Intensive Coping Skills Training to Reduce Anxiety and Depression for Forward-Deployed Troops

Military Medicine, Mar 2008 by Jones, David E, Perkins, Kenneth, Cook, Jeffrey H, Ong, Adeline L

ABSTRACT This study provides descriptive information and 2-year outcome data on the first intensive, outpatient, coping skills training program for forward-deployed troops in the Western Pacific Ocean region. Established in February 2003 by the Mental Health Department of the U.S. Naval Hospital in Okinawa, Japan, the Outpatient Crisis Prevention Program was designed as a multidisciplinary training program to reduce anxiety and depression and to enhance the coping skills of active duty personnel. This study describes the rationale for creating the program, the patient population, and treatment outcome data collected during the first 2 years. The Beck Depression Inventory II and the Beck Anxiety Inventory were administered as pretraining and posttraining measures to patients who completed the program between February 2003 and February 2005 (N = 326). Results revealed that the Outpatient Crisis Prevention Program was effective in reducing depression and anxiety symptoms and promoting healthy coping behaviors among participants. Follow-up data indicated that gains were maintained 1 month after treatment.

INTRODUCTION

According to a 2002 Department of Defense (DoD) report, a significant proportion of active duty personnel reported anxiety and depression.1 Service members who reported anxiety and depression also tended to report higher levels of stress at work and in the family. These individuals reported losses in job productivity associated with their symptoms, which suggests a significant reduction in mission readiness.

Approximately 17% of the DoD survey respondents reported anxiety symptoms (e.g., nervousness, feeling edgy, and excessive worry) in the previous month. In general, rates of anxiety decreased with age. Personnel ≤25 years of age reported almost twice the rates of anxiety as did those ≥35 years of age. Women in the lowest ranks reported the highest levels of anxiety. Additionally, more personnel stationed outside the continental United States reported anxiety, compared with those stationed within the continental United States (22% and 13%, respectively).

Approximately 19% of the DoD survey respondents reported depressive symptoms (e.g., depressed mood, insomnia, fatigue, and difficulties with concentration and decisionmaking). As with anxiety symptoms, greater numbers of younger personnel reported depression, compared with older personnel. A larger proportion of military members stationed outside the continental United States reported depressive symptoms, compared with those stationed within the continental United States (22% and 18%, respectively). These findings suggest that interventions aimed at helping personnel cope with anxiety and depression are needed to promote stress management and improved functionality at home and at work, especially in duty locations outside the continental United States.

At present, there is a small but growing literature on psychoeducational interventions designed to enhance the coping skills of active duty personnel who are at risk for anxiety, depression, or impulse control problems, such as aggression. Coping skills and crisis prevention programs have been developed for a variety of military contexts, but the results have been variable. At the recruit training level, Williams et al.2 reported increased graduation rates associated with a weekly, 45-minute, cognitive-behavioral intervention delivered for 9 weeks. The program was designed to reduce depression among naval recruits by enhancing their sense of belonging and problem-solving skills. However, Cigrang et al.3 found that participation in a two-session, 90-minute, stress management group did not improve the rate of graduation from basic military training for Air Force recruits at risk for early discharge because of mental health problems. In a military occupational setting, Linkh and Sonnek4 demonstrated that a four-session (75-90 minutes per session), cognitive-behavioral, anger management training program reduced workplace stress and enhanced conflict resolution skills among active duty personnel, family members, and civilian employees. However, interpretation of the results was limited because of an attrition rate of ~50% among study participants. In a major medical treatment facility in Portsmouth, Virginia, researchers reported greater decreases in depressive symptoms and substantial cost savings for active duty personnel who participated in a structured, 1-week (6 hours/day and 30 hours/week), intensive, outpatient program, compared with personnel treated in a traditional inpatient hospital program.5 The outpatient program in Portsmouth aimed to enhance the stress management and coping skills of participants, to return them to their work environments with full duty status.

Although there is evidence suggesting the value of cognitive-behavioral interventions for military personnel, results have been equivocal and limited. Previous military studies examined programs in major training centers and military treatment facilities within the continental United States. Little is known about the application of structured outpatient interventions for personnel in highly mobile, operational overseas environments. The purpose of this study was to evaluate the effectiveness of an intensive outpatient training program developed for active duty personnel served by a medium-size (80 beds and 1,000 staff members), forward-deployed hospital in Okinawa, Japan.