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Introduction: Given a high amount of workplace stressors, burnout syndrome, as a depression-related syndrome, is highly relevant for medical service soldiers. This study aims to examine their effects with regard to moral injuries and personal values following foreign deployment., Materials and Methods: This longitudinal study included 91 soldiers of the German Armed Forces Medical Service. Participants completed the Maslach Burnout Inventory (MBI) and the Portrait-Value-Questionnaire (PVQ) before and after a foreign deployment as well as the Moral Injury Scale (SMBE) after deployment. Analysis has been conducted using t -tests to assess potential changes in MBI and PVQ scales between pre-test - t 1 (2-4 weeks before deployment) and post-test - t 2 (up to 6 months after deployment). In addition, correlations were examined between moral injuries (MI) after deployment and MBI scores at t 1 and t 2 as well as between personal values (PVQ t 1 ) and MBI scores at t 1 and t 2 ., Results: The MBI subscales showed mild to moderate burnout symptoms at both pre- and post-tests, with a slight deterioration during the study period, albeit not significant. There were no significant mean differences in PVQ between measurement points. Nevertheless, PVQ self-direction and tradition at t 1 correlated negatively with MBI INV at t 2 (PVQ SD r = -.21, p = .043) and MBI PA at t 2 (PVQ TR r = -.23, p = .027). Furthermore, the subscale PVQ power at t 1 correlated positively with MBI PA at t 2 (PVQ PO r = .28, p = .006), meanwhile PVQ universalism at t 1 correlated positively with MBI INV at t 1 (PVQ UN r = .25, p = .018). Furthermore, positive correlations were found between moral injuries at t 2 (SMBE total score, SMBE_Sub1, SMBE_Sub2) and MBI subscales Emotional Exhaustion (EE; r = -.54, p = .001), Depersonalization (DP; r = .38, p = .001), and Involvement (INV; r = .30, p = .004) before and after the deployment period. No correlation was found between MI and MBI subscale Personal Accomplishment (PA)., Conclusion: The results indicate that medical service soldiers exhibit mild to moderate burnout symptoms even before deployment. Significant associations between moral injuries and burnout were found in 3 out of 4 MBI subscales (EE, DP, INV). There was a significant association with a stronger moral injury and higher burnout levels, persisting both before and after the study period. Furthermore, our results suggest that personal value orientations might be meaningful predictors of burnout. Hence, causal questions regarding general work stress among medical service soldiers should be further explored in more detailed studies. Further research could lay the foundation for future approaches in psychotherapy as well as primary and secondary prevention in this field., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Langner, Börke, Muschner, Muther, Reichelt, Willmund, Wesemann, Zimmermann and Schönsee.)

Introduction: The influence of deployments on family relationships has hardly been investigated. Following a recently proposed new research strategy, military personnel with and without deployment-related life-threatening military incidents during deployment were compared. The hypothesis was that partner and family relationships of military personnel who experienced such an event would deteriorate more., Methods: This study included N = 255 military personnel who had a romantic partner ( n = 78 of them had children) when deployed to Afghanistan. Of these, n = 68 military personnel experienced a deployment-related critical event during the deployment, n = 187 did not. Partnership quality was assessed using a semi-structured pre- and post-deployment interview., Results: The partner relationships of military personnel who experienced a deployment-related life-threatening military incident during deployment broke up significantly more often. The partner relationships of all military personnel deteriorated significantly, with greater deterioration after deployment in the group who faced such incidents. These results were independent of age, rank or number of previous deployments. In addition, there was a significant deterioration in the relationships between all military personnel and their children with greater deterioration after deployment in the group who faced such incidents., Conclusion: Life-threatening military incidents during a deployment abroad appear to have a considerable influence on the quality and stability of the partner and family relationships of military personnel. These findings can be used to inform the development of specific pre- and post-deployment measures and training., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Wesemann, Rowlands, Renner, Konhäuser, Köhler and Himmerich.)

