Eric Bui, MD, PhD, Allison L. Baier, BS, Darshan H. Mehta, MD, MPH, John W. Denninger, MD, PhD, Gregory L. Fricchione, MD, Aggie Casey, MS, RN, Leslee Kagan, MS, FNP-BC, Elyse R. Park, PhD, MPH, and Naomi M. Simon, MD, MScLouisa G. Sylvia
Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston (Dr Sylvia), United States
Harvard Medical School, Boston, Massachusetts (Dr Sylvia), United States
Eric Bui
Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston (Dr Bui), United States
Harvard Medical School, Boston, Massachusetts (Dr Bui), United States
Allison L. Baier
Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston (Ms Baier), United States
Darshan H. Mehta
Harvard Medical School, Boston, Massachusetts (Dr Mehta), United States
Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Dr Mehta), United States
John W. Denninger
Harvard Medical School, Boston, Massachusetts (Dr Denninger), United States
Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Dr Denninger), United States
Gregory L. Fricchione
Harvard Medical School, Boston, Massachusetts (Dr Fricchione), United States
Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Dr Fricchione), United States
Aggie Casey
Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Ms Casey), United States
Leslee Kagan
Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Ms Kagan), United States
Elyse R. Park
Harvard Medical School, Boston, Massachusetts (Dr Park), United States
Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Dr Park), United States
Naomi M. Simon
Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston (Dr Simon), United States
Harvard Medical School, Boston, Massachusetts (Dr Simon), United States
Abstract
Background:
Many veterans deployed after 9/11/2001 are impacted by subthreshold levels of posttraumatic stress, anxiety, or other psychological health problems that may interfere with successful reintegration. Conventional treatments, including medication and trauma-focused individual psychotherapies, may not be optimally adapted, accepted, or effective to treat these subsyndromal symptoms.
Methods:
We developed “Resilient Warrior,” a 4-session, group-based, mind-body stress-management and resilience program targeted to build skills and assessed whether its format was accessible and acceptable, and potentially efficacious, to support resilience among service members.
Results:
From April 2014 to October 2014, 15 participants (53.3% women; mean age=36.6 y; SD=6.2) were surveyed for program acceptability and feasibility and completed self-reported psychological health outcomes before and after program participation. The majority (71.4%) of participants reported that the program included the right number of sessions, and all of them reported that it was helpful and relevant and that they would recommend it to others. While changes in self-reported resilience were only marginal, participation was associated with improvements in depressive symptoms, perceived stress, anxiety, and general sense of self efficacy.
Conclusion:
These pilot data provide preliminary support that “Resilient Warrior,” a group-based, stress reduction and resilience program, may improve psychological health in service members even when delivered in community settings. Randomized controlled trials with longer follow-up periods are needed to establish efficacy and effectiveness for this program.
摘要
背景：“9/11” 后派遣的许多退 伍军人受到了次阈值水平的创伤 后应激、焦虑或可能以干扰其成 功再融入社会的其他心理健康问 题影响。常规治疗，包括药物治 疗和关注创伤的个体心理治疗， 可能并不最佳适应于、被接受或 有效治疗这些亚症候症状。
方法：我们开发了Resilient Warrior 这一项 4 阶段、基于小 组的身心压力管理和康复计划，旨 在于建立技巧并评定其形式是否可 理解及可接受以及是否可能有效， 以支持服务机构人员康复。
结果：从 2014 年 4 月至 2014 年 10 月，15 名参与者（53.3% 女 性；平均年龄 = 36.6 岁；SD=6.2 ）就计划可接受性和可行性接受 研究并且完成参与计划前后的心 理 健 康 自 我 报 告 结 果 。 大 部 分 (71.4%) 参与者报告该计划包括合 适次数的课程，并且他们均报告 本计划有益并且愿意向其他人推 荐。尽管变化自我报告的康复变 化仅为最低限度，但是参与过程 与抑郁症状、感知压力、焦虑和 总体自我效能感改善相关。
结论：这些试验性数据提供以下 初步支持：Resilient Warrior 这一基于小组的减少压力和康复 计划，可以改善服务机构人员的 心理健康，甚至在社区环境下开 展时也是如此。需要随访时间更 长的随机分组对照试验以确定本 计划的疗效和有效性。
SINOPSIS
Antecedentes:
Muchos veteranos destacados tras el 11S están afectados por niveles subumbrales de estrés postraumático, ansiedad u otros trastornos psicológicos que podrían interferir en su correcta reintegración. Los tratamientos convencionales, como la medicación y la psicoterapia individual centrada en el trauma, podrían no estar bien adaptados y aceptados o no resultar eficaces a la hora de tratar estos síntomas subsindrómicos.
