietnam Veterans. 26 tional as well as concrete support mediates the effects of war zone stressors on development of PTSD. 27 Other studies of OEF/OIF Veterans indicate that readjustment stressors, including those related to marriage and chil dren are integral to examination of treatment-seeking behaviors among older returning National Guard Veter ans. 28 In a path analysis examining PTSD symptoms as the outcome, the effects of postdeployment social sup port were equal to those of combat exposure. 29 While younger, recently separated sample. IMPLIC A TIONS FOR BEH A VIOR A L HE A LTH These results suggest that at outreach events like Wel come Home and within the VHA in general, screening might be improved by assessing functional impairments in addition to psychiatric symptoms. Clinicians should port when screening for mental health needs among returning service members. Awareness of PTSD symp toms as well as other mental conditions has improved in military settings. Veterans may believe that these symptoms are a normal part of the homecoming pro where this normal response to abnormal circumstances ty with social support, physical health conditions, and school or work may also indicate that while a PTSD or depression screen is negative, Veterans may still ben through referral. Like any health care system, the VHA has a goal of en rolling new users. In the case of the VHA, this means en rolling veterans at the end of their active duty status (ie, like the current sample). These results could help inform VHA policymakers how to better approach and adver tise potential VHA users who are not currently enrolled in VHA care. For instance, a campaign conceptualizing VHA as an avenue for additional social support, which in our experience it tends to be (similar to a family, circle of friends, or caring individuals) might be considered. The importance of functional outcomes, highlighted in tional impairment, mental health treatments that target both symptom reduction and functional status may be most effective. This could include multidisciplinary care that combines traditional psychotherapy with tangible resources like case management and systems focused MENTAL HEALTH OUTREACH AND SCREENING AMONG RETURNING VETERANS: ARE WE ASKING THE RIGHT QUESTIONS? Table 2 (continued). Functional Impairment, Diagnosis and Prediction of Any VHA Treatment Total Sample (N=152) Number (%N) VHA Treatment Number Who Received Any VHA Treatment (n=44) Number (%n) Number Who Did Not Receive Any VHA Treatment (n=44) Number (%n) 2 P value Sleep None Mild Moderate Severe 63 (41.5%) 36 (23.7%) 33 (21.7%) 20 (13.2%) 15 (34.1%) 10 (22.7%) 13 (29.5%) 6 (13.6%) 19 (43.2%) 11 (25.0%) 8 (18.2%) 6 (13.6%) 1.7087 .6350 Home life None Mild Moderate Severe 97 (63.8%) 42 (27.6%) 11 (7.2%) 2 (1.3%) 25 (56.8%) 13 (29.5%) 6 (13.6%) 0 29 (65.9%) 13 (29.5%) 1 (2.3%) 1 (2.3%) 4.8677 .1817 Stable housing Yes No 137 (92.6%) 11 (7.4%) 39 (88.6%) 5 (11.4%) 38 (90.5%) 4 (9.5%) 0.0776 .7805 Three or more functional difficulties Yes No 26 (29.6%) 62 (70.5%) 17 (38.6%) 27 (61.4%) 9 (20.5%) 35 (79.5%) 3.4938 .0616 Includes mental health treatment. Determined by answering moderate or severe to 3 or more functional difficulties.

