Nathaniel Vincent Mohatt, PhD* ; Robert Boeckmann, PhD ; Nicola Winkel, MPA* ; Dennis F. Mohatt, MA*; Jay Shore, MD

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1 MILITARY MEDICINE, 182, 1/2:e1576, 2017 Military Mental Health First Aid: Development and Preliminary Efficacy of a Community Training for Improving Knowledge, Attitudes, and Helping Behaviors Nathaniel Vincent Mohatt, PhD* ; Robert Boeckmann, PhD ; Nicola Winkel, MPA* ; Dennis F. Mohatt, MA*; Jay Shore, MD ABSTRACT Introduction: Persistent stigma, lack of knowledge about mental health, and negative attitudes toward treatment are among the most significant barriers to military service members and veterans seeking behavioral health care. With the high rates of untreated behavioral health needs among service members and veterans, identifying effective programs for reducing barriers to care is a national priority. This study adapted Mental Health First Aid (MHFA), an evidence-based program for increasing mental health knowledge, decreasing stigma, and increasing laypeople s confidence in helping and frequency of referring people in need, for military and veteran populations and pilot tested the adapted training program with 4 Army National Guard armories. Materials and Methods: A total of 176 community first responders (CFRs) participated in a comparative outcomes study, with 69 receiving the training and 107 participating in the control group. CFRs were individuals in natural positions within the Armory or home communities of Guard members to identify and help service members in mental health crisis. Surveys assessing confidence in helping, attitudes toward help seeking, knowledge of resources, use of MHFA practices, and stigma were completed before the training, immediately post-training, at 4 months post-training, and at 8 months post-training. Analyses included repeated measures analysis of variances on data from CFRs who received the training and mixed between-within subjects analysis of variances comparing the intervention and control group longitudinally at three time points. Institutional review board approval for this study was received from Montana State University and the U.S. Army Medical Department, Medical Research and Materiel Command, Human Research Protection Office. Results: Significant and meaningful improvements in confidence ( p < 0.05, η 2 = 0.49), knowledge ( p < 0.05, η 2 = 0.39), behaviors ( p < 0.05, η 2 = 0.27), and stigma ( p < 0.05, η 2 = 0.16) were observed among trainees. When compared to a control group, statistically meaningful differences in change over time were observed for knowledge (η 2 = 0.03), attitudes (η 2 = 0.02), confidence (η 2 = 0.06), and stigma (η 2 = 0.02), with a significant and meaningful difference observed for practice behaviors ( p < 0.05, η 2 = 0.07). Conclusions: Results from the comparative outcomes pilot study of military and veterans MHFA indicate that the intervention is acceptable and feasible to implement in National Guard Armories and among non-guard community based first responders. There was a significant intervention effect detected for the likelihood that a CFR would use appropriate engagement, support, and referral practices when identifying someone in need of mental health support. In addition, there were positive growth trends in the data for improvements in confidence, knowledge of mental health resources, attitudes toward help seeking, and stigma, which indicate that with a larger number of participants and armories we would expect to see significant intervention effects. Study weaknesses included insufficient power and demographic data for more robust analyses of intervention effects. A larger randomized controlled trial is recommended for better establishing efficacy; however, these results indicate that Military and Veterans MHFA is a promising intervention for reducing critical barriers to care. INTRODUCTION There are over 20 million veterans and military service members living in the United States. An estimated 22 veterans die by suicide every day 1 and research suggests that 12 to 17% of service members that have returned from Iraq and Afghanistan meet the criteria for a mental disorder. 2,3 Yet, nearly half of all cases of behavioral health problems among military service members are untreated, 2 an issue compounded *Western Interstate Commission for Higher Education, Mental Health Program, 3035 Center Green Drive, Suite 200, Boulder, CO University of Colorado Denver School of Medicine, East 17th Place, Aurora, CO Department of Psychology, University of Alaska Anchorage, 3211 Providence Drive, SSB 352, Anchorage, AK Arizona Coalition for Military Families, 2066 West Apache Trail Boulevard, Suite 116, Apache Junction, AZ doi: /MILMED-D by a strong stigma toward behavioral health issues among military personnel. 