Métodos:
Hemos desarrollado Resilient Warrior, un programa de resistencia y control del estrés de 4 sesiones en grupo que combina cuerpo y mente, con el objetivo de desarrollar habilidades y evaluado para comprobar si su formato resulta accesible y aceptable, así como potencialmente eficaz, para aumentar la resistencia de las fuerzas armadas.
Resultados:
Desde abril hasta octubre de 2014, se encuestó a 15 participantes (53,3 % de mujeres; media de edad = 36,6; DE = 6,2) para evaluar la aceptabilidad y viabilidad del programa. Los participantes completaron unos cuestionarios de salud psicológica autonotificados antes y después de su participación en el programa. La mayoría de los participantes (71,4 %) respondió que el programa incluía un número adecuado de sesiones, y todos afirmaron que les había resultado útil y apropiado y que se lo recomendarían a otras personas. Aunque los cambios en la resistencia autonotificada fueron mínimos, la participación en el programa se vio asociada con mejorías de los síntomas de depresión, estrés percibido, ansiedad y sensación general de la propia eficiencia.
Conclusión:
Estos datos piloto ofrecen un respaldo preliminar del hecho de que el programa de resistencia y reducción del estrés en grupo Resilient Warrior podría mejorar la salud psicológica de los miembros de las fuerzas armadas incluso al llevarse a cabo en ámbitos comunitarios. Es necesario efectuar ensayos controlados y aleatorizados con mayores periodos de seguimiento para determinar la eficacia y efectividad de este programa.
METHODS
Participants and Procedures
The study was approved by the Institutional Review Board of the Massachusetts General Hospital/Partners for a retrospective review of data collected for program development and educational outcome evaluation (data repository). Participants were recruited from the community and took 1 of 3 Resilient Warrior courses located in Massachusetts between April 2014 and October 2014. The first group was conducted at an Air Force base and the second 2 groups were administered at a community college. Resilient Warrior was advertised as a stress-reduction resilience training program open to any veteran or active service members by flyers and social media, as well as email and mail distribution lists (eg, Massachusetts National Guard). Interested participants completed a semi-structured interview (phone or in-person) with the program instructor for 30 minutes to assess their interest and ability to attend the program. For example, individual’s personal goals were discussed to ensure that they aligned with the program or that the participant understood and had realistic expectations of the program. The instructor also assessed the participant’s ability to sit in a group and their commitment to attend the program. As a naturalistic trial of acceptability, feasibility, and stress reduction, participants were not required to have a diagnosis of PTSD or other disorder. Course instructors were trained by BHI through coursework, experiential learning (observing and participating in mind-body programs), supervision, and observed teaching. While 40 individuals completed the program across 2 groups, we examined the 15 participants for whom completed pre and post linked data were available. The missing data was due to poor labeling of paper surveys. However, the labeling error was a random administrative error and not linked to participant characteristics—those who were included in the analyses did not differ from those who were not on any of the baseline variables (including age, gender, military status, branch of service, number of deployments; all P values>.138), except marital status, with individuals included in the analysis being more likely to be married than those not included (80% vs 12%, P<.001). Assessment included pre- and post-program surveys, as well as a pre-program demographic and stressors form and a post-program evaluation form. All data were completed in paper and pencil at the course location (ie, the first 10-15 minutes of the first session and the last 10-15 minutes of the last session) and then manually entered by trained study staff at the Home Base Program and stored on their secure server.