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October December 2014 115 focus of treatment. 30,31 centered care approach; meeting the Veteran where they are is important when screening for mental health prob to everyday life rather than distinct PTSD symptoms. This should be an indication of need for treatment just as much as a positive response to the Primary Care PTSD screen. Veterans may not pursue care because they do Clinical Team) and therefore do not necessitate the evi denced-based practices these programs offer. The treat ment indicated in these cases may be a referral to family therapy, recreational therapy, or to community support. These referrals, when applied appropriately, may pre vent Veterans from developing more complex diagnoses later in life. Table 3. Functional Impairment, Diagnosis, and Prediction of VHA Mental Health Treatment VHA Mental Health Treatment Number Who Received VHA Mental Health Treatment (n=23) Number (%n) Number Who Did Not Receive VHA Mental Health Treatment (n=65) Number (%n) Total (N=88) Number (%N) 2 Odds Ratio P value PTSD Screen (2 or more) Positive Negative 7 (30.4%) 16 (69.6%) 18 (28.1%) 46 (71.9%) 25 (28.7%) 62 (71.3%) 0.0441 1.1 .8337 PTSD Screen (3 or more) Positive Negative 5 (21.7%) 18 (78.3%) 13 (20.3%) 51 (79.7%) 18 (20.7%) 69 (80.3%) 0.0210 1.1 .8848 AUDIT-C Positive Negative 18 (81.8%) 4 (18.2%) 35 (62.5%) 21 (37.5%) 3(67.9%) 25 (32.1%) 2.7066 2.7 .0999 TBI Positive Negative 6 (60.0%) 4 (40.0%) 9 (36.0%) 16 (64.0%) 15 (42.9%) 20 (57.1%) 1.6800 2.7 .1949 CAGE Positive Negative 8 (9.8%) 14 (63.6%) 24 (40.0%) 36 (60.0%) 32 (39.0%) 50 (60.9%) 0.0895 0.52 .7649 Depression Positive Negative 10 (43.5%) 13 (56.5%) 20 (31.3%) 44 (68.8%) 30 (34.5%) 57 (65.5%) 1.1199 1.7 .2900 Functional Difficulties Road rage/driving None/Mild Moderate/Severe 15 (65.2%) 8 (34.8%) 49 (75.4%) 16 (24.6%) 64 (72.7%) 24 (27.3%) 0.8854 1.6 .3467 School/education/ work None/Mild Moderate/Severe 14 (60.9%) 9 (39.1%) 55 (84.6%) 10 (15.4%) 69 (78.4%) 19 (21.6%) 5.6584 3.5 .0174 Relationships None/Mild Moderate/Severe 15 (65.2%) 8 (34.8%) 53 (81.5%) 12(18.5%) 68 (77.3%) 20 (22.7%) 2.5768 2.4 .1084 Finances None/Mild Moderate/Severe 18 (78.3%) 5 (21.7%) 55 (84.6%) 10 (15.4%) 73 (83.0%) 15 (17.1%) 0.4851 1.5 .4861 Irritability/anger None/Mild Moderate/Severe 11(47.8%) 12 (52.2%) 41 (72.3%) 18 (27.7%) 58 (65.9%) 30 (34.1%) 4.5316 2.5 .0333 Isolation None/Mild Moderate/Severe 17 (73.9%) 6 (26.1%) 57 (89.1%) 7 (10.9%) 74 (85.1%) 13 (14.9%) 3.0552 0.8 .0805 Physical fights None/Mild Moderate/Severe 21 (91.3%) 2 (8.7%) 61 (93.9%) 4 (6.2%) 82 (93.2%) 6 (6.8%) 0.1728 1.5 .6777 Drug use None/Mild Moderate/Severe 22 (95.7%) 1 (4.4%) 64 (98.5%) 1 (4.4%) 86 (97.7%) 2 (2.3%) 0.6037 2.9 .4372 Social support None/Mild Moderate/Severe 16 (72.7%) 6 (27.3%) 62 (96.9%) 2 (3.1%) 78 (90.7%) 8 (9.3%) 11.3154 11.6 .0008 Physical health None/Mild Moderate/Severe 17 (73.9%) 6 (26.1%) 63 (96.9%) 2 (3.1%) 80 (90.9%) 8 (9.1%) 10.8837 11.1 .0010 Sleep None/Mild Moderate/Severe 10 (43.4%) 13 (56.5%) 45 (69.2%) 20 (30.8%) 55 (62.5%) 33 (37.5%) 4.8071 2.9 .0283 Stable housing Yes No 20 (87.0%) 3 (13.0%) 57 (90.5%) 6 (9.5%) 77 (89.5%) 9 (10.5%) 0.2228 0.70 .6369 Three or more functional difficulties Yes No 11(47.8%) 12 (52.2%) 15 (23.1%) 50 (76.9%) 26 (29.5%) 62 (70.5%) 4.9990 3.1 .0254 Only treatment in a VA medical center, including medication management. Determined by answering moderate or severe to 3 or more functional difficulties.

