1. Innovations in Military Stress and Trauma Research Overview of Litz Lab Research

2. Major Research Areas Longitudinal epidemiology of the mental health toll long wars PTSD treatment innovation ▫Making care more accessible / effective Early intervention trials in military

3. Epidemiological Issues: US Military / VA No population studies in US Sampling and context problems Major methodological problems: ▫Cross-sectional designs ▫Mon0-method bias ▫Very narrow band of predictors ▫Exposure is conceptualized narrowly

4. Marine Resilience Study Prospective study of ~3K ground combat Marines Study of risk and protective factors within and across systems: ▫Psychological and psychiatric ▫Genetic, biological and psychophysiological ▫Social (unit and family) ▫Environmental (stressor exposures) PTSD evaluated with clinical interview (CAPS) Rich set of predictors and outcomes Extensive contact information \ permission Funded by: Navy, VA, Marine Corps, VA HSR&D

5. What Data Does MRS Collect? Four data collection time points: Pre-deployment (4 hrs) 1 week post- deployment (1.5 hrs) 3 months post- deployment (4 hrs) 6 months post- deployment (4 hrs) 5

6. PTSDPTSDSYMPTOMSYMPTOMBURDENBURDENPTSDPTSDSYMPTOMSYMPTOMBURDENBURDEN Severe Moderate Very Low Trajectories of Adaptation to Combat and Operational Stress and Trauma Pre-Deployment 1-week 3-months 6-months Post-Deployment Post-Deployment Post-Deployment Chronic Course Recovery / Resilience Course Resistance Course Delayed Course

7. HIGH MODERATE LOWHIGH MODERATE LOW T I M E Adaptation To Frequent High Magnitude COS Over The Lifespan SYMPTOMSYMPTOMBURDENBURDENSYMPTOMSYMPTOMBURDENBURDEN Pre-military Military Career Retirement Very Old Age DELAYED HIGH CHRONIC MRS ENDURING RECOVERY / RESILIENCE CHRONIC DELAYED MODERATE CHRONIC

8. The Need For Treatment Innovation in Military Existing Evidence- Based Treatments Failure to appreciate military culture Need to show incremental validity: Selection Leadership Leadership Training / preparation Training / preparation Peer / family support Peer / family support Trials among war veterans are poor Few RCT’s with service members

9. Innovations Adaptive Disclosure Trial Internet-based cognitive- behavioral therapies ▫Therapist-assisted / self- management ▫Self-help

10. Adaptive Disclosure (AD) Therapy Developed for Marines A hybrid and extension of CBT Designed to target life-threat, traumatic loss, and moral injury (shame, guilt, inner-conflict) 6 sessions of exposure and a modified empty chair technique to activate and process emotions and meanings Open Trial (N=65): PTSD symptom change d=.80 RCT funded by DoD 10

11. INTERVENTION: DESTRESS DElivery of Self-TRaining and Education for Stressful Situations Internet-based, self-management CBT 6-week, therapist-assisted, 18 logons Self-monitoring; stress and affect management ; trigger management, trauma narrative, planning for long haul Check-in, report, homework Ad lib education, e-mail, phone-calls Back-end oversight

12. INITIAL TRIAL RESULTS Differential effect size =.95

13. Internet-based Therapy Trials / Projects DESTRESS-PC (DoD) Stepped-care consortium in primary care (DoD) Project HEAL (NIMH) Wounded Warrior Project Prevail ….