Hello, my name is Lieutenant Colonel Vincent Capaldi, and today it's a privilege for me to talk to you a little bit about our work in coordination with the Army Public Health Center on the Behavioral Health Advisory Teams, or BHAT, our COVID-19 work, looking at three large core-level groups across the Army during the pandemic. Before I begin, I'd like to let you know that I have no conflicts of interest to disclose, and that my opinions today represent mine alone and don't represent the Department of Defense or the U.S. Army. So here are our objectives today. We're going to provide an overview of the Behavioral Health Advisory Team COVID-19, otherwise known as BHAT Military, which is our COMPO-1-level assessment. We're going to describe the findings from our Phase 1 and Phase 2 data collections. So we have Phase 1 completed, and Phase 2 has also been completed. However, the data analysis, I'm only going to show you a snippet as we're still sifting through that data. Then I'm going to talk to you a little about our future directions and, additionally, our recommendations based on our BHAT data assessment. So as I mentioned, I am part of and lead the Center at Walter Reed Army Institute of Research, the Center for Military Psychiatry and Neuroscience. And our mission at RARE is to design, discover, develop solutions that are military relevant for, in our case, brain health, protecting our service members and optimizing warfighter lethality. And how we do that is we project across the entire globe. So we have our headquarters here in Silver Spring, Maryland. But as you can see with our many soldier touchpoints across the globe, we are in every place where there are soldiers. We make sure that the work that we do in the laboratory absolutely impacts the field. And in order to do that, we need to be in the places where our soldiers are found. So that's our soldier touchpoint map. And as part of our, one of our touchpoints is this behavioral health assessment team and advisory team. That's what you're going to hear about today. So the behavioral health assessment team or advisory team started from our history of doing mental health advisory team or MHAT surveys. And you may have heard of these MHAT surveys. There were nine different surveys that were completed from 2002 all the way up into the past couple of years. And they looked at the impact of behavioral health impact that America's longest war on terror has made on our service members. And so we looked at soldiers in and after they redeployed from places like Iraq and Afghanistan, we went to Africa and even to Korea to look at the mental health effects of our continual conflict in these areas and how they impacted not only our service members, but also their families as well. So that obviously with the advent of COVID-19, we were called upon again to look at how the global pandemic is impacting our service members, particularly our service members in Compo 1 and the creation of BHAT military. We are continuing on to look at how the pandemic, the multiple obligations that our medical staff are undergoing through BHAT medical and looking at our other components through BHAT National Guard. What you're going to hear now is a summary of our technical report. Again, a collaboration between the U.S. Army Public Health Center and Walter Reed Army Institute of Research. At the end of our talk today, I'm going to give you a QR code QR code that you can scan and get access to this technical report and also links to the points of contact at both RARE and APHC if you have further questions regarding the details of these data. So here's an overview. So the BHAT survey characterized behavioral health and the public health concerns of our soldiers in the context of the COVID-19 pandemic. We surveyed over 21,000 active duty soldiers from Eighth Army, I-Corps, and USAREUR with an aggregate response rate of about 28%, which was incredible for a survey this size. Our phase one began at the beginning of May and went into June of 2020. And I'll talk to you a little bit later about our phase two and what timeframe that incorporated. Here's our sample characteristics for phase one. As you can see here, most of our sample came from I-Corps at JBLM and they break down with 85% being male and the majority of our demographic ranging in the age range between 17 and 29 years old. We can see here from table one that our demographic was 50% white with most having at least a high school diploma and some college education and the majority being junior enlisted service members. Most of our service members did not experience COVID-19 symptoms or were hospitalized for COVID-19. Only approximately one in 10 soldiers reported having some COVID-19 symptoms and only 8% being tested for COVID-19 at this point in June of 2020. And only about 1% of service members reported becoming seriously ill from COVID-19, as you can see here. Here's how we're going to break down the highlights for you. We're going to look at individual service soldier data, then look at how leadership responses to COVID-19 impact behavioral health utilization and even protective behavioral factors, protective measures that our service members took in response to leadership responses. And then we're going to look at how COVID-19 impacted our soldiers, family, and other relationships. Then look at information sourcing and information needs that our service members indicated in response to COVID-19. Throughout