Background: Body dysmorphic disorder (BDD) and muscle dysmorphia (MD) are common but often underdiagnosed disorders. These disorders have rarely been explored in the context of military personnel by mental health researchers despite the emphasis on physical fitness in military populations. We conducted a comprehensive systematic literature review on scientific studies of BDD and MD and the accompanying symptoms within the military., Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and used PubMed, Web of Science and PsycINFO as databases with "body dysmorphic disorder," "muscle dysmorphia," "body image," "performance and image enhancing drugs," "anabolic steroid," military personnel," "soldiers," "navy," "air force," "army" and "armed forces" as search terms., Results: A total of 20 eligible articles reporting data of 42 952 study participants were used. According to the identified literature, prevalence rates of BDD in the military are ~10% in men and ~20% in women, whereas ~15% of men and ~5% of women may suffer from MD. Further identified related problems in military populations were excessive bodybuilding, the use of anabolic drugs, the intake of stimulants, weight and shape concerns, and weight-control behaviours., Conclusions: BDD, MD, as well as the use of anabolic and stimulating drugs, are highly prevalent in military personnel. Despite the importance of these problems in the military, there are no military-specific treatment studies available. A pre-existing focus on physical appearance and fitness might contribute to the decision to pursue a professional military career. The military environment might be a maintaining factor of BDD or MD, but not the ultimate cause of the disorder in an affected individual., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: There is very good international research on deployment-related mental disorders in military personnel. The incidence rates show a very wide range. A new strategy is therefore proposed in order to achieve better standardization and thus better comparability of the studies. In addition to a non-deployed comparison group, we propose to compare deployed soldiers with and without critical military incidents during the deployment. This additional distinction makes it possible to differentiate between the influencing variables of actual threat and general deployment stress., Methods: N  = 358 male combat soldiers deployed to Afghanistan were included in the study. Clinical interviews were conducted several days before deployment and after deployment. Of them, n  = 80 soldiers suffered a life-threatening military incident during deployment, whereas 278 soldiers did not. Odds ratios (OR) were calculated for the groups with and without critical military incidents and the new onset for PTSD, anxiety disorders and depressive disorders., Results: When comparing both groups, we found significantly higher 1-year incidence rates in the group with critical military incidents: 6.4% vs. 1.1% (OR 6.2) for post-traumatic stress disorder (PTSD); 7.0% vs. 1.1% (OR 6.5) for depression; and 15.9% vs. 2.8% (OR 6.6) for anxiety disorders. The 1-year incidence rate of mental multimorbidity (PTSD with anxiety or depression) was 4.8% vs. 0.4% (OR 12.0)., Discussion: These results indicate that life-threatening military incidents during military deployment are important to mental health. As the different threat levels of the various missions are taken into account, additional predictors could be determined more precisely in further research., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Wesemann, Renner, Rowlands, Köhler, Hüttermann and Himmerich.)

Background: During the first coronavirus disease 2019 (COVID-19) wave there was a high prevalence of mental health impairments and post-traumatic stress disorder (PTSD), particularly in patients with comorbid cardiac diseases., Methods: During waves 2-5, all hospitalized patients with cardiac problems and suspected COVID-19 were eligible to participate in this study., Results: The prevalence of PTSD was 31.4% (n=48) in 153 participants. No age- and gender-related differences for PTSD were found., Conclusions: The prevalence is lower than during the first wave but higher than in patients reported in other studies who were isolated at home. Routine mental health assessments are strongly recommended for patients at risk., (© The Author(s) 2023. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Introduction: The common connecting factor between PTSD and cardiovascular diseases lies in the disruption of the stress processing system. The COVID-19 pandemic has led to an increase in stress levels worldwide. Due to the life-threatening situation of affected risk patients, this also led to the accumulation of post-traumatic stress symptoms (PTSS). The influence of anger on cardiovascular diseases has hardly been investigated so far. The focus of this study is on anger regulation in cardiovascular risk patients. The COVID-19 pandemic is considered as an additional stressor in this study, but not as a separate entity. The hypothesis is that individuals with inward anger are more prone to post-traumatic stress disorder (PTSD)., Methods: As part of the routine examination, all patients who were hospitalized between January 1st, 2021 and May 31st, 2022 with high-risk cardiovascular diseases were included. A total of N = 153 (84.1%) subjects participated in the study. On admission, anger (STAXI-2) and PTSD (PCL-5) were assessed using questionnaires. The relationship between different domains of anger and PTSS was examined., Results: Inwardly directed anger was more pronounced in this population than in a standard sample (+1 SD) and had a significant impact on the presence of PTSD (B = -0.72, p  < 0.001). Additionally, correlations were found between inward-directed anger and PTSD, as well as all other anger expressions studied and the PTSD total score., Discussion: It can be assumed that anger and its regulation are relevant factors for both cardiac diseases and PTSD. The study results can be used for prevention, rehabilitation and therapeutic measures. However, the impact of inner anger on PTSD is theoretical and based on statistical testing. A confirmatory longitudinal study is needed to substantiate these results., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Nesic, Vogel, Krüger, Wenzel, Sahebi, Rassaf, Siebermair and Wesemann.)