4,5 For community dwelling, reserve component service members, rates of untreated problems may be higher given their limited access to health care compared to other military personnel. 6 Of veterans and service members who do seek help, fewer seek care from a mental health professional than from clergy, primary care physicians, or other community members. 7 Identifying effective interventions to increase community-dwelling veterans and service member s access to effective care has the potential to have a major public health impact. In addition to stigma, education programs should help address other critical barriers. Barriers to care among service members include lack of knowledge about mental health treatment, 8 negative attitudes toward mental health treatment, 4,9 and a strong tendency toward self-reliance (i.e., I can handle it myself ). 9,10 More research is needed e1576

2 to develop and test effective educational interventions to overcome these barriers, especially for reserve component service members who often experience greater challenges and barriers to care upon reintegrating into civilian life postdeployment. 7 Educating the public about military and veterans mental health needs and challenges has been identified by numerous authors as a critical public health strategy to increasing access to effective care for military personnel and veterans living in the community. 5,7,9,11 Mental Health First Aid (MHFA) is a training program originally developed to address widespread lack of knowledge about mental illness in Australia. 12 By training people to recognize behavioral health warning signs and provide basic help and effective referrals to people in need, MHFA improves participants knowledge of mental disorders, reduces stigma, and increases the amount of help provided to others Individuals who have undergone MHFA training show better identification of mental health disorders, 13 greater likelihood of advising individuals to seek professional help, 14 decreases in stigmatizing attitudes, 12 and improved mental health in the participants themselves. 12,14 To complement existing military mental health initiatives, we collaborated with experts in military mental health to adapt MHFA for the military population. Although existing training programs for military personnel such as Battlemind 16 and the Comprehensive Soldier Fitness Program 17 were designed to help soldiers build their resilience and reintegrate into their communities, Military MHFA (M-MHFA) is designed to increase the system of laypeople (both military and civilian) ready to provide basic support and assistance to others with developing mental health problems. To test whether the newly developed M-MHFA is a promising and feasible intervention for replicating prior MHFA research within community dwelling, reserve component service members, we conducted a comparative outcomes trial with four4 Army National Guard (ARNG) armories in the United States. METHODS Development of Military MHFA The project team convened an expert panel to advise the adaptation of the MHFA training module. Panelist included representatives from the Walter Reed Army Institute of Research, the United States Army Medical Research and Materiel Command, the ARNG, the University of Colorado Denver School of Medicine, and the Telemedicine and Advanced Technology Research Center. The panelists met by conference regularly through the initial adaptation phase and were engaged throughout the research period to provide advice on the adaptation, institutional review board (IRB), and research protocol. The expert panel included subject matter experts with specific knowledge of the military population, creating training curriculum, the existing MHFA program, and the landscape of military programs that provide support, training, and assistance to service members and their families. The adaptation of MHFA for use with the military population included the addition of supplemental material relevant to mental health issues in the military a population and military-specific videos and exercises, as well as provided context for the various mental health issues when interacting with service members, veterans, and their families. The final M-MHFA training is an 8-hour seminar. Trainings typically take place over 1 day, in-person, in a group setting. A series of 3 pilot trainings were conducted in Arizona in partnership with the Arizona National Guard and the Arizona Coalition for Military Families. Pilot training participants included a mix of service members, family members, and community first responders (CFRs). Feedback from pilot training participants helped inform finalization of the curriculum. COMPARATIVE OUTCOMES STUDY Design We employed a comparative outcomes design with four matched armories. In coordination with the ARNG, four armories were selected to participate in the study. Two armories were randomly assigned to receive the intervention and two to the control comparison group. The intervention