100
Views
0
CrossRef citations to date
0
Altmetric
REVIEW

Preventing and Mitigating Post-Traumatic Stress: A Scoping Review of Resilience Interventions for Military Personnel in Pre Deployment

ORCID Icon, ORCID Icon, , , , , & show all
Pages 2377-2389 | Received 11 Jan 2024, Accepted 08 Jun 2024, Published online: 17 Jun 2024

Abstract

Purpose

Resilience is considered as a protective factor that can assist individuals to reduce post-traumatic stress reactions. In recent years, armies in many countries have widely implemented resilience training programs before deployment to prevent or reduce post-deployment combat stress reactions. Therefore, this study aims to review what is known about resilience interventions for military personnel in pre deployment.

Methods

Based on Arskey and O’Malley’s framework, a scoping review was completed. This review was performed through searching databases including PubMed, Embase, Web of Science, Medline and the Cochrane Library, and screening literature to extract data, finally summarizing the findings.

Results

A total of 25 studies focusing on resilience interventions for military personnel in pre deployment were involved and analyzed using intervention approaches, outcome measures, intervention effects, and so on.

Conclusion

Based on the existing evidence in this review, it is cautiously believed that the resilience intervention program for military personnel before deployment is effective. However, there is no single effective best method even the same type intervention can make different effects in different situations and populations. Therefore, the population differences and context should be fully considered in constructing and implementing program to build military personnel resilience.

Introduction

Modern military operations are characterized by their particularity, complexity, and uncertainty. Therefore, military personnel usually face a variety of stressors, including live ammunition, bloody terror, disability, and death. Excessive stress can lead to serious mental disorders and cognitive impairment, manifesting as anxiety, fear, suicide or homicide, lack of attention, and loss of behavioral control. Finally, non-combat attrition may appear.Citation1,Citation2 Two longitudinal studies on veterans of Operational Iraqi Freedom (OIF) and Operational Enduring Freedom (OEF) have indicated that the incidence of posttraumatic stress disorder (PTSD) is 2 to 3 times higher among those exposed to combat relative to those who did not report significant combat exposure.Citation3,Citation4

Large-scale non-combat attrition significantly affects the ability and efficiency of troops to carry out diversified military tasks, lowering overall combat effectiveness and increasing the economic burden of the military’s health care system. The US military healthcare system spends $3.1 billion annually on treatment for PTSD alone, depression alone, and comorbid PTSD and depression.Citation5

Prophylactic intensive training targeting protective factors of traumatic stress has been found to lower the incidence and severity of post-traumatic reactions.Citation6,Citation7 Resilience, the ability to resist, adapt, recover, and grow from challenges,Citation8 is currently recognized as a protective factor in post-traumatic stress response.Citation9 Multiple studies have revealed that individuals with higher resilience have a more stable emotional state and mental health when experiencing stressful events,Citation10–12 develop lower stress levels, and are better capable of dealing with challenges and complete tasks.

In a longitudinal study performed by the Canadian Forces,Citation13 it was found that post-deployment individuals’ resilience was higher than that of undeployed individuals at baseline, and deployment experience significantly improved the resilience of some military personnel. Therefore, it is suggested that stress stimulation may positively impact resilience, providing a feasible basis for resilience training strategies.

Realizing the importance of resilience, the US Department of Defense conducted extensive research on measuring and nurturing resilience and launched the Resilience Program in 2007.Citation14,Citation15 This program aims to transform disease-focused care models within the military into a mental health-focused prevention model. Then, various branches of the US military proposed a series of programs to improve the resilience of military personnel, including the Comprehensive Soldier Fitness (CSF), the Air Force Resilience Training (ART), the Operational Stress Control (OSC), the Naval Operational Stress Control (OSC), and the Marine Corps Combat Operations Stress Control (COSC) program.Citation16 Many countries around the world have widely taken resilience training as a preventive program rather than a medical program, such as the US military’s Master Resilience Training (MRT),Citation17 and the British Army’s Traumatic Risk Management, TRiM.Citation18