this, we're going to talk about data-supported recommendations. So after the individual soldier data, I'm going to talk to you about recommendations that we can glean from the results that were presented here. In terms of individual soldier behavioral health highlights, we're going to talk about anxiety, depression, thoughts of suicide, alcohol consumption, sleep, and look at the differences between rank, race, and ethnicity as they relate to these factors. And I'm going to try to put into context how these relate to other earlier epicons and other studies that give some context to whether or not the level of these behavioral health concerns outpaced or eclipsed what we've seen in the past. So in terms of behavioral health findings, the rates overall for behavioral health problems were comparable to other similar sample metrics and lower than those compared to periods of high operational tempo as we've seen in Operation Iraqi Freedom, OIF, or Operation Enduring Freedom, OEF. In further analysis, we found that female service members, especially junior enlisted and racial ethnic minority soldiers, showed elevated risks for increased positive screening to behavioral health issues with and without impairment. So let's dig into the data. For anxiety, overall, 16.3 percent of our service members screened positive for generalized anxiety based on a two-item score. So 63 percent showed a positive rate of, excuse me, 16.3 percent showed a positive rate but without related impairment, and 5.4 percent indicated significant anxiety symptoms with functional impairment. We can see the breakdown here as it relates, and you'll get very used to these three different buckets that we break things down by, gender, race, ethnicity, and rank. On the y-axis, you can see screening positive for whatever we're looking for, whether it be anxiety, depression, sleep issues, breakdown by gender. In terms of anxiety, you can see higher rates for females compared to males. In race and ethnicity, you can see the breakdown here, whites only, Hispanic, Latino only, Black, and African American, and then other here. In the rank section, you can see junior enlisted being in green, senior enlisted in blue, and warrant officers and officers in yellow. And that color schematic is going to be maintained throughout the presentation today. In terms of depression, 17.4 percent of the sample indicated a significant screen for a positive for possible depression based on the patient health questionnaire 2. 5.6 percent related significant functional impairment associated with depressive symptoms. As you can see, higher rates were found in junior enlisted service members compared to senior enlisted and warrant officers, higher rates in Black or African American soldiers, and higher rates in female service members. Just over 10 percent of our sample reported having at least some thoughts that they'd be better off dead or hurting themselves. Approximately 5 percent of service members reported that they had experienced thoughts more than half of the days over the past two-week period prior to completing the survey. We can see that here again, you see a preponderance of these type of symptoms in junior enlisted service members, in African Americans or Black soldiers, and in male service members. Now let's look how this compares to previous studies. You will see here in the gray the other samples that we are using as comparative data, that being a OCONUS Korea comparison from one of our MHAT studies, an EPICON CONUS comparison from 2018 and 2019, and a USAREUR comparison unit in 2013. So we tried to pick comparison units that were comparable to Eighth Army, I-Corps, and USAREUR. And what we found was the rates of depression and anxiety were generally comparative to what we had seen previously. And here we break it down by Eighth Army, I-Corps, and USAREUR. Likewise, in terms of positive screening for depression and anxiety, you can see the rates here. This is the rate of the land combat study looking at post-combat deployment. And that was a higher OPTEMPO time period with Operation Iraqi Freedom and Operation Enduring Freedom. You can see that positive screen rates for depression anxiety were significantly higher than what we have seen here. Likewise, we see that positive rates for being better off dead were somewhat comparable to what we've seen previously in our other comparison samples, slightly less than what we saw during high OPTEMPO times vis-a-vis the land combat survey with a rate of 13.9% of people experiencing thoughts of being dead or self-harm. Let's look at alcohol consumption. So 19.5% of the sample endorsed potentially hazardous alcohol consumption. This is using the military-specific Audit C cutoff scores. And we can see that males, white service members, and junior enlisted were at highest risk of hazardous, potentially hazardous alcohol consumption activities. If we look here, we can see that, just as I showed you before, the almost 20% of service members meeting hazardous drinking criteria. We'll switch our attention now to think about sleep as one of the indicators. I like to talk about it as one of the best behavioral health vital signs. We can see that, unfortunately, which is consistent with previous work, that most of our service members are getting six or less hours of sleep per night. And I'll show you in the next slide how significant this is. In terms of insomnia, 31% of our service members