Introduction: The COVID-19 pandemic changed not only the working conditions but also the private conditions we live in. Health care professionals especially were confronted with multiple stressors, e.g., the risk of infection, lack of staff, and high workloads., Methods: To estimate some of the pandemic-related impacts this anonymous personnel survey was conducted in two German military hospitals (Hamburg and Berlin). This study presents a comparative analysis of the hospital staff in general vs. the psychiatric personnel ( N  = 685) at two measurement time points (MTPs) in April 2021 ( n  = 399) and December 2021 ( n  = 286). The survey contains the German version of the Covid Stress Scale (CSS) to assess the perceived level of pandemic-related stress, the Patient Health Questionnaire (German Version: PHQ-D) to screen for three major mental disorders, and the adjustment disorder-New Module (ADNM) to estimate the problems of adaptation to change., Results: The results showed a process of adaptation over the two MTPs with significant stress reduction at MTP2 in the general staff. The psychiatric staff did not report significantly higher pandemic-related symptoms. Quite the contrary, not only did the CSS show significantly lower xenophobia, traumatic stress, and compulsive checking, but the PHQ also showed lower stress symptoms and somatic symptoms at both MTPs. Also, the ADNM scores delivered evidence for a more effective adaptation process in psychiatric personnel (e.g., depressive mood, avoidance, anxiety)., Discussion: The presented results must be interpreted while taking the unique situations of German military clinics into account. The supply of protective material was sufficient and there was no dramatic shortage of psychiatric staff during the pandemic. The inpatients were quite often (40%) elective treatments for trauma-related disorders, which could be discontinued in the case of a COVID-19 infection. The results of this study showed good adaptative skills among the psychiatric staff in military hospitals, which could be interpreted as a sign of good resilience. This might have led to lower stress-related symptoms during the COVID-19 pandemic., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Willmund, Müller, Schneegans, Höllmer, Wesemann, Zimmermann and Helms.)

Objectives: In this single-case-by-group comparison, we examine whether previously found cisgender differences in paranoid ideation after a terror attack are also seen in a transgender male emergency worker., Methods: Sixty emergency personnel who were exposed to the 2016 terror attack in Berlin were evaluated 3 to 4 and 21-25 mo after the attack., Results: On paranoid ideation, the transgender male showed higher scores than cisgender males (+2 standard deviations [SD]) and the overall group (+1 SD)., Conclusions: This underpins the previously identified gender effects. It would be useful to consider specified pre- and postdeployment modules that take cis- and transgender differences into account.