Assessments
The Patient Health Questionnaire-8 was used to assess the presence and severity of depressive symptoms. Items were scored on a 4-point likert scale (“not at all” to “nearly every day”), with increased total scores indicating increased depressive symptom severity. 17 The instrument has been found to exhibit good reliability (Cronbach α=.82).18 The Generalized Anxiety Disorder-7 questionnaire was used to assess anxiety symptom severity.19 Items were scored on a 4-point likert scale (“not at all” to “nearly every day”), with increased total scores indicating greater anxiety. The instrument has been well validated (Cronbach α=.92).19 The 10-item Perceived Stress Scale (PSS) was used to assess participants’ perception of stress.20 Items were scored on a 5-point scale (“never” to “very often”) and a composite score could be obtained by reverse scoring the 4 positively stated items and then summing all, with higher scores indicating a greater perceived stress. The PSS-10 has demonstrated good reliability as well as internal consistency (Cronbach α = .84-.86).20 The General Self-Efficacy Scale is a 10-item self-report questionnaire assessing perceived self-efficacy or one’s belief in one’s ability to complete tasks and accomplish their goals.21 Items are scored on a 1 to 4 likert scale (“not at all true” to “exactly true”) and are summed to yield a total score with greater scores indicating greater self-efficacy. High internal consistency ratings have been found with αs between .82 and .93.22 The 14-item Resilience Scale was used to assess how well an individual copes with change or adverse events.23 The Resilience Scale measures 5 core characteristics of resilience: meaningful life, perseverance, self reliance, equanimity, and existential aloneness. Items are scored from 1 to 7 (“strongly disagree” to “strongly agree”) and are summed to yield a total score (higher scores indicate higher resiliency). The instrument has good reliability and validity with αs between .76 and .91.23
Statistical Analyses
Paired t-tests were conducted to determine change in outcome measures from pre- to post-course completion and also report effect sizes (Cohen’s d). Descriptive statistics were used for sociodemographic characteristics as well as for questions pertaining to acceptability. All analyses were conducted with STATA version 12.1 (StataCorp, College Station, Texas). The level of statistical significance was set to P<.05 (2-tailed).
RESULTS
The mean age of participants was 36.64 years (SD=1.65). The majority of participants were female (53.33%), married (80%), active duty (50%), in the Army (93.3%), and had at least 1 overseas deployment (80%) (Table 1).
Table 1
Demographic Characteristics of Resilient Warrior Participants With Paired Dataa
| N | Mean ± SD or % (n) | |
|---|---|---|
| Age, y | 14 | 36.64 ±1.65 |
| Female | 15 | 53.30% (8) |
| Marital status | 15 | |
| Married | 80.00% (12) | |
| Divorced | 6.67% (1) | |
| Never married | 13.33% (2) | |
| Military status | 14 | |
| Active duty | 50.00% (7) | |
| Retired | 21.42% (3) | |
| National Guard | 21.42% (3) | |
| Activated reserve | 7.14% (1) | |
| Service Branch | 15 | |
| Army | 93.3% (14) | |
| Air Force | 6.66% (1) | |
| Overseas deployment | 15 | 80.00% (12) |
| Number of deployments | 12 | 2.17±1.34 |
a Some participants chose not to answer every demographic question, explaining the variation in sample size.
Overall, despite relatively low levels of symptoms at baseline, participants exhibited medium effect size changes in symptoms pre- to post-program (Cohen’s d ranging 0.55-0.65) that were significant for depressive symptoms and perceived stress, and marginally significant for anxiety symptoms and self-efficacy (Table 2). However, there was virtually no change in resilience as measured by the Resilience Scale during the course of our 4-week program (Table 2).
Table 2
Change in Outcomes Over Resilient Warrior Program
| Pre-course
|
Post-course
|
||||||
|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | t (dfa) | P | Cohen’sd | |
| PHQ, range: 0-24 | 6.36 | 5.21 | 4.5 | 3.72 | 2.25 (13) | .04 | 0.60 |
| GAD-7, range: 0-21 | 8.43 | 6.89 | 5.36 | 2.90 | 2.05 (13) | .06 | 0.55 |
| PSS, range 0-40 | 22.62 | 7.41 | 19.46 | 4.41 | 2.25 (12) | .04 | 0.62 |
| GSE, range 10-40 | 28.73 | 4.20 | 31.36 | 5.99 | –2.16 (10) | .06 | 0.65 |
| RS, range 14-98 | 77.42 | 16.05 | 76.75 | 16.82 | 0.18 (11) | .86 | 0.05 |
Abbreviations: GAD-7, generalized anxiety disorder-7 scale; GSE, general self-efficacy scale; PHQ, patient health questionnaire; PSS, perceived stress scale; RS, resiliency scale.
a Only participants with complete data were included in the analyses; thus degrees of freedom vary between outcomes.