Unfortunately, many of these programs have not been empirically evaluated prior to implementation,Citation19 and some resilience-building programs may exert little or no positive impact on mental health outcomes for military personnel, with interventions diminishing over time.Citation20,Citation21 Based on a systematic review,Citation22 Skeffington et al discovered that no high-quality randomized controlled study confirmed the effectiveness of PTSD prevention strategies in 2013. However, a study by the Irish Defence Forces showed that an effective resilience intervention plan was necessary before deployment.Citation23 Hourani et alCitation24 surveyed resilience interventions undertaken by forces in the United States, the United Kingdom, and the United Nations, concluding that pre-traumatic exposure strategies and stress reduction training methods were the most promising ways to prevent PTSD in 2011. Leppin et alCitation25 reported that resiliency training programs had a small to moderate impact on enhancing resilience and other mental health outcomes within three months of follow-up in 2014, while the research subjects did not include active military personnel. A recent meta-analysis on randomized controlled trials of resilience interventions for military personnel and emergency responders suggests that cognitive-behavioral interventions and mindfulness training can enhance the resilience of military personnel in pre deployment.Citation26

This study aims to review what is known about resilience interventions for military personnel in pre deployment. Using a scoping approach, the intervention of building military resilience can be discussed and elucidated, which is beneficial for understanding how to enhance resilience and formulate effective military personnel resilience intervention programs. It is of great significance for promoting the resilience building of military personnel, preventing and alleviating post-traumatic stress response, lowering the adverse consequences of post-traumatic stress and strengthening the overall combat effectiveness of troops in future studies.

Materials and Methods

This scoping review was based on the scope review framework proposed by Arksey et alCitation27 and the scope review guidelines issued by Peters et alCitation28 The stages are shown below:

  1. Identifying questions

  2. Identifying studies

  3. Selecting studies

  4. Extracting data

  5. Collating, summarizing, and reporting results

Stage1: Identifying Questions

This scoping review was performed to deal with the following questions:

  1. What resilience interventions are available for pre deployment military personnel?

  2. Which concepts do these interventions use and what theories do they depend on?

  3. What are the characteristics, purposes and contents of these resilience interventions?

  4. What are the (main) outcomes and effects of these resilience interventions?

Stage 2: Identifying Studies

A systematic search was performed between November 2023 and March 2024. Five databases, namely PubMed, Embase, Web of Science, Medline and the Cochrane Library, were chosen. In terms of each database, there was a detailed research string combining the term “military personnel” or “military” or “army” or “soldier” or “national guard” or “marines” or “navy” or “airforce” or “pilots” or “airman” or “armed forces” or “coastguard” or “sailor” or “submariner” and “Resilience” or “psychological, adaptation” or “psychological, stress” or “psychological, adjustment” or “stress” or “adjustment disorders”. The search was performed within titles, abstracts, and keywords. Furthermore, an additional search was made by snowballing the reference lists of retrieved literature.

Two review authors independently assessed the titles and abstracts of studies which were identified by the literature search following the predefined inclusion criteria. We resolved any disagreement through consensus or, if necessary, by consultation with a third review author. If necessary, the original study author was contacted by Email or telephone to acquire uncertain but vital information for the present study. A total of 1645 papers were retrieved (772 PubMed, 206 Embase, 595 Web of Science, 9 Medline, and 63 The Cochrane Library). Among them, 421 repetitive papers were removed, while 105 studies were included after reading the title and abstract. Finally, 25 studies were involved after reading the full text.

Inclusion Criteria

  1. Participants: military personnel of all services and arms, including the National Guard Force and the reserve service.

  2. Intervention Characteristics: any specifically resilience-based intervention, irrespective of content, duration, setting, or delivery media in pre deployment.

  3. Outcome Measures: resilience (measured with specific resilience scales) and resilience related indicators in mental health, physical health, psychological functioning, and work performance.

  4. Study Design: randomized controlled trials (RCTs), cluster-RCTs, cross-over trials, Quasi-RCTs, and controlled trials.

  5. Published in English and peer-reviewed

Exclusion Criteria

  1. Studies evaluating treatment interventions for established psychological illness.

  2. Unable to get full text.

Stage 4: Extracting Data

Selected data were tabulated. Extracted information includes the first author, publication year, location, study design, duration of intervention, sample size and pertinent outcomes (see ).

Table 1 Characteristics of Included Studies

Stage 5: Collating, Summarizing, and Reporting Results

Types of Interventions

Cognitive–behavioral therapy-based interventions were performed in six studies; seven studies adopted mindfulness and relaxation-based training; two studies were concentrated on stress inoculation training; four studies used biofeedback-based programmes; two studies applied neuropsychological-based programmes; two studies used psychoeducational-based programmes, and in the final two studies, family-centered resilience interventions were performed (See for a brief description of each intervention).