Introduction: Medical workers involved in responding to the earthquake are exposed to frightening scenes and witness dead bodies and severely injured moaning people, predisposing them to multiple mental health consequences. This study was aimed to determine the prevalence of Post-Traumatic Stress Disorder (PTSD) after earthquakes among medical workers using a systematic review and meta-analysis., Materials and Methods: The review study was performed following PRISMA guidelines, and the study's protocol was registered in PROSPERO with the code CRD42022333069. The data resources of Google Scholar, Science Direct, Web of Science, PubMed, and Scopus were searched to specify the related studies. To perform meta-analysis, the random effects model was utilized, and the I 2 index was considered to assess heterogeneity between studies. The STATA software was used for data analysis., Results: In the initial data resources search, 1399 articles were identified. From these articles, 13 were finally chosen for meta-analysis and quality assessment. The meta-analysis results indicated that the prevalence of post-earthquake PTSD among medical workers involved in the earthquake response was 16.37% (95% CI: 11.63-21.11, I 2  = 97.33%, p = 0 < 0.001)., Conclusion: The medical workers involved in response to the earthquake have a relatively high risk of PTSD in the short and long term. Therefore, medical workers involved in response to disasters should undergo screening for mental health disorders before and after disasters and receive the necessary training with regard to stress management, psychological resilience, and how to express their feelings and emotions., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Severe trauma exposure may lead to symptoms of both posttraumatic stress disorder and depression. Neuroanatomical theories suggest that both disorders may share imbalances in fronto-limbic circuits. Longitudinal studies are necessary to better understand the impact of a stressful life situation on potential long-term fronto-limbic imbalances. Here we investigated soldiers neural processing of combat-related stimuli versus negative affective stimuli before and after the deployment in different war zones. In the final analysis we included 104 deployed soldiers (combat group) and 36 soldiers that were not deployed (control group). Behaviorally, we found a significant group by time interaction regarding depression symptom scores with an increase in the combat group. Depressive symptoms were subclinical. On the neural level, neither the whole brain analysis nor the region of interest (ROI) analyses including frontal and limbic ROIs revealed any significant results in the group by time interaction. However, extracted ROI values of the group by time interaction of amygdala and hippocampus were positively associated with the change in depression symptom scores in the combat group, but not in the control group. These results highlight the role of depression in individuals that experience stressful life situations. Future studies may need to investigate the role of depressive symptoms after trauma exposure with different tasks that may be particularly sensitive to changes due to depressive symptoms., (© 2022. The Author(s).)

Background: Terrorist attacks have strong psychological effects on rescue workers, and there is a demand for effective and targeted interventions., Aims: The present systematic review aims to examine the mental health outcomes of exposed emergency service personnel over time, and to identify risk and resilience factors., Method: A literature search was carried out on PubMed and PubPsych until 27 August 2021. Only studies with a real reported incident were included. The evaluation of the study quality was based on the Quality Assessment Tool for Quantitative Studies, and the synthesis used the 'Guidance on the Conduct of Narrative Synthesis in Systematic Reviews'., Results: Thirty-three articles including 159 621 individuals were identified, relating to five different incidents with a post-event time frame ranging from 2 weeks to 13 years. The post-traumatic stress disorder prevalence rates were between 1.3 and 16.5%, major depression rates were between 1.3 and 25.8%, and rates for specific anxiety disorders were between 0.7 and 14%. The highest prevalence rates were found after the World Trade Center attacks. Reported risk factors were gender, no emergency service training, peritraumatic dissociation, spatial proximity to the event and social isolation., Conclusions: The inconsistency of the prevalence rates may be attributable to the different severities of the incidents. Identified risk factors could be used to optimise training for emergency personnel before and after catastrophic events. Voluntary repetitive screening of rescue workers for mental health symptoms is recommended.

Background: Exposure to patients with COVID-19 can have a significant impact on mental health of hospital medical staff. The aim of this study was to examine the influence of proximity to patients with COVID-19 considering occupational position and gender on the mental health of hospital staff., Subjects and Methods: N=78 participants were included in the study, with n=40 of them with direct contact to patients with COVID-19 (51%); eight had contact with patients suspected of having COVID-19 (10%), and n=30 with no direct contact to people with COVID-19 (39%)., Results: Multinomial regression analyses showed that proximity had a negative (inverse) influence on avoidance behaviour as part of PTSD, physical symptoms, somatization, compulsiveness and anger expression-in as tendency to suppress anger. In addition, there was a significant impact of the female gender on increased physical symptoms, while age, work experience and occupation had no further influence., Conclusions: These results that hospital medical staff is less psychologically stressed when closer to COVID-19 patients are inconsistent with previous studies. Self-efficacy and locus of control in these situations are relevant for processing the trauma. In summary, perception of personal risk is essential. Proximity is believed to be a proxy variable for personal risk perception. As a synopsis of these results, regular briefings of the hospital staff are recommended to prevent psychological impairment. They should contain specific information about conditions in the affected wards and the risk of infection, which could help reduce risk perception of medical personnel.