were also meeting criteria for insomnia vis-a-vis the insomnia severity index. So our service members are generally not sleeping very well in terms of their insomnia risk and also in terms of their quantity over a 24-hour period. So unlike what some would think being in a pandemic period where some people are working from home, having more of a sleep opportunity, it looks like our service members continue to be underslept in terms of their self-reported sleep time. As I mentioned before, 63% of our service members, our soldiers, reported getting an average six or less hours of sleep per day. One in three reported less than six. So the difference here is either it includes six hours, if they said, yeah, I sleep six hours, those that reported sleeping less than six hours were about 33%. But still, six hours of sleep is too little based on national recommendations from the National Sleep Foundation. So looking at it by gender, we don't see much of a difference in terms of males or females in terms of the positive for short sleep duration as less than six hours of sleep per night. African-Americans or black soldiers tended to show less sleep than other race, ethnicity counterparts. And likewise, if we look at it by rank, we can see a significant difference between the junior enlisted and rather enlisted service members overall compared to warrant and officers and other officers showing only about 15% of them endorsing less than six hours of sleep per night. In terms of insomnia, we see the same with slightly more females endorsing insomnia symptoms overall, about 30% of our service members endorsing insomnia symptoms. And again, more enlisted service members endorsing insomnia than officers. And looking at the subgroup analyses, we see that there are differences in behavioral health outcomes between rank categories as a generally robust predictor. Differences remain statistically significant even when controlling for other demographics and self-reported levels of COVID-19 stress, concerns, and fears. We also observed, as I showed you, differences between race and ethnicity groups. As more minority service members reporting more COVID-19 related stressors, fears, and concerns. Here is just a broad overview of different ranks and how they were endorsing anxiety, depression, suicidal thinking, alcohol use, and insomnia, which has been stable throughout that more junior enlisted service members are endorsing all these behavioral health outcomes more than senior enlisted and warrant or officers respectively. In terms of utilization of behavioral health resources, about two in 10 service members meeting criteria for any behavioral health problem endorsed seeing or utilizing a mental health professional, either in person or virtually. We didn't specify whether or not they saw a person virtually or in person. So you can see 19.6% sought out care from a behavioral health professional. And then here are the other areas where people who are screening positive for behavioral health concerns went and sought out care. They include places like the chaplaincy, military one source, military and family life consultants, army substance abuse program, family advocacy, and even other members of the unit. So here are our recommendations based on these data. It's important to make soldiers aware of the resources that are available to them when they're experiencing the stress and knowing where they can reach out to is absolutely critical. And then encouraging them to engage in adaptive coping or stress management skills. And I'm going to give you at the end links to some of these quick guides that are available to our service members that you can print off and give them evidence-based ways of mitigating and managing stress as it relates to COVID-19. Next, we're going to talk about leadership responses to COVID-19. Overall, what you're going to see if leaders work on COVID-19 specific or pandemic specific responses, they can show improved outcomes as it relates to behavioral health and also protective responses in their service members. So here are the areas that we looked into as it relates to COVID-19 leadership items. Majority of service members reported that their immediate supervisors engaged in these type of behaviors. They include things like encouraging service members to report COVID-19 symptoms, taking steps to keep service members socially connected while physically apart, encouraging people to think positively during the pandemic and to focus on gratefulness during the COVID-19 pandemic. What we found was, as I mentioned before, even when controlling for rank, potential exposure to COVID-19, COVID-19 concerns in general leadership, we found that COVID-19 specific leadership directly impacted the positivity rates for depression, anxiety, sleep problems, potentially hazardous alcohol consumption, and loneliness. Here are the fears and concerns that individuals had for COVID-19. They were concerned how COVID-19 might impact their unit's readiness. You can see here the percentage of people that said not at all, slightly or moderately concerned, or very concerned. Now, these concerns all impacted their risk for behavioral health difficulties. Those individuals that endorsed more fears or concerns related to COVID-19 showed higher rates of behavioral health issues. So here on the Y-axis, we can see the percent positive screen for behavioral health problems as it relates to people with the lowest