In terms of acceptability, all participants (100%) felt comfortable during the group as reported on the post-course evaluation form. More than two-thirds (71.4%) of participants reported that the course consisted of the right number of sessions, while the remainder felt that there were too few sessions and all (100%) reported that the length of the sessions was optimal. Further, all participants reported that the course was very helpful or somewhat helpful, that it was very or somewhat relevant, and that they would recommend it to other service members.
DISCUSSION
Initial evaluation of the Resilient Warrior program, including preliminary feasibility and acceptability and efficacy data, support a potential role for improving psychological health in service members. Our preliminary data suggest that a 4-week relaxation-response resilience program adapted to military culture might improve symptoms of depression, perceived stress, anxiety, and self-efficacy in veterans and service members, with effect sizes in the medium to large range. Our data are consistent with similar findings from the US Department of Defense–sponsored Battlemind Training program that found that a brief intervention, or even a single session, postdeployment, could improve psychological health.24
Despite promising findings on many facets of psychological health, we did not find that our self-rated measure of resilience improved over the Resilient Warrior program. It may be that resilience requires more time to change and our program evaluation did not include a follow-up session. For example, the 5 core characteristics of resilience (meaningful life, perseverance, self-reliance, equanimity, existential aloneness) could take ongoing reflection and practice of skills over time to change. It is also possible that other modalities may be beneficial to further impact one’s resilience, but the best supporting evidence for improving resilience (meditation, mindfulness, and progressive muscle relaxation) are included in this program.25 Finally, we also need a new assessment of resilience, as it has been considered a difficult construct to measure.26 A resilience measure specific to military populations may also be beneficial. Further research should thus evaluate the long-term impact of Resilient Warrior.
Our initial pilot data support that Resilient Warrior was acceptable and well tolerated. Specifically, participants generally had positive perceptions of the course including the length of sessions, content, and its delivery. Perhaps most importantly, all participants stated that they would recommend it for other service members.
These data should be considered in light of several limitations. First, our study relied on self-report data primarily collected for program evaluation of an uncontrolled open naturalistic delivery of our program. In addition, our sample was not formally assessed for the presence of psychiatric disorders or for trauma experiences, and there were no specific inclusion or exclusion criteria other than willingness to participate and ability to manage a group program. We included in the analyses only a subset of the 40 participants who completed the program with intact linked data (n=15). The only significant difference was that included respondents were more often married. This may have skewed the study group to those with higher baseline resilience, making impact of the intervention more difficult to show. Finally, there was no long term follow-up.
Overall, our data suggest that the brief Resilient Warrior program may be feasible and acceptable, with preliminary data on its efficacy in improving psychological health in veterans and service members even when it is delivered in the community without specific diagnostic screening or exclusion criteria. Randomized controlled trials and longer follow-up periods are needed to determine the efficacy of this intervention.
Notes
Disclosures The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and had no conflicts to disclose.
Contributor Information
Louisa G. Sylvia, Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston (Dr Sylvia), United States. Harvard Medical School, Boston, Massachusetts (Dr Sylvia), United States.
Eric Bui, Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston (Dr Bui), United States. Harvard Medical School, Boston, Massachusetts (Dr Bui), United States.
Allison L. Baier, Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston (Ms Baier), United States.
Darshan H. Mehta, Harvard Medical School, Boston, Massachusetts (Dr Mehta), United States. Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Dr Mehta), United States.
John W. Denninger, Harvard Medical School, Boston, Massachusetts (Dr Denninger), United States. Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Dr Denninger), United States.
Gregory L. Fricchione, Harvard Medical School, Boston, Massachusetts (Dr Fricchione), United States. Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Dr Fricchione), United States.
Aggie Casey, Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Ms Casey), United States.
Leslee Kagan, Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Ms Kagan), United States.
Elyse R. Park, Harvard Medical School, Boston, Massachusetts (Dr Park), United States. Benson Henry Institute for Mind-Body Medicine, Massachusetts General Hospital, Boston (Dr Park), United States.