Table 2 A Brief Description of Interventions

Effects of Interventions

Cognitive–Behavioral Therapy-Based Interventions

Cognitive Behavior Therapy (CBT) is a psychological intervention to change or reconstruct negative cognition through cognitive and behavioral techniques. The core of CBT is to change irrational negative beliefs and thoughts, which can thus alter an individual’s psychology and behavior.Citation53

Cacioppo et alCitation31 reported significant improvements in military hardiness, military environment tolerance, loneliness, empathy, and compassion after the SRT. Similarly, Chongruksa et alCitation32 considered that the Rangers’ resilience scale (CD-RISC) score was dramatically higher than that of the control group after Integrated Group Counselling (IGC). However, this intervention program adopted Buddhist concepts and may not apply to groups of other religious or cultural beliefs. Cohn and PakenhamCitation33 found that the intervention group reported less self-blame, better perceived coping, greater positive states of mind and lower psychological distress than the control group at the end of the brief cognitive–behavioral program. Fornette et alCitation35 discovered that cognitive adaptation training changed their stress management practices, while no differences existed in mood and anxiety between the intervention group and the control group. Regula et alCitation47 indicated that cortisol increased in both resilience training (RT) and diversity management (DMT) groups during stress, while there was a slighter cortisol increase in the RT group thereafter. The RT group perceived the military stressor as more challenging, exhibiting higher values in motivation and exerting positive impacts than the DMT group. Williams et alCitation51 pointed out that BOOTSTRAP Recipients were more likely to develop significantly higher cohesion, better perceived problem-solving strategies and social support, and had less anger-based coping strategies than controls.

Mindfulness-and Relaxation-Based Training

Mindfulness refers to focusing on the present moment while paying attention to observing, and describing feelings, thoughts, and sensations. It is a protective factor for physical and mental health.Citation54 In 1979, Kabat-Zinn proposed mindfulness-based stress reduction therapy and pioneered mindfulness training in the medical community.Citation55

Crane et alCitation34 discovered that relative to the control group, participants in the self-reflection group had improvements in mental health outcomes on depression, anxiety symptoms, and perceived stressor frequency at longer-term follow-up. Nevertheless, no difference was found in depression symptoms at initial follow-up. Fikretoglu et alCitation21 conducted a mindfulness-based program, named the Road to Mental Readiness (R2MR), with Canadian military recruits. Then, it was found that no difference existed in levels of depression and resilience at a five-week follow-up or at a nine-week follow-up. Jha et alCitation38 pointed out that marines receiving greater Mindfulness-Based Mind Fitness Training (MMFT) experienced lower levels of negative emotion and higher levels of positive emotion. Johnson et alCitation39 discovered that recipients exhibited greater reactivity (heart rate), enhanced recovery (heart rate), breathing rate after stressful training and lower plasma neuropeptide Y concentration after MMFT. Meland et alCitation45 considered that reductions in somatic anxiety associated with performance occurred, and improvements in self-perceived skills related to mindfulness, attention regulation and arousal regulation were observed after mindfulness training. Taylor et alCitation49 reported that psychological skill training (PST) did not notably lower symptoms of post traumatic stress versus a control condition; there existed a reduction in symptoms of post traumatic stress at 24 hours, 1 month, and 3 months after completing training. Nevertheless, the difference in recovery between intervention and control was not significant. Stanley et alCitation48 carried out MMFT with Marine Corps, and confirmed that spending more time in engaging in MMFT corresponded with greater self-reported mindfulness, and that increases in mindfulness were related to reductions in perceived stress.

Stress Inoculation Training

Stress Inoculation Training (SIT) refers to a psychological training model that aims to provide a form of vaccination-like immunity against possible future stressors. The idea is that early exposure to stressful events of a certain intensity can prevent future negative stress effects.Citation56 SIT, proposed by Meichenbaum in 1985, is a three-stage model, including the concept stage, skill acquisition and consolidation stage, and application and follow-through stage. It mainly involves cognitive restructuring, relaxation training, self-guidance, and self-monitoring, and is used to improve negative emotions, enhance stress resistance, and prevent post-traumatic stress disorder.Citation57

Hourani et alCitation36 in 2016 reported that Pre-Deployment Stress Inoculation Training (PRESIT) was not successful at lowering PTSD diagnosis and self-reported Perceived Stress Scale (PSS) scores compared to the control condition. However, when baseline mental health issues were controlled, participants in the control condition were at 6.9 times the risk of a diagnosis of PTSD compared with the intervention group. Nevertheless, Hourani et alCitation37 in 2017 mentioned that PRESIT was not efficient in lowering the number of subsequent clinical diagnosis and symptoms of PTSD and the score on the PSS.