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116 http://www.cs.amedd.army.mil/amedd_journal.aspx LIMIT A TIONS within this study. First, the questionnaire relied upon self-report data using very short yet validated scales as well as scales developed from the literature and clinical experience. Researchers have questioned the diagnostic validity of self-report scales that do not have the input of clinicians. 32 Secondly, this population, which consists of mostly white, male Marines, is not indicative of the entire population of Veterans returning from OEF/OIF/ Operation New Dawn. Finally, not all Veterans surveyed had a chart review completed, creating a small sample for these analyses. ACKNO W LEDGEMENT The authors sincerely thank the Veterans who participat ed in this research study for their time and their service. This study was approved by the Washington, DC VHA Medical Center Institutional Review Board. This study was conducted at the VHA Medical Center, 50 Irving Street NW, Washington, DC. REFERENCES 1. Thomas JL, Wilk JE, Riviere LA, Castro CA, Hoge CW. Prevalence of mental health problems and functional impairment among active compo nent and National Guard soldiers 3 and 12 months following combat in Iraq. Arch Gen Psychiatry 2010;67(6):614-623. 2. Milliken CS, Auchterlonie JL, Hoge CW. Longitu dinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. JAMA 2007;298(18):2141-2148. 3. Tanielian T, Jaycox LH, eds. Invisible Wounds of War, Psychological and Cognitive Injuries, Their Con sequences, and Services to Assist Recovery Santa Monica, CA, RAND Corporation; 2008. Avail able at: http://www.rand.org/pubs/monographs/ MG720.html. Accessed October 8, 2014. 4. Department of Veterans Affairs. Analysis of VHA Health Care Utilization among Operation Endur ing Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans: Cumulative from 1st Qtr. FY2002 through 3rd Qtr. FY2012 (October 1, 2001-June 30, 2012). Washing ton, DC: Epidemiology Program, Postdeployment able at: http://www.publichealth.va.gov/docs/epide miology/healthcare-utilization-report-fy2012-qtr3. pdf. Accessed November 15, 2012. 5. Prins A, Ouimette P, Kimerling R, Cameron RP, Hugelshofer DS, Shaw-Hegwer J, Thrailkill A, Gusman FD, Sheikh JI. The primary care PTSD screen (PC-PTSD), development and operating characteristics. Prim Care Psychiatry 2003;9(1):914. Available at: http://www.ptsd.va.gov/profes sional/articles/article-pdf/id26676.pdf. Accessed October 7, 2014. 6. Wright KM, Huffman AH, Adler AB, Castro CA. Psychological screening program overview. Mil Med 2002;167:853-861. 7. Friedman MJ. Posttraumatic stress disorder among military returnees from Afghanistan and Iraq. Am J Psychiatry 2006;163(4):586-593. 8. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs health care system on the quality of care. N Engl J Med 2003;348:2218-2227. 9. Prins A, Ouimette P, Kimerling R, Cameron RP, Hugelshofer DS, Shaw-Hegwer J, Thrailkill A, Gusman FD, Sheikh JI. The primary care PTSD screen (PC-PTSD), Corrigendum. Prim Care Psychiatry 2003;9(1):151. Available at: http:// www.ptsd.va.gov/professional/articles/article-pdf/ id26676.pdf. Accessed October 7, 2014. 10. VA/DoD Clinical Practice Guideline for the Man agement of Post-Traumatic Stress. Washington, DC: US Dept of Veterans Affairs, US Dept of De fense; 2010. Available at: http://www.healthquality. va.gov/PTSD-FULL-2010c.pdf. Accessed Novem ber 14, 2012. 11. Seal KH, Berthenhal D, Maguen S, Gima K, Chu A, Marmar CR. Getting beyond dont ask; dont tell, an evaluation of US Veterans Administration postdeployment mental health screening of vet erans returning from Iraq and Afghanistan. Am J Public Health 2008;98(4):714-720. 12. Borowsky SJ, Rubenstein LV, Meredith LS, Camp P, Jackson-Triche M, Wells KB. Who is at risk of nondetection of mental health problems in primary care?. J Gen Intern Med 2000; 15: 381-388. 