and control armories were matched on rurality. Two trainings were conducted with CFRs connected to each of the intervention armories. Pretest surveys were completed with participants from each armory before implementation. At 4 and 8 months postintervention, these same assessments were repeated. In addition, the CFRs who received the training (i.e., from intervention armories) completed the survey immediately after receiving the MHFA training. Preintervention and immediate postintervention for those receiving the training were completed in person using paperand-pencil methods. Four- and 8-month follow-up surveys were completed using either an Internet survey ed to participants or a paper-and-pencil survey mailed to participants with a stamped return envelope, on the basis of respondent preference. IRB approval for this study was received from Montana State University and the U.S. Army Medical Department, Medical Research and Materiel Command, Human Research Protection Office. Recruitment and Retention The Expert Panel and ARNG representatives helped determine the CFRs to target for study recruitment. CFRs were either civilians or ARNG members. ARNG advisors identified the CFRs as being in natural positions within the Armory or home communities of Guard members to identify and help service members in mental health crisis. Identified CFRs included embedded medics, ARNG leaders, employers in the Armory communities, family advocates, and other community-identified supports/helpers. Approximately 30 CFRs were identified for each of the intervention e1577

3 communities. Registration for the training was on a firstcome, first-served basis. Trainings were held in-person at the armories over a single day 8-hour session. The trainings were facilitated by two instructors, with the same lead instructor conducting all trainings for this study for improved consistency. ARNG members were prohibited by the IRB from receiving compensation for completing the surveys, whereas non-arng CFRs were offered a $150 stipend for completing the training and a $15 gift card for each survey they completed. Participants A total of 176 CFRs participated preintervention, 69 CFRs in the intervention group and 107 in the control group preintervention. Of the intervention group, 50.7% were from a rural Armory, whereas 39.3% of the control group was from a rural Armory. No data were collected on gender, age, or race/ethnicity following recommendations from the ARNG. Of the 69 CFRs in the intervention group, 47 completed both 4- and 8-month follow-up surveys (approximately 68% return rate), whereas 18 participants from the control group completed surveys at both follow-up time points (approximately 17% return rate). MEASURES The CFR survey included 17 items to assess confidence, attitudes, knowledge, stigma, and behaviors using a 5-point Likert scale from strongly disagree to strongly agree. Confidence in one s ability to help people with a mental health problem was assessed with four items. The items ask respondents about their confidence in: (1) recognizing problems, (2) knowing what to say and (3) do, and (4) their knowledge of mental illness. Attitudes toward mental health treatments was assessed with three items assessing (1) belief that counseling is helpful, (2) belief that medications are helpful, and (3) belief that people can get better with help. Knowledge of mental health resources was assessed with four items, including knowledge of (1) at least two resources in the National Guard, (2) at least two resources in the community, (3) the phone numbers for one or more crisis line, and (4) at least two trusted resources to refer someone to. To assess the use of MHFA practices, respondents were asked to rate whether they were likely to use specific practices. Practice behaviors assessed include: (1) reaching out and talking, (2) asking about suicidal thoughts, (3) listening, (4) offering basic first aid information, (5) assisting in seeking professional help, and (6) assisting in connecting with supports. Observed reliability was sufficient to strong for each of these scales confidence (α = 0.78), attitudes (α = 0.70), knowledge (α = 0.76), and practice behaviors (α = 0.86). Although no scale for either public or personal stigma was included, a single item on the survey was used as a proxy for measuring stigma toward mental illness: People are generally supportive when a person is experiencing stress and related mental health issues. This item most closely matches Link s modified labeling theory and devaluation subscale for assessing stigma and its impacts on people s willingness to seek or offer help. 18,19 Link s research on devaluation suggests that people who respond more negatively to this question, or similar questions, are less likely to seek help and more likely to engage in secretive behaviors. Research similarly indicates that people who score low on this