Biofeedback-Based Programmes

Biofeedback involves using electrical mechanical equipment for measuring physiologic processes occurring in a person and subsequently feeding this information back to them with the purpose of developing a greater awareness and capability of controlling changes within their bodies.Citation58

Bouchard et alCitation30 considered that the participants in the biofeedback-assisted management training group were less stressed than control group members in stressful first-aid simulation. Additionally, the intervention group had greater anticipated self efficacy than the control group participants. Lewis et alCitation44 indicated that symptoms of post traumatic stress were not significantly decreased by their predeployment stress inoculation training (PRESTINT) compared to controls, while experimental subjects showed greater heart rate variability (HRV) during a post-training combat simulation. HRV is considered a protective factor for reducing traumatic stress.Citation59 Pyne et alCitation46 believed that no observable overall effect of the “heart rate variability biofeedback” program was found on post-deployment symptoms of post traumatic stress, and there was no obvious difference between intervention and the control arms at 12-month post-deployment. Wessemann et alCitation51 conducted Chaos Driven Situations Management Retrieval Systems (CHARLY) programme with German military medical personnel. The CHARLY group exhibited a significantly lower level of traumatic stress on the PDS scale following deployment relative to the control group.

Neuropsychological-Based Programmes

Keynan et alCitation41 revealed the specificity of neurofeedback learning to the targeted amygdala electrical fingerprint (Amyg-EFP) signal, resulting in reduced alexithymia and faster emotional stroop. This suggested better stress coping skills following Amyg-EFP-NF relative to controls. Wald et alCitation50 conducted attention bias modification training (ABMT) which is an intervention method, where a pre-designed processing mode is used to directly manipulate attentional bias through task scenarios,Citation60 and they reported four sessions of ABMT reduced risk for PTSD associated with the no-training condition. In addition, no other between-group differences were found.

Psychoeducational-Based Programmes

Adler et alCitation29 considered that there existed no obvious differences between conditions concerning depression symptoms, anxiety symptoms, or sleep problems, and resilience training was rated as less useful than military history classes by participants. Jones et alCitation40 reported that levels of PTSD, common mental disorder symptoms, alcohol misuse, help-seeking and homesickness were not of significant difference between groups at post intervention or at three-month follow-up.

Family-Centered Resilience Interventions

Family and social support is a protective factor of resilience.Citation61 The Mental Health Task Force of the US Department of Defense recognizes that maintaining the overall combat effectiveness of the force requires support for the resilience of military personnel and their families. In 2008, the US Marine Corps launched the Families Overcoming Under Stress (FOCUS) project, enhancing communication and understanding among family members through structured narrative to cultivate family resilience and cohesion.Citation62 Lester et alCitation42 conducted the FOCUS project, and the results indicated that the parents who participated in the project had significantly lower stress, anxiety, depression index, and Family Assessment Device (FAD) unhealthy family function score. In addition, Lester et alCitation43 also suggested that FOCUS training before deployment vastly alleviated parents’ anxiety and depression symptoms and positive coping skills, and improved the overall resilience of the family.

Conclusion and Expectation

By reviewing previous studies, it is evident that the contents and methods of resilience building for military personnel are diverse, when cognitive–behavioral therapy-based interventions, mindfulness and relaxation-based training, stress inoculation training, biofeedback-based programmes, neuropsychological-based programmes, Psychoeducational-based programmes and the family-centered resilience interventions are included. In addition, there is no single effective method; even the effects of the same resilience intervention method can vary in different situations and populations. Therefore, when constructing and implementing intervention program to build military personnel resilience, the population differences and context should be fully considered. For example, cognitive behavioral intervention methods have a certain “cultural specificity” and lack of generalizability.Citation63 Stress inoculation training should further clarify the critical values for different populations to produce learned helplessness and training effects; Besides, ABMT should select appropriate training times that can activate the reward system and reduce stress based on different populations.