concerns versus the highest quartile of concerns related to COVID-19. I already showed you those that, as it pertained to COVID-19 specific leadership qualities. Again, the majority of people said that their leaders were encouraging them to report symptoms they have, leading by example, sharing useful and accurate information and so on. What we found was those individuals that had the strongest COVID-19 leadership resulted in a decreased risk for behavioral health difficulties. So you can see here the highest quartile of COVID-19 related leadership qualities, and the lowest over here, and so on. The second quartile, third quartile, and Y-axis being the positivity rate for behavioral health symptoms. Soldiers reported that their supervisors engaged in COVID-19 leadership behaviors were more likely to report frequently or always practicing preventive health behaviors. So that means like washing their hands or wearing a mask. If you as a leader showed positive COVID-19 leadership qualities, even when controlling for these other factors, your service members were more likely to engage in preventive health behaviors. So here's an example. This is low COVID-19 leadership qualities, and the blue or the teal is a high COVID-19 leadership qualities. This, I'm not sure if you can see it very well, but it says wearing a mask, washing hands, using hand sanitizer, avoiding gatherings of 10 or more, covering coughs and sneezes, monitoring for self-symptoms. You're more likely to engage in these positive preventive health behaviors if your leader was demonstrating and portraying positive COVID-19 leadership qualities. So how can we help our leaders gain these qualities, learn these qualities, learn these abilities and skills? We can use these quick guides. So if you pause your video right now and pull out your cell phone and take a picture of these QR codes, you will be led to RARE's quick guides, and there's several of them that are COVID-related. In addition to USU or CSTS's pandemic response resources, and there's a huge amount of information at both of these sites that will be able to help you as you refer to your leaders on how to best inform their service members during this pandemic and potentially future pandemics or future crises, crises in the future. So again, this is from RARE and this is the Uniformed Services University of the Health Sciences Center for Traumatic Stress Studies pandemic response resources. So let's talk about the impact of COVID-19 on family and other relationships. Here we're gonna highlight financial considerations, impact on spouses and partners, and impact on children and childcare. Some marital status, about half and half of our sample were either never married or married and living with spouse. 31% had children under the age of 18, 3% in their household also had adults over the age of 65, and about 20% of our participants endorsed having a family member in the EFMP program. In terms of financial considerations, half of our service members reported a financial impact related to COVID-19. Soldiers were more likely to report moderate, major or severe COVID-19 related financial impacts if they were male, married or previously married, in a racial or ethnic minority, junior or senior enlisted, and had children less than the age of 18 in their household. These financial impacts were also correlated with behavioral health issues, including depression, anxiety, and potentially hazardous alcohol consumption. Let's look at the financial impact. Again, the majority of our service members reported at least minimal, moderate or major severe impact financially related to the pandemic. Let's look at this by gender. So if we look at male and female soldiers, female soldiers endorsed more spouses, partners, partners shifting to work from home or telework, whereas more male service members reported that their spouse had to take an unpaid leave of absence or for furlough from a workplace due to COVID-19. Also male service members reported more frequently that their spouse or partner was no longer employed outside the home as they were impacted by the pandemic. So just looking at this a different way, as we break it down by junior enlisted, senior enlisted, and warrant officers, we can see that for officers, most officers reported, or about 43% of officers reported that their spouse or partner shifted from working from home or teleworking at least part or full time. And then the higher percentage of junior enlisted service members reported that their spouse or partner was no longer employed outside the home. So at least 64% of our sample had experienced some level of difficulty coping with the impact of the pandemic. The extent to which they experienced this difficulty was correlated with worse behavioral health outcomes. As you can see here, the coping difficulty, only 36% said they had no difficulty at all. But again, the majority saying they had some level of difficulty. And then most of the sample as well, over 49% showed some level of distress among their children as well. So it's not only the soldiers having difficulty, but their children were also experiencing difficulty associated with the pandemic. So more than half of our soldiers with children living at home reported that their children, the children's daycare or school was closed or had reduced hours due to COVID-19. Half of our service members with children under the age of 18 reported that their children experienced