Can a Novel Algorithmic Approach Operationalise the Management of Depression & Anxiety for Primary Care?

Research Paper Title

Effects of Brief Depression and Anxiety Management Training on a US Army Division’s Primary Care Providers.


There is a nation-wide gap between the prevalence of mental illness and the availability of psychiatrists. This places reliance on primary care providers (PCPs) to help meet some of these mental health needs.

Similarly, the US Army expects its PCPs to be able to manage common mental illnesses such as anxiety and depression. Therefore, PCPs must be able to close their psychiatric skills gaps via lifelong learning.


Following needs assessment of PCPs in a US Army division, the curriculum was developed. Objectives targeted pharmacological management of depression and anxiety. Behavioural intervention skills were also taught to treat insomnia.

Didactics and case-based small groups were used. A novel psychotropic decisional tool was developed and provided to learners to assist and influence their future psychiatric practice. Pre-training, immediate post-training, and 6-month assessments were done via survey to evaluate confidence and perceived changes in practice.

The curriculum was executed as a quality improvement project using the Plan, Do, Study, Act framework.


Among 35 learners, immediate confidence in selecting optimal psychotropic and perceived knowledge, skill to change the dose or type of medication, and confidence in prescribing behavioural sleep improved significantly with large effect sizes.

At 6-month follow-up, learners reported that they were more likely to adjust medications for anxiety or depression and were more likely to start a new medication for anxiety or depression because of the training with moderate effect sizes. Use and satisfaction with the psychotropic decisional tool are also reported.


The psychotropic decisional tool illustrates a novel algorithmic approach for operationalising the management of depression and anxiety.

Similar approaches can improve the skills of a variety of PCPs in the management of psychiatric disorders.

Further studies in the military operational setting are needed to assess the effects of similar educational interventions on access to behavioural health care, suicidal behaviours, and unit medical readiness.


Amin, R. & Thomas, M.A. (2020) Effects of Brief Depression and Anxiety Management Training on a US Army Division’s Primary Care Providers. Military Medicine. doi: 10.1093/milmed/usz443. Online ahead of print.

Let There Be Light (1946)


Let There Be Light (1946) – known to the US Army as PMF 5019 – is a documentary film directed by American filmmaker John Huston.

Intended to educate the public about posttraumatic stress disorder and its treatment among returning veterans, the film’s unscripted presentation of mental disability led to Let There Be Light being suppressed by the US government; it was not released until the 1980’s.

It is featured in the docuseries “Five Came Back“.

Outline (Background)

As the US Army was demobilising near the end of World War II it had the task of reintegrating returning military veterans back into peacetime society.

An obstacle veterans faced was the stigma surrounding “shell shock” or “psychoneurosis”, the old terms for posttraumatic stress disorder.

To convince the public, and especially employers, that veterans being treated for battle-induced mental instability were completely normal after psychiatric treatment, on 25 June 1945, the Army Signal Corps tasked Major John Huston with producing the documentary The Returning Psychoneurotics.

Huston visited multiple Army hospitals on the East and West Coasts before deciding upon Mason General Hospital on Brentwood, Long Island. The reasons being that Mason General was the biggest mental health facility on the East Coast, the hospital was located near the Army motion picture production center at Astoria Studio in Queens, New York, and the doctors were very open and receptive to the filming and any psychiatric questions he had.

The new title that Huston gave the film, Let There Be Light, was a reference to Genesis 1:3 of the King James Version of the Bible. This was an allusion to the documentary revealing truths that were previously concealed as too frightening or shameful for acknowledgement.

Outline (Documentary)

The film begins with an introduction, stating that 20% of wartime casualties are of a psychiatric nature.

Veterans are transported from a medical ship to Mason General Hospital to be treated for mental conditions brought about by war.

A group of seventy-five US service members – recent combat veterans suffering from various “nervous conditions” including psychoneurosis, battle neurosis, conversion disorder, amnesia, severe stammering, and anxiety states – arrive at the facility. They are brought into a room and told by an admissions officer to not be alarmed by the cameras, which will make a photographic record of their progress.

Next are scenes of interviews between a doctor and some of the patients about their problems and circumstances leading to that point. Afterwards, various treatment methods are employed to cure them.

Treatments depicted include narcosynthesis, hypnosis, group psychotherapy, music therapy, and work therapy. One soldier who had amnesia was hypnotised to remember the trauma of the Japanese bombings on Okinawa and his life before then. Another is given an intravenous injection of sodium amytal to induce a hypnotic state, curing him of his mental inability to walk.