Resilience is a complex, multidimensional structure. Therefore, the effectiveness of resilience interventions cannot be measured solely by the diagnosis of PTSD and other psychological disorders, and there is no “gold standard”.Citation26 Mcclung et alCitation64 provided an overview of physiological factors impacting or predicting resilience in military populations, which included physical performance, body composition, nutrition and diet quality, and biomarkers. It is no predictive value considering any single influencing factor alone for individual resilience.Citation65 Therefore, linking psychological and physiological indicators of resilience in future studies plays a vital role in forming more comprehensive assessments of resilience in military populations.

In future studies, algorithms could be developed and validated to predict PTSD by integrating various data sources, including self-report, vital signs, demographics, psychological traits, stress response, genomics, proteomics, transcriptomics, metabolomics, and epigenetics. Moreover, a multidimensional and multimodal approach across multiple systems, paths, or mechanisms could be employed to build personalized, systematic, and diversified resilience intervention programs enhancing the overall combat effectiveness of the military. The Maximal Adaptability Model predicts that when stressors progress to the extremes of hyper-stress, limits of maximal psychological and physiological adaptability may be exceeded, causing dynamic instability. Thus, we should choose and adjust the appropriate training level and training content according to psychological status and cognitive behavior monitoring of different individuals when carrying out the SIT.Citation66 For instance, a smartphone-delivered version of Skills for Life Adjustment and Resilience (SOLAR) could be implemented to manage stress and prevent PTSD.Citation67 Similarly, the Biofeedback Assisted Resilience Training (BART) digital health platform could support remote intervention and physiological and behavioral information collection.Citation68 Finally, Mcclung et alCitation64 believed that various perspectives of physical performance, nutrition, body composition, and biomarkers contribute to physiological resilience in military personnel, which can provide potential targets for future resilience intervention research.

Disclosure

The authors report no conflicts of interest in this work.

Acknowledgments

The authors thank Dr. Mi Song for her invaluable advice.