construct are less likely to openly discuss mental health issues with someone they see who may be struggling. This theory regarding our proxy measure is confirmed by the item having significant correlations with confidence (r = 0.23, p = 0.003), knowledge (r = 0.28, p = 0.000), and practice behavior scales (r = 0.28, p = 0.000). ANALYSES We first tested the feasibility of M-MHFA replicating prior research on MHFA effects with paired-sample t tests of confidence, attitudes, knowledge, and stigma among CFR trainees pretest to immediate postintervention. Second, we conducted repeated measures analysis of variances (ANOVAs) on data from CFRs who received the training to confirm whether the intervention resulted in significant and sustained changes over the 8-month study period on confidence, attitudes, knowledge, practice behaviors, and stigma. Finally, to develop preliminary evidence of intervention efficacy we conducted mixed between-within subjects ANOVAs comparing the intervention and control group longitudinally at three time points: pretest, at 4 months, and at 8 months. The mixed ANOVA as implemented here tests the null hypothesis that there is no significant interaction between time (three repeated measures) and intervention grouping (intervention vs. control) on the identified dependent variables. All analyses were completed using IBM SPSS Statistics version 22. RESULTS Paired Sample t Tests Table I displays the means and standard deviations for the behaviors, confidence, knowledge, attitudes, and stigma at pre- and post-training, and the t test results and effect sizes. t tests confirmed that the M-MHFA training resulted in significant positive gains in CFRs confidence or self-perceived ability to help people in need, t(61) = 10.74, p < 0.00; attitudes toward help seeking, t(61) = 5.29, p < 0.00; and knowledge of mental health resources, t(61) = 9.87, p < In addition, CFRs exhibited significant decreases in stigma, t(61) = 2.51, p = The effect sizes for the trainings impact on confidence (d = 2.75), attitudes (d = 1.35), and knowledge are all very large on the basis of Cohen s convention of effect sizes larger than 0.80 being considered large. The effect size for stigma (d = 0.64) was also meaningful on the basis of the convention of effect sizes between 0.5 and 0.8 being considered moderate. These e1578

4 TABLE I. Descriptive Statistics and t Test Results for CFRs Pre-training- and Post-training on Practice Behaviors, Confidence, Knowledge, Attitudes, and Stigma N Mean Time 1 (SD) Mean Time 2 (SD) Mean Difference t df Significance (2-Tailed) Effect Size Confidence (0.60) 4.32 (0.42) Attitude (0.63) 4.22 (0.60) Knowledge (0.74) 4.49 (0.47) Stigma (0.90) 3.42 (1.00) results confirm that M-MHFA is a feasible training program for increasing trainee confidence in helping others, positive attitudes toward help seeking, and knowledge of mental health resources, whereas also reducing stigma toward mental illness. Repeated Measures ANOVA Table II displays the results of the one-way repeated measures ANOVAs for CFR trainees on confidence, knowledge, attitudes, behaviors, and stigma. For all variables except attitudes, there were statistically significant positive effects over time. Post hoc tests, also displayed in Table II indicate that there are statistically significant gains in confidence, knowledge, behaviors, and stigma from preintervention to 4 months postintervention and from preintervention to 8 months postintervention, with no statistically significant difference between 4 and 8 months post. These results indicate that the CFRs showed improvements in their confidence, knowledge, and behaviors and decreases in stigma from preintervention to postintervention, with those changes being sustained and stable through to 8-month postintervention. For attitudes, however, there were no significant effects detected. Furthermore, effect sizes were large for confidence (η 2 = 0.49), knowledge (η 2 = 0.39), behaviors (η 2 = 0.27), and stigma (η 2 = 0.16), on the basis of conventions indicating that η 2 >0.13 is a large and meaningful effect. 20 Although there was no statistically significant effect detected on attitudes, the effect size is nonetheless moderate (η 2 = 0.06), suggesting that a better powered study and/or greater measurement precession may lead to a detectable effect on attitudes toward help seeking as well. Mixed ANOVA Table III displays the results from the mixed between-within subjects ANOVA comparing intervention and control groups on confidence, attitudes, knowledge, behavior, and stigma across three time points (preintervention, 4-month postintervention, and 8-month postintervention). The interaction effects between time and intervention group on confidence (F 2 = 2.98, p = 0.06), knowledge (F 2 = 1.61, p = 0.21), attitudes (F 2 = 0.83, p = 0.44), and stigma (F 2 = 1.23, p = 0.30) TABLE II. One-Way Repeated Measures ANOVAs for CFR Trainees at Pre-intervention, 4-Month Postintervention, and 8-Month Postintervention - - and Post Hoc Comparisons With Bonferroni Correction Computed on the Basis of Estimated Marginal Means Repeated Measures ANOVA Post Hoc Comparisons Measure F (df) Significance Partial Eta Squared Observed Power a (I) Time (J) Time Mean Difference (I J) SE Significance b Confidence (2) * * * Attitudes 2.32 (2) Knowledge (2) * * * Behaviors (2) * * * Stigma 7.46 (2) * * * df, degrees of freedom. *The mean difference is significant at the 0.05 level. a Computed using α = b Adjustment for multiple comparisons: Bonferroni. e1579