emotional, behavioral or other difficulties since the start of the pandemic. A sizable portion of our soldiers reported they were working from home and caring for children, that's 28%, that they had experienced a change in their work situation, 23%, or even unable to make alternative childcare arrangements, about 22%. Soldiers reported changes in their work situation, impact of their household finances or impact of their children's emotional or behavioral concerns were more likely to screen positive for behavioral health issues. If we look at here, the impact on childcare, you can see in the gray, no versus yes. So daycare or childcare closure, majority said yes. Working from home to care for children, 28.6 said that they had to do that. Their work changed, 22% said they were unable to make alternate childcare arrangements. Comparing the impact of daycare and childcare closures versus between male and female soldiers, in female soldiers, you can see in red, more female soldiers endorsed that they're working from home while caring for children or homeschooling children. More female soldiers endorsed that their work situation changed as a result of childcare issues and more female soldiers said that they had not been able to make alternate childcare arrangements than did male soldiers. So here are our recommendations. We know that COVID-19 is having a significant impact on our families, especially when it comes to financial impacts and how those financial impacts are associated with increased likelihood of behavioral health issues. We need to consider ways to support spouses seeking employment if they've been furloughed or no longer working out of the home due to COVID-19, due to the pandemic. We should accommodate children as much as possible and support them as they're dealing with challenges of school and daycare closures. And I know that this even continues as we're transitioning out of this pandemic as more and more service members and their families are being inoculated. They need to be aware of support systems available to them, including the Family Advocacy Program, Financial Readiness and Employee Readiness Program. We should also work to support the childcare arrangements that we have within the military, including the Child Development Centers and the Child and Youth Services and keep them open as close to fully operational as possible communicating to parents about their options if their other off-base childcare opportunities are not available to them. And then we need to continue to explore how family impacts vary based on their structure, demographics, such as gender, race, and rank, and then try to mitigate it by targeted interventions for these vulnerable families. Consider policy changes to subsidize childcare during the pandemic, and then address stress in children through psychoeducation opportunities and developing child-based psychoeducation packages. Next, we're gonna talk about information sourcing. What information did individuals say that they needed during this phase one and phase two surveying, and then where were they getting their information from and did they consider it valuable? So let's look at where most soldiers are getting their news. Most soldiers reported using more than one information source to obtain information related to COVID-19. Over a greater percentage of junior and senior enlisted service members reported using social media only or only online resources to access COVID-19-related data relative to officers and warrant officers. So we can see here, these are the individuals using only online resources, more junior enlisted than did officers and warrant officers, social media as the sole source of information compared, and we can see the rank breakdown there, and then the majority of officers and warrant officers were using multiple sources of information as it relates to getting information for COVID-19. So more than half of our soldiers reported accessing local command guidance, installation guidance, and Department of Army guidance as it was provided prior to completing the VHAT survey. One third of soldiers reported other government sources, including the Center for Disease Control and Prevention and White House press briefings within the month prior to completing the VHAT survey. One in four soldiers reported they did not need information related, excuse me, one in four soldiers reported that they did not need information related to COVID-19, and a greater percentage of female soldiers reported needing more information across all topics related to COVID-19. So we can see here that here are the hot topic areas that people are looking for information related to COVID-19 include travel, and we can see the rank breakdown there, maintaining mission readiness, and facts and statistics related to COVID-19 spread. Here's the information as they needed it across the board. Most were looking for information related to travel. They were unsure as to where they could go, what restrictions were there, what was the radius that was acceptable, what were the safe ways to travel. Facts and statistics were also in high demand related to the spread of COVID-19, how to protect themselves, how to protect others, and maintaining mission readiness related to COVID-19. Here are the recommendations that we have based on these findings. We need to leverage social media resources to distribute up-to-date information and organize and coordinate through