References

  • Riley E, Mitko A, Stumps A, et al. Clinically significant cognitive dysfunction in OEF/OIF/OND veterans: prevalence and clinical associations. Neuropsychology. 2019;33(4):534–546. doi:10.1037/neu0000529
  • Seal KH, Bertenthal D, Samuelson K, Maguen S, Kumar S, Vasterling JJ. Association between mild traumatic brain injury and mental health problems and self-reported cognitive dysfunction in Iraq and Afghanistan Veterans. J Rehabil Res Dev. 2016;53(2):185–198. doi:10.1682/JRRD.2014.12.0301
  • Smith TC, Ryan MA, Wingard DL, Slymen DJ, Sallis JF, Kritz-Silverstein D. New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. BMJ. 2008;336(7640):366–371. doi:10.1136/bmj.39430.638241.AE
  • LeardMann CA, Smith TC, Smith B, Wells TS, Ryan MA. Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: prospective US military cohort study. BMJ. 2009;338(2):b1273. doi:10.1136/bmj.b1273
  • Vyas KJ, Fesperman SF, Nebeker BJ, et al. Preventing PTSD and depression and reducing health care costs in the military: a call for building resilience among service members. Mil Med. 2016;181(10):1240–1247. doi:10.7205/MILMED-D-15-00585
  • Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol. 2000;68(5):748–766. doi:10.1037/0022-006X.68.5.748
  • Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull. 2003;129(1):52–73. doi:10.1037/0033-2909.129.1.52
  • Brown L, Cohen B, Costello R, Brazhnik O, Galis Z. Conceptualizing a resilience research framework at The National Institutes of Health. Stress Health. 2023;39(S1):4–9. doi:10.1002/smi.3260
  • Horn SR, Charney DS, Feder A. Understanding resilience: new approaches for preventing and treating PTSD. Exp Neurol. 2016;284(Pt B):119–132. doi:10.1016/j.expneurol.2016.07.002
  • Sefidan S, Pramstaller M, La marca R, et al. Resilience as a protective factor in basic military training, a longitudinal study of the Swiss armed forces. Int J Environ Res Public Health. 2021;19(1):18. doi:10.3390/ijerph19010018
  • Daffey-Moore E. Why is building psychological resilience relevant to UK Service personnel in order to improve military mental health? BMJ Mil Health. 2020;166(2):89–94. doi:10.1136/jramc-2018-000962
  • Nindl BC, Billing DC, Drain JR, et al. Perspectives on resilience for military readiness and preparedness: report of an international military physiology roundtable. J Sci Med Sport. 2018;21(11):1116–1124. doi:10.1016/j.jsams.2018.05.005
  • Sudom KA, Lee JE, Zamorski MA. A longitudinal pilot study of resilience in Canadian military personnel. Stress Health. 2014;30(5):377–385. doi:10.1002/smi.2614
  • Scammell J. Resilience in the workplace: personal and organisational factors. Br J Nurs. 2017;26(16):939. doi:10.12968/bjon.2017.26.16.939
  • Meredith LS, Sherbourne CD, Gaillot SJ, et al. Promoting psychological resilience in the US Military. Rand Health Q. 2011;1(2):2.
  • Bowles SV, Bates MJ. Military organizations and programs contributing to resilience building. Mil Med. 2010;175(6):382–385. doi:10.7205/MILMED-D-10-00099
  • Reivich KJ, Seligman ME, McBride S. Master resilience training in the US Army. Am Psychol. 2011;66(1):25–34. doi:10.1037/a0021897
  • Greenberg N, Langston V, Jones N. Trauma risk management (TRiM) in the UK Armed Forces. J R Army Med Corps. 2008;154(2):124–127. doi:10.1136/jramc-154-02-11
  • Polusny MA, Erbes CR. A dynamic, multilevel approach to conceptualising and designing resilience research in the context of military stress. Stress Health. 2023;39(S1):40–47. doi:10.1002/smi.3277
  • van Rooij SJH, Stevens JS, Ely TD, et al. Childhood trauma and COMT genotype interact to increase hippocampal activation in resilient individuals. Front Psychiatry. 2016;7:156. doi:10.3389/fpsyt.2016.00156
  • Fikretoglu D, Liu A, Nazarov A, Blackler K. A group randomized control trial to test the efficacy of the Road to Mental Readiness (R2MR) program among Canadian military recruits. BMC Psychiatry. 2019;19(1):326. doi:10.1186/s12888-019-2287-0
  • Skeffington PM, Rees CS, Kane R. The primary prevention of PTSD: a systematic review. J Trauma Dissociation. 2013;14(4):404–422. doi:10.1080/15299732.2012.753653
  • Doody CB, Egan J, Bogue J, Sarma KM. Military personnels’ experience of deployment: an exploration of psychological trauma, protective influences, and resilience. Psychol Trauma. 2022;14(4):545–557. doi:10.1037/tra0001114
  • Hourani LL, Council CL, Hubal RC, Strange LB. Approaches to the primary prevention of posttraumatic stress disorder in the military: a review of the stress control literature. Mil Med. 2011;176(7):721–730. doi:10.7205/MILMED-D-09-00227
  • Leppin AL, Bora PR, Tilburt JC, et al. The efficacy of resiliency training programs: a systematic review and meta-analysis of randomized trials. PLoS One. 2014;9(10):e111420. doi:10.1371/journal.pone.0111420