13. Lu MW, Carlson KF, Duckart JP, Dobscha SK. The effects of age on initiation of mental health treat ment after positive PTSD screens among Veterans Affairs primary care patients. Gen Hosp Psychia try 2012;34(6):654-659. MENTAL HEALTH OUTREACH AND SCREENING AMONG RETURNING VETERANS: ARE WE ASKING THE RIGHT QUESTIONS? Table 4. Odds Ratio Predicting VA Mental Health Treatment Adjusting for Positive PTSD Screen and Positive Depression Screen PTSD Screen Positive Depression Functional Odds Ratio (95% OR) P value Odds Ratio (95% OR) P value School or work 3.5 (1.2-10.5) .0239 3.3 (1.0-10.2) .0425 Irritability or anger 3.2 (1.1-9.6) .0339 2.6 (0.9-7.4) .0721 Social support 11.8 (2.1-65.9) .0049 10.9 (2.0-59.8) .0059 Physical health 12.9 (2.2-76.5) .0050 10.4 (1.8-60.1) .0087 Sleep 3.1 (1.1-8.6) .0333 2.7 (0.9-7.8) .0642 Two or more questions in screen answered affirmatively.

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October December 2014 117 14. Pietrzak RH, Goldstein MB, Malley JC, Johnson DC, Southwick SM. Subsyndromal posttraumatic stress disorder is associated with health and psy during Freedom and Iraqi Freedom. Depress Anxi ety 2009;26:739-744. 15. Institute of Medicine of the National Academies. Returning Home from Iraq and Afghanistan. Pre liminary Assessment of Readjustment needs of Vet erans, Service Members, and Their Families Wash ington, DC: The National Academies Press; 2010. 16. Sayer NA, Noorbaloochi S, Frazier P, Carlson K, Gravely A, Murdoch M. Reintegration problems and treatment interests among Iraq and Afghani stan combat veterans receiving VHA medical care. Psychiatr Services 2010;61(6):589-597. 17. Jakupcak M, Conybeare D, Phelps L, Hunt S, Holmes HA, Felker B, Klevens M, McFall ME. Anger, hostility, and aggression among Iraq and Afghanistan war veterans reporting PTSD and subthreshold PTSD. J Trauma Stress 2007;20(6):945-954. 18. Naylor JC, Dolber TR, Strauss JL, Kilts JD, Strau man TJ, Bradford DW, Szabo ST, Youssef NA, Connor KM, Davidson JRT, Marx CE. A pilot randomized control trial with paroxetine for sub threshold PTSD in Operation Enduring Freedom/ Operation Iraqi Freedom era veterans. Psychiatry Res 2013;206(2-3):318-320. 19. Marshall RD, Olfson M, Hellman F, Blanco C, Guardino M, Struening EL. Comorbidity, impair ment, and suicidality in subthreshold PTSD. Am J Psychiatry 2001;158(9):1467-1473. 20. Whooley MA, Avins AL, Miranda J, Browner WS. J Gen In tern Med 1997;12(7):439-445. 21. naire, validation of a new alcoholism screening in strument. Am J Psychiatry 1974;131(10):1121-1123. 22. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C), an effective brief screen ing test for problem drinking. Arch Intern Med 1998;158(3):1789-1795. 23. TBI Screening-National VHA Clinical Reminder. Washington, DC: Veterans Healthcare Administra tion; 2007. Appendix 4: VHA Directive 2007-013. Available at: http://www.rehab.research.va.gov/ jour/07/44/7/pdf/page1027append4.pdf. Accessed October 23, 2012. 24. Hoge CW, Castro CA, Messer SC, McGurk D, Cot ting DI, Koffman RL. Combat duty in Iraq and Af ghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351(1):13-22. 25. Batten SV, Pollack SJ. Integrative outpatient treat ment for returning service members. J Clin Psy chol 2008;64(8):928-939. 26. Boscarino JA. Posttraumatic stress and associ ated disorders among Vietnam veterans: the sig J Trauma Stress 1995;8(2):317-336. 27. King DW, King LA, Fairbank JA, Keane TM, Ad ams G. Resilience-recovery factors in posttraumat ic stress disorder among female and male Vietnam Veterans: hardiness, postwar social support, and additional stressful life events. J Pers Soc Psychol 1998;74,420-434. 28. Pietrzak RH, Johnson DC, Goldstein, MB, Malley, JC, Rivers AJ, Morgan CA, Southwick SM. Psycho social buffers of traumatic stress, depressive symp erations Enduring Freedom and Iraqi Freedom: the role of resilience, unit support, and postdeployment social support. J Affect Disord 2010;120:188-192. 