CRITICALLY APPRAISED PAPER (CAP) Biggs, Q. M., Fullerton, C. S., McCarroll, J. E., Liu, X., Wang, L., Dacuyan, N. M.,... Ursano, R. J. (2016). Early intervention for post-traumatic stress disorder, depression, and quality of life in mortuary affairs soldiers postdeployment. Military Medicine, 181(11), e1553 e1560. https://doi.org/10.7205/milmed-d-15-00579 CLINICAL BOTTOM LINE Troop Education for Army Morale Troop Education for Army Morale (TEAM) is an early intervention for mortuary affairs (MA) soldiers postdeployment. MA soldiers are exposed to high levels of stress when recovering and identifying fallen soldiers. This group of soldiers particularly has been known to experience psychological difficulties and psychiatric disorders after their return home from duty. These problems may extrapolate to the soldiers functioning in their home and community, influencing their behaviors and perceptions of the events that occur in their daily life. This could place them at an increased risk for participating in harmful behaviors, which might affect them and the people around them as well. Because no intervention has been designed for this specific branch of the army, TEAM was developed on the basis of the principles of psychological first aid (PFA) and integrates other psychosocial principles to reduce stress and facilitate adaptation among these soldiers. By promoting safety, calmness, connectedness, self-efficacy, hope, and optimism, TEAM s goal is to minimize postdeployment posttraumatic stress disorder (PTSD) and depression symptoms and enhance the overall quality of life (QOL) of MA soldiers. According to a randomized controlled design, MA soldiers (N = 126) were randomized into TEAM or a comparison group (receiving no treatment) 1 month postdeployment, with four sessions occurring at 2, 3, 4, and 7 months. At completion of the intervention and follow-up, no differences were found between the two groups. High attrition rates were documented in both groups, particularly with men. Implications for Occupational Therapy Given the large number of soldiers returning home from active duty, occupational therapists 1
need to be cognizant of the psychological effects of deployment, in particular for MA soldiers. Early intervention is important in the recovery and reintegration of the soldier into active duty or into his or her family environment. Occupational therapists need to be aware of the tools they can use in early intervention to facilitate this transition and help minimize the psychological effects of war. Although TEAM, the first known postdeployment intervention for MA soldiers, was found to be ineffective overall, it informs occupational therapy practice by encouraging the design and implementation of other postdeployment early interventions. Occupational therapists may work toward finding an intervention that is effective in reducing MA soldiers negative psychological responses to active combat by using the findings of this study. A possible floor effect might have occurred during the TEAM intervention, which indicates that MA soldiers with milder psychological symptoms might be limited in the reduction of their symptoms. Because of the unique and individualized needs of soldiers returning from active duty, the development of interventions targeted at specific subgroups may be beneficial, including the refinement of TEAM to potentially target soldiers with more severe psychological symptoms. In addition, because increased attendance was associated with increased benefits from the intervention, occupational therapists may serve an essential role in further determining how the intervention may be individualized to support adherence to the protocol or how future interventions may be adapted to better meet the needs of MA soldiers postdeployment. Future research is needed to help design effective interventions that meet the needs of these specific subgroups. RESEARCH OBJECTIVE(S) Examine the effectiveness of TEAM, a postdeployment early intervention based on the principles of PFA, on PTSD, depression, and QOL among MA soldiers DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Longitudinal randomized controlled trial PARTICIPANT SELECTION How were participants recruited and selected to participate? U. S. Army MA soldiers were given the opportunity to voluntarily join the study 1 month after their return from deployment. These soldiers were recruited in 10 cohorts over 5 years. Inclusion criteria: For soldiers to be included in this study, they needed to be a part of the MA branch of the U.S. 2
Army and voluntarily join the study within 1 month of their return from deployment in the Middle East. Exclusion criteria: No exclusion criteria explicitly reported PARTICIPANT CHARACTERISTICS N= 126 #/ % Male: 85/68% #/ % Female: 41/32% Ethnicity: 72 (57.6%) White Disease/disability diagnosis: Not applicable INTERVENTION AND CONTROL GROUPS Group 1: TEAM intervention Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Group 2: Comparison group Brief description of the intervention Each TEAM intervention consisted of an interactive group session that lasted 2 hours and incorporated informational handouts, dedicated website access, email, and a phone-line service to support the participants and their success in the program. The TEAM interventions were designed to reduced distress and facilitate adaptation, on the basis of the principles of PFA. To help facilitate this change among the MA soldiers, the intervention used five principles of PFA: safety, claiming, connectedness, self-efficacy, and hope and optimism. 68 MA soldiers (22 by Month 10) Not reported Two trained psychologists or psychiatrists ran each of the TEAM sessions. TEAM sessions were held at 2, 3, 4, and 7 months postdeployment. The intervention occurred over a 10-month period. The comparison group did not receive postdeployment intervention. Soldiers completed assessments at 1, 2, 3, 4, 7, and 10 months. How many participants 58 MA soldiers (26 by Month 10) 3