PAO offices, disseminate and distribute guidance through multiple communication channels, follow best practices in communication by having at least three to four exposures to service members, refreshing and repackaging content to keep it fresh and up-to-date so it doesn't become stale and perceived as irrelevant, and then incorporate videos into communication campaigns, utilize two-way communication platforms, including town halls with question and answer sessions. So here's a brief overview of what we already talked about related to our phase one results for the BHAT survey. Again, we had positive screening rates that were generally comparable to what we've seen in non-deployment type settings. It's notable that one in 10 soldiers reported thoughts that they'd be better off dead or hurting themselves, and again, this is unfortunately comparable to what we've seen in other samples, not during COVID-19. We've seen that the financial impact on the family is significant in that it's associated with behavioral health concerns, and in terms of the impact on childcare, it is significant with most reporting that their children's daycare or childcare was closed, that they were unable to, some of them, 20% of 20% saying that they were unable to make alternative arrangements for their childcare. So if you want to learn more and delve deeper into the results, take a picture here of the QR code for the BHAT tech report, and you can read in-depth the methods that were used to develop some of these results and look at the data, look at the breakdown. It's a great resource. I highly recommend it. What I'd like to show you now is work from our phase two follow-up. This was completed in early January this year. It had an N that was less than what we saw in the phase one with only about 10,000 participants. I'm gonna show you information from the I-Corps portion of this. This COVID-19 phase two included an enhanced suicide risk assessment, a virtual psychological healthcare assessments, initial briefs to stakeholders, and we are working on a tech report in spring of 2021. So that's upcoming, perhaps by the time this video is released in the amygdala conference, that tech report will be available for phase two. And then we're planning additional follow-up in phase three at these sites and additional sites to add as well. So here are some initial results from the phase two trial, the phase two survey that went out 9 December through 19 January, 21. They had about, in this I-Corps sample, about 5,000 soldiers. And here's what we saw. Impact on mission readiness. Despite being in COVID for almost a year, the need for information still remains high. We can see that almost a quarter of our participants continue to have needs concerning how to maintain mission readiness during COVID-19. There are continued concerns about the impact of the pandemic on unit readiness as it increased by 45% from May of 2021. Most soldiers reported that their unit had taken appropriate precautions in response to COVID-19 with about 36% saying that their unit took too many precautions, and 9% saying that they had not taken enough precautions to protect service members. 25% had concerns about the impact of COVID-19 on their unit, saying that it's decreasing their unit's physical conditioning, as many service members have not been able to do PT, difficulty maintaining unit cohesion. That's particularly an issue where most people are doing their business now over online media such as Teams and so on. And then their perception of leadership responses basically stayed the same between phase one and phase two, with nearly 40% more soldiers met criteria for behavioral health problems who reported lower versus higher perceptions of their immediate supervisor's response to the COVID-19 pandemic. So we can see here that, again, COVID-19 leadership skills were absolutely critical in mitigating soldiers' risk for behavioral health problems. Unfortunately, we also found that suicidal thoughts, a corrosive, as we consider it in the Army, increased, at least in this sample, going from about 10% to 12% of service members wishing they were dead or killing themselves. About 4.2% of those who reported killing themselves was 148 service members within the sample of 5,000. 61% said that they thought about a plan, 61%, excuse me, 39%, about 40% said that they had reported an intention of acting, and then 31% stated that they started to work out details of their suicide attempt, as you can see there. And then the impact of the pandemic on the soldier's family continued to be an issue with very little changes in terms of how the pandemic had impacted these service members and their coping skills. And they had difficulty coping among soldiers and their spouses or partners. Here are the points of contact for these technical reports. They include Dr. Cortana at Walter Reed Army Institute of Research and Dr. Milliken-Bell from the Army Public Health Center. And there are their contact informations with the details of those who have contributed to this tech report. With that, if you have any questions, you can take a picture of this QR code here. And contact me directly, or I believe that there's also a Q&A session that I will be at. With that, thank you so much for your time. I appreciate your attention. Thanks.

BHAT team

soldiers

COVID-19 pandemic

behavioral health concerns

mission readiness

sleep problems

financial impacts

suicidal thoughts