The treatments are followed by classes (designed to reintegrate patients into civilian life) and group therapy sessions. Therapists make a point of reassuring the patients that there is nothing to be ashamed of for receiving treatment for their mental conditions, and that civilians subjected to the same stresses would develop the same conditions.

At this point the documentary shifts the tone to a sense of normalcy, with the soldiers performing regular activities and complaining about everyday problems.

The film ends with a number of the featured patients participating in a ceremony in which they are discharged, not just from the hospital, but from military service, and returned to civilian life.

Production & Filming Details

  • Narrator(s): Walter Huston.
  • Director(s): John Huston.
  • Producer(s): John Huston and US Army Pictorial Service.
  • Writer(s): John Huston and Charles Kaufman.
  • Music: Dimitri Tiomkin.
  • Cinematography: Stanley Cortez, John Doran, Lloyd Fromm, Joseph Jackman, and George Smith.
  • Editor(s): William H. Reynolds and Genre Fowler Jr.
  • Distributor(s): US Army.
  • Release Date: 1946.
  • Running Time: 58 minutes.
  • Country: US.
  • Language: English.

Suicidal Ideation: Linking the Role of Major Depressive Disorder & Noncombat Trauma

Research Paper Title

Factors Associated With Suicide Ideation in US Army Soldiers During Deployment in Afghanistan.


Understanding suicide ideation (SI) during combat deployment can inform prevention and treatment during and after deployment.

Therefore the purpose of this study was to examine associations of sociodemographic characteristics, lifetime and past-year stressors, and mental disorders with 30-day SI among a representative sample of US Army soldiers deployed in Afghanistan.


In this survey study, soldiers deployed to Afghanistan completed self-administered questionnaires in July 2012. The sample was weighted to represent all 87 032 soldiers serving in Afghanistan. Prevalence of lifetime, past-year, and 30-day SI and mental disorders was determined. Logistic regression analyses examined risk factors associated with SI. Data analyses for this study were conducted between August 2018 and August 2019.

The main outcomes and measures were suicide ideation, lifetime and 12-month stressors, and mental disorders were assessed with questionnaires. Administrative records identified sociodemographic characteristics and suicide attempts.


A total of 3,957 soldiers (3473 [weighted 87.5%] male; 2135 [weighted 52.6%] aged ≤29 years) completed self-administered questionnaires during their deployment in Afghanistan.

Lifetime, past-year, and 30-day SI prevalence estimates were 11.7%, 3.0%, and 1.9%, respectively. Among soldiers with SI, 44.2% had major depressive disorder (MDD) and 19.3% had posttraumatic stress disorder in the past 30-day period.

A series of analyses of the 23 grouped variables potentially associated with SI resulted in a final model of sex; race/ethnicity; lifetime noncombat trauma; past 12-month relationship problems, legal problems, and death or illness of a friend or family member; and MDD.

In this final multi-variable model, white race/ethnicity (odds ratio [OR], 3.1 [95% CI, 1.8-5.1]), lifetime noncombat trauma (OR, 2.1 [95% CI, 1.1-4.0]), and MDD (past 30 days: OR, 31.8 [95% CI, 15.0-67.7]; before past 30 days: OR, 4.9 [95% CI, 2.5-9.6]) were associated with SI.

Among the 85 soldiers with past 30-day SI, from survey administration through 12 months after returning from deployment, 6% (5 participants) had a documented suicide attempt vs 0.14% (6 participants) of the 3872 soldiers without SI.


This study suggests that major depressive disorder and noncombat trauma are important factors in identifying SI risk during combat deployment.


Ursano, R.J., Mash, H.B.H., Kessler, R.C., Naifeh, J.A., Fullerton, C.S., Aliaga, P.A., Stokes, C.M., Wynn, G.H., Ng, T.H.H., Dinh, H.M., Gonzalez, O.I., Zaslavsky, A.M., Sampson, N.A., Kao, T-C., Heeringa, S.G., Nock, M.K. & Stein, M.B. (2020) Factors Associated With Suicide Ideation in US Army Soldiers During Deployment in Afghanistan. JAMA Network Open. 3(1):e1919935. doi: 10.1001/jamanetworkopen.2019.19935.

Do PTSD, TBI & Sleep Distrubances affect Military Performance Individually or in Combination?

Research Paper Title

Posttraumatic Stress Disorder, Traumatic Brain Injury, Sleep, and Performance in Military Personnel.


Sleep disturbances, post-traumatic stress disorder, and traumatic brain injury are highly prevalent in military personnel and veterans.

These disorders can negatively impact military performance.