  • Doody CB, Robertson L, Cox KM, Bogue J, Egan J, Sarma KM. Pre-deployment programmes for building resilience in military and frontline emergency service personnel. Cochrane Database Syst Rev. 2021;12(12):Cd013242. doi:10.1002/14651858.CD013242.pub2
  • Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32. doi:10.1080/1364557032000119616
  • Peters MDJ, Marnie C, Tricco AC, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Implement. 2021;19(1):3–10. doi:10.1097/XEB.0000000000000277
  • Adler AB, Williams J, McGurk D, Moss A, Bliese PD. Resilience training with soldiers during basic combat training: randomisation by platoon. Appl Psychol Health Well Being. 2015;7(1):85–107. doi:10.1111/aphw.12040
  • Bouchard S, Bernier F, Boivin E, Morin B, Robillard G, Lucia A. Using biofeedback while immersed in a stressful videogame increases the effectiveness of stress management skills in soldiers. PLoS One. 2012;7(4):e36169. doi:10.1371/journal.pone.0036169
  • Cacioppo JT, Adler AB, Lester PB, et al. Building social resilience in soldiers: a double dissociative randomized controlled study. J Pers Soc Psychol. 2015;109(1):90–105. doi:10.1037/pspi0000022
  • Chongruksa D, Prinyapol P, Sawatsri S, Pansomboon C. Integrated group counselling to enhance mental health and resilience of Thai army rangers. Asia Pac J Couns Psychother. 2015;6(1–2):41–57. doi:10.1080/21507686.2015.1091018
  • Cohn A, Pakenham K. Efficacy of a cognitive-behavioral program to improve psychological adjustment among soldiers in recruit training. Mil Med. 2008;173(12):1151–1157. doi:10.7205/MILMED.173.12.1151
  • Crane MF, Boga D, Karin E, et al. Strengthening resilience in military officer cadets: a group-randomized controlled trial of coping and emotion regulatory self-reflection training. J Consult Clin Psychol. 2019;87(2):125–140. doi:10.1037/ccp0000356
  • Fornette M-P, Bardel M-H, Lefrançois C, Fradin J, Massioui FE, Amalberti R. Cognitive-Adaptation Training for Improving Performance and Stress Management of Air Force Pilots. Int J Aviation Psychol. 2012;22(3):203–223. doi:10.1080/10508414.2012.689208
  • Hourani LL, Tueller SJ, Kizakevich P, Strange L, Nelson J. Effects of Stress Inoculation Training (SIT) with relaxation breathing on posttraumatic stress disorder and other mental health outcomes in the military: a longitudinal study. J Fam Reprod Health. 2016. doi:10.13140/RG.2.2.34448.20489
  • Hourani L, Tueller S, Kizakevich P, et al. Effect of stress inoculation training with relaxation breathing on perceived stress and posttraumatic stress disorder in the military: a longitudinal study. Int J Stress Manage. 2017;25(S1):124. doi:10.1037/str0000082
  • Jha AP, Stanley EA, Kiyonaga A, Wong L, Gelfand L. Examining the protective effects of mindfulness training on working memory capacity and affective experience. Emotion. 2010;10(1):54–64. doi:10.1037/a0018438
  • Johnson DC, Thom NJ, Stanley EA, et al. Modifying resilience mechanisms in at-risk individuals: a controlled study of mindfulness training in Marines preparing for deployment. Am J Psychiatry. 2014;171(8):844–853. doi:10.1176/appi.ajp.2014.13040502
  • Jones N, Whelan C, Harden L, Macfarlane A, Burdett H, Greenberg N. Resilience-based intervention for UK military recruits: a randomised controlled trial. Occup Environ Med. 2019;76(2):90–96. doi:10.1136/oemed-2018-105503
  • Keynan JN, Cohen A, Jackont G, et al. Electrical fingerprint of the amygdala guides neurofeedback training for stress resilience. Nat Hum Behav. 2019;3(1):63–73. doi:10.1038/s41562-018-0484-3
  • Lester P, Saltzman WR, Woodward K, et al. Evaluation of a family-centered prevention intervention for military children and families facing wartime deployments. Am J Public Health. 2012;102(Suppl 1):S48–S54.
  • Lester P, Liang LJ, Milburn N, et al. Evaluation of a family-centered preventive intervention for military families: parent and child longitudinal outcomes. J Am Acad Child Adolesc Psychiatry. 2016;55(1):14–24. doi:10.1016/j.jaac.2015.10.009
  • Lewis GF, Hourani L, Tueller S, et al. Relaxation training assisted by heart rate variability biofeedback: implication for a military predeployment stress inoculation protocol. Psychophysiology. 2015;52(9):1167–1174. doi:10.1111/psyp.12455
  • Meland A, Fonne V, Wagstaff A, Pensgaard AM. Mindfulness-based mental training in a high-performance combat aviation population: a one-year intervention study and two-year follow-up. Int J Aviation Psychol. 2015;25(1):48–61. doi:10.1080/10508414.2015.995572
  • Pyne JM, Constans JI, Nanney JT, et al. Heart rate variability and cognitive bias feedback interventions to prevent post-deployment PTSD: results from a randomized controlled trial. Mil Med. 2019;184(1–2):e124–e132. doi:10.1093/milmed/usy171