in the group? Where did the intervention take place? Who delivered? How often? For how long? Not applicable Not applicable Not applicable The study occurred over a 10-month period. INTERVENTION BIASES Contamination: NO Co-intervention: NO Timing of intervention: Site of intervention: NR Although direct contamination was not reported, the authors did not report whether soldiers in the control group received any similar group therapy over the period of the study. The authors did not report any cointervention for the TEAM group. They did not, however, report whether the TEAM intervention group was instructed not to use other services or interventions while participating in the TEAM intervention postdeployment. The study was conducted over a 10-month period, so general improvement of symptomatology might have contributed to the results. Psychological symptoms have been found to have a natural increase in the first 4 months after deployment, which might explain the spike in symptoms for intervention-group men during the 3rd month of the study. The comparison group did not have the same increase in symptoms, however. The site of intervention was not reported in the study. Use of different therapists to provide intervention: Two psychologists or psychiatrists ran each of the TEAM sessions. Baseline equality: At baseline, no significant differences were found between the two groups. NO The authors noted, however, that more MA soldiers in the intervention group 4
MEASURES AND OUTCOMES had a spouse or significant other on active duty. Measure 1: Posttraumatic Stress Disorder Checklist Name/type of measure used: What outcome is measured? Is the measure reliable (as reported in the article)? Is the measure valid (as reported in the article)? When is the measure used? 17-item Posttraumatic Stress Disorder Checklist (PCL-17) PTSD symptom total scores and Criteria B, C, and D of the Diagnostic and Statistical Manual of Mental Disorders (fourth ed.; DSM IV) diagnosis of PTSD First assessed at Month 1 (baseline) to use as a reference; then used with both groups at 2, 3, 4, 7, and 10 months Measure 2: Patient Health Questionnaire Depression Scale Name/type of measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? Nine-item Patient Health Questionnaire Depression Scale (PHQ-9) Symptom severity score and probable major depression First assessed at Month 1 (baseline) to use as a reference, then used with both groups at 2, 3, 4, 7, and 10 months Measure 3: World Health Organization Quality of Life Assessment Brief Version Name/type of measure used: What outcome is measured? Is the measure reliable as reported Psychological Health and Environmental domains of the 26-item World Health Organization Quality of Life Assessment Brief Version (WHOQOL BREF) QOL (psychological health and environmental domains) 5
in the article? Is the measure valid as reported in the article? When is the measure used? Measure 4: Combat Experiences Scale Name/type of measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? First assessed at Month 2, and month 10 was used as a reference; also assessed at Months 3, 4, and 7 Adapted 27-item Combat Experiences Scale, with two mortuary-specific items added Exposure to traumatic events (for DSM IV Criterion A) in the past 12 months, more than 1 year ago, or never Only at baseline MEASUREMENT BIASES Were the evaluators blind to treatment status? NO Was there recall or memory bias? Self-report measures were not blinded: MA soldiers were aware of whether they were receiving the intervention. When MA soldiers completed assessments on their QOL, they had to recall events from the previous 4 weeks. Also, to assess exposure to traumatic events, MA soldiers had to report whether each event occurred in the past 12 months, more than 1 year ago, or never. Last, because this was a qualitative assessment, recall and memory bias cannot be completely avoided. Other measurement biases: (List and explain) RESULTS List key findings based on study objectives: Traumatic Events 6
No difference was found in the traumatic events experienced between groups. The intervention group had an average of 7.6 events (SD = 2.5), and the comparison group had an average of 7.7 events (SD = 2.6). Attendance In all, 71.6% (n = 48) of the intervention group attended at least two intervention sessions, but men attended fewer sessions than women (men: M = 1.97, SD = 1.03; women: M = 2.70, SD = 1.9; p =.02). The number of intervention sessions attended was correlated with the soldiers PCL-17 total score (p =.04), PHQ-9 score (p <.01), WHOQOL BREF Psychological Health score (p =.02), and WHOQOL BREF Environmental score (p =.03). PTSD At baseline, there was no difference between groups, and 25% of all participants had probable PTSD. Although the two groups did not differ significantly in PCL-17 scores throughout the six time points, at Months 2 and 3, there was a significant Time Treatment interaction (p =.04 for Month 2; p =.01 for Month 3) that resulted