Although literature evaluating how post-traumatic stress disorder and traumatic brain injury directly impact military performance is limited, there is evidence supporting that these disorders negatively impact cognitive and social functioning.

What is not clear is if impaired performance results from these entities individually, or a combination of each.

Further research using standardised evaluations for the clinical disorders and metrics of military performance is required to assess the overall performance decrements related to these disorders.


Moore, B.A., Borck, M.S., Brager, A., Collen, J., LoPresti, M. & Mysliwiec, V. (2020) Posttraumatic Stress Disorder, Traumatic Brain Injury, Sleep, and Performance in Military Personnel. Sleep Medicine Clinics. 15(1), pp.87-100. doi: 10.1016/j.jsmc.2019.11.004. Epub 2020 Jan 8.

Can Acupressure Reduce Soldiers’ Anxiety in Stressful Situations?

Research Paper Title

Effects of Acupressure at the P6 and LI4 Points on the Anxiety Level of Soldiers in the Iranian Military.


Military service is a stressful environment. Methods to reduce stress may result in the mental health promotion of military forces.

There are various methods for relieving anxiety. Acupressure is one of them.

Hence, this study was carried out to explore effects of acupressure at the P6 and LI4 acupressure points on the anxiety level of army soldiers.


A randomised double-blind design was undertaken. A total of 120 Iranian army soldiers were randomly assigned to three groups, namely P6, LI4 and control. The P6 and LI4 acupressure points are effective in lowering the anxiety level.

In the intervention groups, acupressure was applied at the P6 and LI4 points three times for 10 min at 30 min intervals. In the control group, the thumb pad, which is not an acupressure point, was pressed.

The anxiety level of the subjects was measured before the intervention and 30 min after the last intervention. The instruments included a demographics questionnaire and the State-Trait Anxiety Inventory.


There was no significant difference between the three groups with respect to the anxiety level in the preintervention phase. However, the mean anxiety score in the P6 group decreased significantly from 53.35±9.7 to 49.02±9.3 (p=0.005).

The mean anxiety score in the LI4 group also decreased significantly from 53.37±8.39 to 45.47±8.16 (p<0.001).

In the control group, there was no significant difference between the preintervention and postintervention phases (p=0.16).

In the postintervention phase, the analysis of variance test showed a significant difference between the three groups in terms of the anxiety level (p=0.04).


Acupressure can reduce soldiers’ anxiety at the acupressure points, especially at the LI4 point.

It is recommended that this simple and cost-effective intervention be used to relieve soldiers’ anxiety in stressful situations.


Rarani, S.A., Rajai, N. & Sharififar, S. (2020) Effects of Acupressure at the P6 and LI4 Points on the Anxiety Level of Soldiers in the Iranian Military. BMJ Military Health. doi: 10.1136/jramc-2019-001332. Online ahead of print.

Are Soldiers-in-training Likely to Seek Help when Experiencing a Problem?

Research Paper Title

Identifying Risk and Resilience Factors Associated With the Likelihood of Seeking Mental Health Care Among U.S. Army Soldiers-in-Training


The Department of Defence aims to maintain mission readiness of its service members. Therefore, it is important to understand factors associated with treatment seeking in order to identify areas of prevention and intervention early in a soldier’s career that can promote positive functioning and increase their likelihood of seeking mental health care when necessary.


Using a theory of planned behaviour lens, this study identified potential barriers (risk) and facilitators (resilience) to treatment seeking among 24,717 soldiers-in-training who participated in the New Soldiers Study component of the “Army Study to Assess Risk and Resilience in Servicemembers” (Army STARRS). Hierarchal linear regression modelling and independent samples t-tests were used to examine associations between demographics and study variables, intersections of risk and resilience, and to explore differences in the likelihood of seeking help based on mental health diagnoses.


A four-stage hierarchical linear regression was conducted, using likelihood of help-seeking as the dependent variable, to identify the most salient factors related to help-seeking. “Step one” of the analysis revealed soldiers-in-training who identified as female, Hispanic or Other ethnicity, and married, divorced, or separated reported a greater likelihood of seeking help. “Step two” of the analysis indicated soldiers-in-training with a history of sexual trauma, experience of impaired parenting, and clinical levels of mental health symptomatology (anxiety, depression, PTSD) reported a greater likelihood of seeking help.

Inversely, soldiers-in-training with a history of emotional trauma and parental absence/separation reported a lower likelihood of seeking help. “Step three” of the analysis demonstrated soldiers-in-training with a prior history of seeking help and larger social networks had a greater likelihood of seeking help. “Step four” of the analysis revealed several interactive effects between risk and resilience factors.