  • Zueger R, Niederhauser M, Utzinger C, Annen H, Ehlert U. Effects of resilience training on mental, emotional, and physical stress outcomes in military officer cadets. Mil Psychol. 2023;35(6):566–576. doi:10.1080/08995605.2022.2139948
  • Stanley EA, Schaldach JM, Kiyonaga A, Jha AP. Mindfulness-based mind fitness training: a case study of a high-stress predeployment military cohort. Cognit Behav Pract. 2011;18(4):566–576. doi:10.1016/j.cbpra.2010.08.002
  • Taylor MK, Stanfill KE, Padilla GA, et al. Effect of psychological skills training during military survival school: a randomized, controlled field study. Mil Med. 2011;176(12):1362–1368. doi:10.7205/MILMED-D-11-00149
  • Wald I, Fruchter E, Ginat K, et al. Selective prevention of combat-related post-traumatic stress disorder using attention bias modification training: a randomized controlled trial. Psychol Med. 2016;46(12):2627–2636. doi:10.1017/S0033291716000945
  • Wesemann U, Kowalski JT, Jacobsen T, et al. Evaluation of a technology-based adaptive learning and prevention program for stress response-a randomized controlled trial. Mil Med. 2016;181(8):863–871. doi:10.7205/MILMED-D-15-00100
  • Williams A, Hagerty BM, Andrei AC, Yousha SM, Hirth RA, Hoyle KS. STARS: strategies to assist navy recruits’ success. Mil Med. 2007;172(9):942–949. doi:10.7205/MILMED.172.9.942
  • Schrader C, Ross A. A Review of PTSD and Current Treatment Strategies. Mo Med. 2021;118(6):546–551.
  • Smith BW, Ortiz JA, Steffen LE, et al. Mindfulness is associated with fewer PTSD symptoms, depressive symptoms, physical symptoms, and alcohol problems in urban firefighters. J Consult Clin Psychol. 2011;79(5):613–617. doi:10.1037/a0025189
  • Benzo RP, Anderson PM, Bronars C, Clark M. Mindfulness for healthcare providers: the role of non-reactivity in reducing stress. Explore. 2018;14(6):453–456. doi:10.1016/j.explore.2018.03.008
  • Southwick SM, Charney DS. The science of resilience: implications for the prevention and treatment of depression. Science. 2012;338(6103):79–82. doi:10.1126/science.1222942
  • Admi H. Stress intervention. A model of stress inoculation training. J Psychosoc Nurs Ment Health Serv. 1997;35(8):37–41. doi:10.3928/0279-3695-19970801-16
  • Thabrew H, Ruppeldt P, Sollers JJ. Systematic review of biofeedback interventions for addressing anxiety and depression in children and adolescents with long-term physical conditions. Appl Psychophysiol Biofeedback. 2018;43(3):179–192. doi:10.1007/s10484-018-9399-z
  • Minassian A, Geyer MA, Baker DG, Nievergelt CM, O’Connor DT, Risbrough VB. Heart rate variability characteristics in a large group of active-duty marines and relationship to posttraumatic stress. Psychosom Med. 2014;76(4):292–301. doi:10.1097/PSY.0000000000000056
  • Xia HS, Li YX, Zhang QY, et al. Attention bias modification for depression: a systematic review and meta-analysis. Front Psychiatry. 2023;14:1098610. doi:10.3389/fpsyt.2023.1098610
  • Saltzman WR, Lester P, Beardslee WR, Layne CM, Woodward K, Nash WP. Mechanisms of risk and resilience in military families: theoretical and empirical basis of a family-focused resilience enhancement program. Clin Child Fam Psychol Rev. 2011;14(3):213–230. doi:10.1007/s10567-011-0096-1
  • Lester P, Mogil C, Saltzman W, et al. Families overcoming under stress: implementing family-centered prevention for military families facing wartime deployments and combat operational stress. Mil Med. 2011;176(1):19–25. doi:10.7205/MILMED-D-10-00122
  • Thompson B. Foundations of Behavioral Statistics: An Insight-Based Approach. Guilford Press; 2006.
  • McClung JP, Beckner ME, Farina EK. Assessing the physiological basis for resilience in military personnel. Stress Health. 2023;39(S1):33–39. doi:10.1002/smi.3271
  • Osório C, Probert T, Jones E, Young AH, Robbins I. Adapting to stress: understanding the neurobiology of resilience. Behav Med. 2017;43(4):307–322. doi:10.1080/08964289.2016.1170661
  • Flood A, Keegan RJ. Cognitive resilience to psychological stress in military personnel. Front Psychol. 2022;13:809003. doi:10.3389/fpsyg.2022.809003
  • Metcalf O, Gibson K, Fredrickson J, Finlayson-Short L, Varker T, O’Donnell M. Design, development and randomised controlled trial protocol of a smartphone-delivered version of ‘SOLAR’ for emergency service workers to manage stress and trauma. BMJ Open. 2023;13(2):e062710. doi:10.1136/bmjopen-2022-062710
  • Davila MI, Kizakevich PN, Eckhoff R, et al. Use of mobile technology paired with heart rate monitor to remotely quantify behavioral health markers among military reservists and first responders. Mil Med. 2021;186(Supplement_1):17–24. doi:10.1093/milmed/usaa395