5 TABLE III. Main Effects of Time and Interaction Effects of Time by Intervention Group for Mixed Between-Within Subjects ANOVA of CFR Results Measure F df Significance Partial Eta Squared Observed Power a Time Confidence Knowledge Attitudes Behaviors b Stigma Time * Intervention Group Confidence Knowledge Attitudes Behaviors b Stigma df, degrees of freedom. a Computed using α = b Results for behavior apply the Greenhouse-Geisser correction for violations of sphericity. Other variables did not violate sphericity and the results reported do not employ the correction. were all nonsignificant. For knowledge, attitudes, and stigma the observed effect sizes were small but meaningful (η 2 =0.03 for knowledge, η 2 = 0.02 for attitudes, η 2 =0.02forstigma), whereas the observed effect size was moderate for confidence (η 2 = 0.06). Finally, there was a significant interaction effect between time and intervention group and a moderate effect size for practice behaviors (F 1.75 =3.94,p =0.03,η 2 =0.07) indicating that there was a significant difference between the intervention and control group in the change in practice behaviors over time. To aid in interpretation, inspection of the means for each variable points to important differences in how the intervention group changed on each variable compared to the control group. Figure 1 displays plots of the means for each variable over time and comparing intervention and control groups. For confidence and resource knowledge, the intervention group means rise from time 1 to time 2 and then remain relatively stable to time 3, whereas for the control group the means rise from time 1 to time 2, but then fall from time 2 to time 3. In the case of practice behaviors, the means for the intervention group rises dramatically from pre-intervention to 4-month post-intervention and then remains stable through 8-month post-intervention. In contrast, the control group actually begins with higher mean practice behaviors than the intervention group, but then falls from time 2 to time 3, with a lower mean practice behavior score by the time 3 assessment compared to the intervention group. The differences in the pattern of change over time between the intervention and control group points toward a positive intervention impact on confidence, resource knowledge, and practice behavior when compared to a control group. The change patterns for attitudes and stigma are not as clear. For attitudes, both groups start with similar scores and conclude with similar scores, with the intervention group s attitudes improving more immediately than the control group. These results, coupled with the nonsignificant ANOVAs, indicate that there may not be an intervention effect for attitudes toward help seeking when compared to a control group. With stigma, the intervention group s mean score increases steadily over time indicating a reduction in stigma, but the intervention group starts off with greater stigma towards mental illness than the control group. In contrast, the control group s mean score increases a small amount from time 1 to time 3. Despite the nonsignificant ANOVA, and the overall improvement in stigma across both groups, the intervention group does appear to have made more dramatic improvement in stigma. DISCUSSION Results from the comparative outcomes pilot study of Military MHFA indicate that the intervention is acceptable and feasible to implement in National Guard Armories and among non-guard community based first responders. First, and most critically, there was a significant intervention effect detected for the likelihood that a CFR would use appropriate engagement, support, and referral practices when identifying someone in need of mental health support. Second, there was a clear trend showing a similar effect for confidence in helping someone in need. And third, for all the other three measured variables knowledge of mental health resources, attitudes toward help seeking, and stigma there were positive growth trends in the data and small but meaningful effect sizes, which indicate that with more power (a larger number of participants and armories) we would expect to see significant intervention effects. These results strongly suggest that a better powered study would be able to detect positive intervention effects among people trained in Military MHFA. Our results indicate that CFRs trained in Military MHFA achieved statistically meaningful improvement, with moderate to large effect sizes, in confidence in one s ability to help someone facing a mental health challenge, attitudes toward mental health treatment, knowledge of mental health resources, MHFA practice behaviors, and stigma toward people with mental illness. The observed effects were statistically significant for confidence, knowledge, behaviors, and stigma, but nonsignificant for attitudes. Across all variables the effects were sustained to 8-months post-training. e1580