Specifically, soldiers-in-training who reported greater depressive symptomatology in combination with prior history of treatment seeking reported a greater likelihood of help seeking, whereas soldiers-in-training who reported prior sexual trauma and PTSD in combination with large social networks reported a lower likelihood of seeking help. Finally, a greater percentage of soldiers-in-training with clinical levels of anxiety, depression, and PTSD indicated they would likely seek help in comparison to soldiers-in-training without clinical symptoms.


Findings suggest few soldiers-in-training are likely to seek help when experiencing a problem. General efforts to encourage help-seeking when needed are warranted with particular focus on subsets of soldiers-in-training (e.g., men, those with a history of some adverse childhood experiences).

Strengths of this study include the examination of a large sample of soldiers-in-training to identify possible leverage points for early intervention or prevention prior to entering stressful military operating environments.

Limitations of this study include the examination of only one military branch and exclusion of soldiers not “in-training.”

Future studies could consider replicating the current study using a sample of military personnel longitudinally to track behavioral trends as well as looking at military populations outside of basic combat training.


Duncan, J.M., Reed-Fitzke, K., Ferraro, A.J., Wojciak, A.S., Smith, K.M. & Sanchez, K. (2020) Identifying Risk and Resilience Factors Associated With the Likelihood of Seeking Mental Health Care Among U.S. Army Soldiers-in-Training. Military Medicine. doi: 10.1093/milmed/usz483. Online ahead of print.

What is the Role of Combat Exposure & Malevolent Environments in Mental Health?

Research Paper Title

Do different types of war stressors have independent relations with mental health? Findings from the Korean Vietnam Veterans Study.


South Korea had the second largest contingent of soldiers in the Vietnam War, but little is known about their adaptation, especially in later life.

Previous work in a different sample found very high rates of post-traumatic stress disorder (PTSD; 41%) among Korean Vietnam veterans (KVVs; Kang, Kim, & Lee, 2014), compared to 19-31% for American Vietnam veterans.

The researchers explored possible reasons for this high rate of PTSD, as well as anxiety and depressive symptoms, utilising both vulnerability factors (e.g., war stressors) and protective factors (optimism, unit cohesion, and homecoming experiences).


The sample included 367 male KVVs surveyed by mail (M age = 72, SD = 2.66).

Using hierarchical regressions controlling for demographics, the researchers examined the relative contributions of different types of war stressors and then the protective factors.


Combat exposure was significantly associated with the three types of negative psychological symptoms, but their associations became non-significant when “subjective” war stressors (malevolent environments, perceived threat, and moral injury) were added.

In the final models, malevolent environments were the strongest predictor for all three outcomes.

In addition, moral injury was independently associated with PTSD symptoms, while perceived threat was marginally associated with depressive and anxiety symptoms.

Among psychosocial factors, only optimism was negatively associated with the mental health outcomes.


KVVs had very high rates of combat exposure, but malevolent environments played a more important role in their mental health in later life.

These findings suggest the importance of considering adverse environmental factors in understanding PTSD in future studies.


Lee, H., Aldwin, C.M. & Kang, S. (2020) Do different types of war stressors have independent relations with mental health? Findings from the Korean Vietnam Veterans Study. Psychological Trauma: Theory, Research, Practice, and Policy. doi: 10.1037/tra0000557. [Epub ahead of print].

Can Adverse Childhood Experiences have an Affect on Mental Health Outcomes through Disrupted Sleep?

Research Paper Title

Sleep disturbance mediates the association of adverse childhood experiences with mental health symptoms and functional impairment in US soldiers.


Adverse childhood experiences (ACEs) can have long-term impacts on a person’s mental health, which extend into adulthood.

There is a high prevalence of ACEs among service members.

Further, service members also report frequently experiencing disrupted sleep.


The researchers hypothesised that disrupted sleep may serve a mechanistic function connecting ACEs to functional impairment and poorer mental health.


In a cross-sectional sample (n = 759), the researchers found evidence for an indirect effect of ACEs on mental health outcomes through disrupted sleep.

In a different sample using two time-points (n = 410), they found evidence for an indirect effect of ACEs on changes in mental health outcomes and functional impairment during a reset period, through changes in disrupted sleep during the same period.


Implications, limitations and future research directions are discussed.


Conway, M.A., Cabrera, O.A., Clarke-Walper, K., Dretsch, M.N., Holzinger, J.B., Riviere, L.A. & Quartana, P.J. (2020) Sleep disturbance mediates the association of adverse childhood experiences with mental health symptoms and functional impairment in US soldiers. Journal of Sleep Research. e13026. doi: 10.1111/jsr.13026. [Epub ahead of print].