29. Interian A, Kline A, Callahan L, Losonczy M. Re adjustment stressors and early mental health treat ment-seeking by returning National Guard Soldiers with PTSD. Psychiatr Services 2012;63(9):855-861. 30. Fontana A, Rosenheck R. War zone Veterans returning to treatment: effects of social func tioning and psychopathology. J Nerv Ment Dis 2010;198:699-707. 31. Monson CM, Taft CT, Fredman SJ. Military-relat ed PTSD and intimate relationships, From descrip tion to theory-driven research and intervention de velopment. Clin Psychol Rev 2009;29:707-714. 32. Shalev AY, Freedman S, Peri T, Brandes D, Sahar T, Orr SC, Pitman RK. Predicting PTSD in trauma survivors: prospective evaluation of self-report and clinician administered instruments. Br J Psychia try 1997;170:558-564. AU THORS Ms Bloeser is with the War Related and Injury Study Health. Dr McCarron is with the Polytrauma System of Care, VHA Medical Center, Washington, DC. Mr Batorsky is with the RAND Corporation. Dr Reinhard is with the War Related and Injury Study Dr Pollack is with Mental Health Services, Department of Veterans Affairs. Dr Amdur is Chief of Biostatistics at the VHA Medical Center, Washington, DC.

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118 http://www.cs.amedd.army.mil/amedd_journal.aspx Skilled and Resolute chronicles the history of the 12th Evacuation Hospital which then became the 212th Mo bile Army Surgical Hospital (MASH), covering the years from 1917 to 2006. Each chapter provides a com prehensive summary from researched resources and be gins with the role of the hospital for that time period. The chapters are supplemented with excellent maps, dia grams, photos, abbreviations and acronyms, and a list of all oral histories. Dr Marble outlines the chapters in a clear narrative style while he explains the strategic and technological impor tance of a mobile hospital. Additionally, he ties in the sociopolitical and environmental contextual elements with the type of trauma care available at each time pe riod, and has blended his research analysis with many oral history accounts to help readers better understand the progress made by the Army Medical Departments (AMEDD) oldest mobile/deployable hospital unit. Skilled and Resolute is the culmination of a 7-year quest to capture the story of this mobile hospital unit with compasses 90 years of who we are and what we do It is the authors goal to give credit to where references ful picture of capabilities and missions. He has made the information available to the reader with valuable depic tions of results, observations, ideas, and perspectives of military medicine. scriptions of mobile medical care that transformed with regard to military force structure and doctrine, along with advances in medical military technology and its applications. Over the years, the capabilities of military medicine have dramatically expanded, a fact directly re context while seeing the details of life and medical care throughout those times provides a fascinating picture of military innovation, leadership, and caring. Dr Marble expertly weaves numerous eyewitness accounts into the chapters, providing welcomed additions and a virtual account of the challenges and successes of providing dresses numerous areas of interest, including how edu cation, training and experience can help staff actions remain within the commanders intent and in support sive for quality patient care solutions. a comprehensive reference for how the AMEDD deliv ers care at every level. It examines Level III hospitals, hospitals. Skilled and Resolute is chronologically organized, en compassing service in World War I, World War II, the Vietnam War, Operation Desert Shield/Desert Storm, snippets of interesting facts to entice readers to read the called for not only a surgical focus, but the addition of chanics, 2 buglers (there was no public address system), A New Offering from the Borden Institute History Series Skilled and Resolute Sanders Marble, PhD Center of History and Heritage