6 FIGURE 1. Plots of the means for confidence, knowledge, attitudes, practice behaviors, and stigma comparing intervention and control groups over three time points (pre-intervention, 4-months post-intervention, and 8-months post-intervention). When comparing the intervention group to a control group, we observed positive trends that indicate a larger randomized control trial would be able to detect intervention effects. On all variables, we observed small to moderate and meaningful differences in the change pattern over time for the intervention group compared to the control group. We only observed a statistically significant difference between the intervention and control group for practice behaviors. e1581

7 Further inspection of the comparative results indicated that the intervention group displayed more positive outcomes than the control group on confidence, knowledge, and behaviors. However, the control group also displayed some positive growth from time1totime2onbothconfidence and knowledge. This contradictory finding may be related to the small sample size for this group, measurement error, or the effect of participating in the study. Whatever the cause, the control group was unable to maintain these gains through to time 3, whereas the intervention group displayed sustained improvements. LIMITATIONS Despite the promise of military and veterans MHFA to have substantial and meaningful impacts, the results of this study remain preliminary. The study was underpowered to detect true intervention effects as a result of small sample sizes, especially within the control group at follow-up measurement times. Our initial recruitment efforts failed to enroll as many CFRs as anticipated, with particular challenges identifying and connecting with community-based civilian CFRs. Attrition among the control group had detrimental effects on the retention of participants and statistical power, as well as being a likely source of bias. We suspect that lack of honorariums for many CFRs, no wait-list control, and limited ongoing communication with the study participants resulted in a low incentive for the control group participants to be engaged in the study. In this study, we were prohibited from offering even small honorariums to National Guard participants for completing the surveys, a technique that is standard practice in similar studies and greatly improves return rates for follow-up surveys. Furthermore, in a larger study we would recommend a wait-list control design so that every CFR, including those randomized to the control group, would receive the training, thereby increasing buy-in and commitment from participants in the control group. Another important limitation was the lack of demographic and other related health data on participants. Because of ARNG restrictions, we were not able to collect participants age, race/ethnicity, or gender. We also had to substantially reduce our original survey, excluding measures of individuals mental health status and a more robust scale of stigma. Basic demographic data and participant health are important to identifying and controlling for any potential group differences. Also, our simple single item stigma question may have lacked the necessary sensitivity. Interestingly, for stigma, as well as resource knowledge and attitudes toward help seeking, the control group showed a similar pattern of change over time to the intervention group, suggesting that there may be some other confounding variable in the ARNG that is also driving change in these variables. For example, if there were an effort external to this study to increase awareness of mental health resources and reduce stigma. In future studies it will be critical to track and measure potential confounds. Finally, this study did not attempt to measure actual referral rates or other indicators that service members and veterans in need are being effectively identified and assisted. A more robust study with substantially greater participation and study control would be needed to assess the impact of M-MHFA on access to care. As is, this study focused solely on testing the impact of the training on proximate factors believed to be critical to increasing more distal access to care outcomes. CONCLUSION The development of the military module for MHFA has the potential for significant impact on the military and veteran population across the country there is a need for more public education programs on military and veterans mental health needs and reduction of stigma among military and veteran populations. 