in the intervention group displaying higher scores. This indicated that the main effects of time and treatment were meaningful for the analysis. When the authors examined men and women separately, PCL-17 scores were significantly higher for intervention men than comparison men at Months 2 (p.05) and 3 (p.01). There were no significant differences at any points between women in the two groups. Intrusion, Avoidance, and Hyperarousal A Time Treatment interaction occurred at Month 2 for avoidance (p.05) and hyperarousal (p =.02) and again at Month 3 for all subscales (intrusion: p =.03; avoidance: p.05; hyperarousal: p =.03). Significant effects of time for the hyperarousal subscale occurred at Month 2 (p =.04) and Month 10 (p =.04). Scores on all PCL-17 subscales were higher for those in the intervention group. Depression There was no significant difference between the two groups at baseline for probable depression, nor did PHQ-9 scores differ between the two groups throughout the six time points. At Month 3, however, male soldiers displayed a Time Treatment interaction (p =.03) and an overall effect of time (p =.04), and higher scores were displayed in the intervention group (p <.01). QOL At baseline, no difference was found between the two groups QOL on the basis of the two WHOQOL BREF subscales. It was found, however, that the treatment did affect the results of the Psychological Health subscale (p =.04), with lower scores in the intervention group (p =.04). 7
Intervention Evaluation While evaluating the intervention, 88.7% of soldiers reported that, overall, the TEAM training was helpful. In particular, soldiers rated the following content as helpful: communicating with others (90.6%), having a positive outlook on things (88.7%), relaxation techniques (84.9%), providing support to a buddy (84.9%), and problem solving (81.1%). Soldiers who rated the intervention more positively also had lower symptoms of PTSD (p <.01) and depression (p =.03) and higher QOL for both subscales (p <.001). Was this study adequately powered (large enough to show a difference)? NO Because of the small sample size, the effect size shown in the study was small (<0.3). Also, the low number of female participants might have affected the power to find differences across the intervention and control groups for gender. Were the analysis methods appropriate? The authors conducted preliminary analyses that tested for equivalence of groups at baseline to ensure random assignment. They then completed crosssectional analysis at each time point for each of the variables using appropriate methods. Were statistics appropriately reported (in written or table format)? The results were clearly stated in written format and also through the use of graphs and tables. Was participant dropout less than 20% in total sample and balanced between groups? YES NO Although 67 soldiers in the intervention group and 58 soldiers in the control group were included in the analysis, by Month 10 of the study, both groups had lost more than 20% of their participants. What are the overall study limitations? Multiple biases were found throughout the duration of the study that limit the results. First, one limitation of this study is the self-selection for enrollment. Because MA soldiers had the choice to join the study, participants who believed that the intervention would be successful might have rated it as so, even if no true difference was seen, which would have caused the potential of selection bias to influence the results. In addition, the study s findings are limited by the attrition rates, with both the comparison and the intervention group losing more than 20% of their participants by Month 10. Although these participants dropped out of the study at any time from Month 1 to Month 10, their information was still included in the analysis. Last, the TEAM intervention might be limited to change only among MA soldiers who experience high PTSD symptoms, rather than less-severe symptoms, so 8
floor effects might occur. Future research on the effects of early interventions for this population is needed. CONCLUSIONS State the authors conclusions related to the research objectives. Although TEAM is the first known early intervention designed for MA soldiers postdeployment, the intervention had no overall effect on PTSD, depressive symptoms, or QOL for the participants. Throughout the study, PTSD symptoms varied among the groups, but at Month 3, the intervention-group men showed an increase in all measures of PTSD and depression and a decrease in psychological QOL. This might be explained by the fact that PTSD and depression have been found to increase in the first 4 months postdeployment. In addition, the increase of symptoms in the intervention group might be explained by the soldiers increased awareness of symptoms. Furthermore, throughout the study and across all measures, significant differences were found between intervention-group and comparison-group men. Such differences did not exist between groups for women. Overall, although the measures were not significant, the majority of the MA soldiers reported TEAM to be helpful in increasing communication skills, maintaining a positive outlook, using relaxation techniques, and providing support. This work is based on the evidence-based literature review completed by Lauren Lange, OTS (author), and Karla Ausderau, PhD, OTR/L, faculty advisor, University of Wisconsin. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 9