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October December 2014 119 which to be mobile. tant as in WWI, but they could handle major surgical and medical procedures for casualties. These hospi tals had a neurosurgical team, a thoracic surgeon, and a plastic-maxillofacial team. There were also 3 gener the 12th Evacuation Hospitals stay in England in 1943, they treated about 8,000 patients, and another 26,000 from landing ships at Normandy beaches, and a glider insertyet only 2 staff died, both were nurses. Hospital was sent to an undisclosed location in the over 37,000 patients. Over 36,000 survived because of treatment received there. The 12th Evacuation Hospital Civil Action Honor Medal. In 1970, the 12th Evacuation Hospital (semimobile) was deactivated for the third time. ation Hospital was in Saudi Arabia from December 1990 until April 1991. It was augmented with 3 medical sia. The 12th Evacuation Hospital treated injured from older active duty personnel with seizures, diabetes, high pital operations, they saw 10,309 outpatients and 1,299 was converted to the 212th MASH. tional operation and was under foreign command, some thing that had not happened since 1918, and had to have vehicles and equipment painted white with light blue from 34 countries across 5 continents, which obviously produced some language problems. Landmines caused 9 wounds, and there were 2 gunshot wounds. Supplies States, and some local procurement. The 212th cared for 4,454 outpatients, and admitted 333 inpatients in 6 months time. Kosovo had seen 788 patients and 32 surgical patients. In 6 months during 2000, the 212th handled 339 major In October 2006, the 212th MASH became the 212th Combat Support Hospital (CSH). As of that redesigna tion, this units history already included service in 5 wars, over 18 campaigns, and many humanitarian and Armys oldest deployable hospital and illustrates how it gave the best care for its time and remains effective today, no matter the mission or the locations. The sym bolism of the distinctive unit insignia of the 212th CSH includes the maroon and white colors associated with commemorate campaign credits earned in WWI and WWII. The red and gold stripes signify service in Viet nam. The scarlet motto scroll and ribbon symbolize the during WWII and Vietnam 1966-1967), and the circle suggests mobility and speed. The cross is symbolic of medical care. best way to provide quality medical and surgical care to Warriors and other designated patients as soon as it is ian environments. In approximately 250 pages of Skilled and Resolute Dr Marble reminds us that much of this practical infor mation can help healthcare providers of today, not only in appreciating AMEDD history and heritage, but in planning and responding to current situations. COL Vane is the Army Nurse Corps Historian at the AMEDD Center of History and Heritage, Joint

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120 http://www.cs.amedd.army.mil/amedd_journal.aspx The headquarters and primary instructional facility of the Army Medical Department Center and School, Joint Base San Antonio Fort Sam Houston, Texas.

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SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewe d print medium to encourage dialogue concerni ng health care issues and initiatives. REVIEW POLICY All manuscripts will be reviewed by the AMEDD Journal Â’s Editorial Review Board and, if re quired, forwarded to the appropriate subject matter expert for further review and assessment. IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST 1. Related to individual authorsÂ’ commitments: Each author is responsible for the full disclosure of all financial and personal relationships that might bias the work or information presented in the manuscript. 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