3,7,21 The National Council for Behavioral Health manages dissemination of the MHFA curriculum throughout the United States, and there are now more than 8,000 instructors throughout the country 22 and is actively disseminating this intervention as targeting both military and veteran populations. Once those who are qualified to teach the military adaptation complete the process to receive this designation, there is the potential to reach a significant number of service members, veterans, their families, and their community-based supports. Military MHFA may also complement existing military mental health programs. There are numerous resilience trainings for service members disseminated by the various branches of the military. 23 Program such as the Comprehensive Soldier Fitness Program, 17 are promising approaches to building resilience by giving service members tools and techniques to better handle the stress of deployment; however, they do not specifically address knowledge, attitudes, and opinions that may impede help seeking. Psychological First Aid and Combat and Operational Stress First Aid are potentially critical approaches to mitigating the impacts of traumatic event through helping people in the immediate aftermath of the traumatic event. 24 Military MHFA on the other hand is tailored to use in the community and without the context of an immediately preceding traumatic event, in order to better identify people with mental health needs, de-escalate a mental health crisis when it occurs, and help people access the services they need. MHFA provides a mental health literacy component that is currently not addressed. In addition, Military MHFA can be delivered to civilian community gatekeepers to help the community support system gain a deeper understand and expanded knowledge of military-specific mental health issues and needs. In conclusion, we feel that Military MHFA is a promising intervention for reducing critical barriers to care. Throughout the study, we heard numerous stories from National Guard trainees about how the training had helped. One unit leader told a trainer upon follow-up data collection that shortly after the training he noticed a noticed a significant and concerning change in behavior in a soldier and that his response was e1582

8 directly linked to the training, and, as a result, they were able to get the soldier the help he needed. On another occasion, a Sergeant First Class said, Remember all that role playing you had us do? It worked! I had a kid that I could tell was just out of sorts. I talked to him and he d had a breakup. I flat out asked him if he d thought about killing himself and he said he had. We went and got his gun from his house and got him some help, so thank you! ACKNOWLEDGMENTS N.V.M. contributed primary authorship of the manuscript, all data management and analyses, and supervised completion of the data collection, and research protocols for the study. R.B. provided statistical consultation, oversaw data analyses, and writing up of results. N.W. assisted with writing the program development section, provided project management for the trainings and in-person data collection, provided consultation in the development of the Military and Veterans Mental Health First Aid Training, managed the early phase pilot trainings, and provided review and edits for the final manuscript. D.F.M. was the co-principal investigator of the study and provided review and edits for the final manuscript. J.S. was the co-principal investigator of the project at the time and collaborated closely with the primary author to write the final manuscript. He also served as the advisor on the expert review panel and an employee of the funding agency. In addition to the manuscript authors, Kristin Musch provided trainings and assisted with data collection. This research and development project/program/initiative was conducted by Western Interstate Commission on Higher Education and is made possible by a research grant that was awarded and administered by the U.S. Army Medical Research and Materiel Command (USAMRMC) and the Telemedicine and Advanced Technology Research Center (TATRC), at Fort Detrick, Maryland, under Contract Number W81XWH The authors are grateful to the many research participants who shared their time, including those from the Army National Guard who participated in this study and those who shared their time to help with the early stage adaptation. Finally, this work would not have been possible without the cooperation of the National Council for Behavioral Healthcare. REFERENCES 1. 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