Naomi M. Simon, Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston (Dr Simon), United States. Harvard Medical School, Boston, Massachusetts (Dr Simon), United States.
REFERENCES
Reintegration challenges in U.S. service members and veterans following combat deployment. Soc Issues Policy Rev.
2014;8(1):33–73. [Google Scholar]
Washington, DC: National Academies Press; 2010. [PubMed] [Google Scholar]
et al.
Trajectories of trauma symptoms and resilience in deployed U.S. military service members: Prospective cohort study. Br J Psychiatry.
2012;200:317–23. [PubMed] [Google Scholar]
et al.
Comorbidity, impairment, and suicidality in subthreshold PTSD. Am J Psychiatry.
2001;158(9):1467–73. [PubMed] [Google Scholar]
et al.
Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002–2008. Am J Public Health.
2009;99:1651–8. [PMC free article] [PubMed] [Google Scholar]
et al.
Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med.
2004;351(1):13–22. [PubMed] [Google Scholar]
et al.
Subsyndromal posttraumatic stress disorder is associated with health and psychosocial difficulties in veterans of operations enduring freedom and Iraqi freedom. Depress Anxiety.
2009;26(8):739–44. [PubMed] [Google Scholar]
et al.
Subsyndromal posttraumatic stress disorder symptomatology in primary care military veterans: treatment implications. Psychol Serv.
2012;9(4):383–9. [PubMed] [Google Scholar]
Mindfulness-based interventions in context: past, present, and future. Clin Psychol.
2003;10(2):144–56. [Google Scholar]
Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness.
New York, NY: Delacorte; 2009. [Google Scholar]
Perceived benefits in a behavioral-medicine insomnia program: a clinical report. Am J Med.
1996;100(2):212–6. [PubMed] [Google Scholar]
et al.
Association of participation in a mindfulness program with measures of PTSD, depression, and quality of life in a veteran sample. J Clin Psychol.
2011;68(1):101–16. [PubMed] [Google Scholar]
Mindfulness for trauma and posttraumatic stress disorder. : Fabrizio D, editor.
editor
Clinical handbook for mindfulness.
New York: Springer; 2009: 299–317. [Google Scholar]
et al.
Exploring the effectiveness of a comprehensive mind-body intervention for medical symptom relief. J Altern Complement Med.
2010;16(2):187–92. [PubMed] [Google Scholar]
et al.
Exploring the effectiveness of a modified comprehensive mind-body intervention for medical and psychologic symptom relief. Psychosomatics.
2014;55(4):386–91. [PubMed] [Google Scholar]
et al.
The development of a patient-centered program based on the relaxation response: The relaxation response resiliency program (3RP). Psychosomatics.
2012;54(2):165–74. [PubMed] [Google Scholar]
The PHQ-9: A new depression diagnostic and severity measure. Psychiatr Ann.
2002;32(9):509–21. [Google Scholar]
et al.
Measuring depressive symptoms in heart failure: Validity and reliability of the patient health questionnaire-8. Am J Crit Care.
2011;20(2):146–52. [PubMed] [Google Scholar]
et al.
A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med.
2006;166(10):1092–7. [PubMed] [Google Scholar]
A global measure of perceived stress. J Health Soc Behav.
1983;24:385–96. [PubMed] [Google Scholar]
et al.
Is general self-efficacy a universal construct? Psychometric findings from 25 countries. Eur J Psychol Assess.
2002;18(3):242–51. [Google Scholar]
Generalized self-efficacy scale. : Weinman J, Wright S, Johnston M, editors.
editors
Measures in health psychology: A user’s portfolio. Causal and control beliefs.
Windsor, UK: NFER-Nelson; 1995: 35–7. [Google Scholar]
Development and psychometric evaluation of the resilience scale. J Nurs Meas.
1993;1(2):165–78. [PubMed] [Google Scholar]
Time-driven battlemind psychological debriefing: a group-level early intervention in combat. Mil Med.
2004;174(1):21–8. [PubMed] [Google Scholar]
Overview of outcome data of potential mediation training for soldier resilience. Mil Med.
2011; 176(11):1232–42. [PubMed] [Google Scholar]
Resilience in the context of chronic stress and health in adults. Soc Pers Psychol Compass.
2011; 5(9):634–52. [PMC free article] [PubMed] [Google Scholar]