Are there Differences in Sources of Help & Barriers to Care in Deployed vs. Post-Deployment Environments?

Research Paper Title

Mental Health Service Utilization and Perceived Barriers to Receiving Care in Deployed Soldiers.


Scant research has examined mental health treatment utilisation and barriers to care in deployed US soldiers.

This study aims to assess mental health treatment utilisation in deployed soldiers, including providers used and barriers to care.


US Army soldiers (n = 2,412) in a combat environment were surveyed on psychiatric symptoms, mental health help received, sources of care, and perceived barriers to care by Mental Health Advisory teams from 2009 to 2013.


Of the 25% of soldiers at mental health risk, 37% received mental health help, with 18% receiving help from a provider. Non-provider sources of care were utilised significantly more frequently than providers.

Soldiers at mental health risk reported significantly greater anticipated career-related stigma, organisational barriers to care, self-reliance views, and negative attitudes toward care, yet these constructs did not differ between who did or did not receive help.

Soldiers who received help from providers exclusively reported significantly more anticipated career-related stigma and fewer organisational barriers to care than those that received no help.

Soldiers who spent no time living outside the forward operating base and soldiers with six or more types of combat exposures were more likely to receive help.


Prevalence of common psychopathology and receipt of care in a combat environment was similar to previous reports from post-deployment settings.

Non-provider sources of care were more frequently utilised as compared to an in-Garrison report.

Findings suggest important differences exist in sources of help and barriers to care in deployed vs. post-deployment environments.

The hypothesised barriers to care did not preclude receiving any help, however, less than one-half of soldiers at mental health risk received help.

Thus, future research should identify factors that have the greatest influence on help seeking behaviour in both deployed and Garrison settings.


Nugent, K.L., Riviere, L.A., Sipos, M.L. & Wilk, J.E. (2020) Mental Health Service Utilization and Perceived Barriers to Receiving Care in Deployed Soldiers. Military Medicine. pii: usaa019. doi: 10.1093/milmed/usaa019. [Epub ahead of print].

PTSD & Korean War Veterans

Research Paper Title

Aging and Trauma: Post Traumatic Stress Disorder Among Korean War Veterans.


Having experienced posttraumatic stress disorder 30 years prior to its recognition as a formal disorder, Korean War veterans are now an ageing population that requires unique clinical management.

The Korean War lasted from 25 June 1950 through 27 July 1953. Although many veterans of the Korean War experienced traumas during extremely stressful combat conditions. However, they would not have been diagnosed with post-traumatic stress disorder (PTSD) at the time because the latter did not exist as a formal diagnosis until the publication of the third edition of the Diagnostic and Statistical Manual (DSM) in 1980. Prior to 1980, psychiatric syndromes resulting from war and combat exposure where known by numerous other terms including shell shock, chronic traumatic war neurosis, and combat fatigue/combat exhaustion. Military psychiatrists attended to combat fatigue during the course of the Korean War, but as was true of World War I and II, the focus was on returning soldiers to duty. Combat fatigue was generally viewed as a transient condition.

Although now octo- and nonagenarians, in 2019 there are 1.2 million living Korean War veterans in the US, representing 6.7% of all current veterans. Understanding their war experiences and the nature of their current and past presentation of PTSD is relevant not only in formal mental health settings, but in primary care settings, including home-based primary care, as well as community living centres, skilled nursing facilities and assisted living facilities. Older adults with PTSD often present with somatic concerns rather than spontaneously reporting mental health symptoms. Beyond the short-term clinical management of Korean War veterans with PTSD, consideration of their experiences also has long-term relevance for the appropriate treatment of other veteran cohorts as they age in coming decades.

The purpose of this article is to provide a clinically focused overview of PTSD in Korean War veterans, to help promote understanding of this often-forgotten group of veterans, and to foster optimised personalised care. This overview will include a description of the Korean War veteran population and the Korean War itself, the manifestations and identification of PTSD among Korean War veterans, and treatment approaches using evidence-based psychotherapies and pharmacotherapies. Finally, the researches provide recommendations for future research to address present empirical gaps in the understanding and treatment of Korean War veterans with PTSD.


Palmer, B.W., Friend, S., Huege, S., Mulvaney, M., Badawood, A., Almaghraby, A. & Lohr, J.B. (2019) Aging and Trauma: Post Traumatic Stress Disorder Among Korean War Veterans. Federal Practitioner. 36(12), pp.554-562.