Background: Impact of telemedicine with remote patient monitoring (RPM) in implantable cardioverter-defibrillator (ICD) patients on clinical outcomes has been investigated in various clinical settings with divergent results. However, role of RPM on patient-reported-outcomes (PRO) is unclear. The INFRARED-ICD trial aimed to investigate the effect of RPM in addition to standard-of-care on PRO in a mixed ICD patient cohort., Methods and Results: Patients were randomized to RPM (n = 92) or standard in-office-FU (n = 88) serving as control group (CTL). At baseline and on a monthly basis over 1 year, study participants completed the EQ-5D questionnaire for the primary outcome Quality of Life (QoL), the Hospital Anxiety and Depression Scale, and the Florida Patient Acceptance Survey questionnaire for secondary outcomes. Demographic characteristics (82% men, mean age 62.3 years) and PRO at baseline were not different between RPM and CTL. Primary outcome analysis showed that additional RPM was not superior to CTL with respect to QoL over 12 months [+ 1.2 vs. + 3.9 points in CTL and RPM group, respectively (p = 0.24)]. Pre-specified analyses could not identify subgroups with improved QoL by the use of RPM. Neither levels of anxiety (- 0.4 vs. - 0.3, p = 0.88), depression (+ 0.3 vs. ± 0.0, p = 0.38), nor device acceptance (+ 1.1 vs. + 1.6, p = 0.20) were influenced by additional use of RPM., Conclusion: The results of the present study show that PRO were not improved by RPM in addition to standard-of-care FU. Careful evaluation and planning of future trials in selected ICD patients are warranted before implementing RPM in routine practice.

In search of the neural basis of severe trauma exposure and post-traumatic stress disorder (PTSD), a multitude of cross-sectional studies have been conducted, most of them pointing at structural deficits in the hippocampus and medial prefrontal cortex including the anterior cingulate cortex (ACC) and ventromedial prefrontal cortex (vmPFC). Since cross-sectional studies are silent to causality, the core question remains: which brain structural alterations constitute a risk factor for disease and therewith precede the stressor, and which brain regions may undergo alterations as a consequence of exposure to the stressor. We assessed 121 soldiers before and after deployment to regions of war and 40 soldiers as controls, who were not deployed. Analysis using voxel-based morphometry revealed volumetric reductions in the ACC, vmPFC (region of interest analysis, effect does not survive conservative multiple test correction) and in bilateral thalamus (whole-brain analysis) in the deployment group. Remarkably, the ACC and vmPFC volume decrease was not limited to the period of deployment, but continued over the following 6 months after deployment. Volumetric reductions did not correlate with increases in PTSD symptoms. The volume decreases in medial prefrontal cortex and thalamus seem to be driven by trauma exposure rather than a vulnerability factor for PTSD. However, data indicate that the volume decrease in medial prefrontal cortex surpasses the time period of deployment. This may hint at an initiated pathobiological process below a symptom threshold, potentially paving the way to future mental health problems.

Purpose: Occupational exposure to patients with COVID-19 is a stress factor. The aim of this study was to assess gender differences in anger among medical hospital staff. Methods: N =78 hospital employees with direct or indirect contact to patients with COVID-19 completed State-Trait Inventory-2. Results: Female personnel showed higher scores in the main "trait anger" scale and its subscale "anger temperament," whereas "anger control-out" was significant lower. Direct patient contact had no influence. Conclusion: More specific training for female hospital staff could achieve health-related equity. Focusing on anger as a leading indicator could lead to better prevention and self-monitoring. Registered at Clinicaltrials.gov (NCT04368312)., Competing Interests: No competing financial interests exist., (© Ulrich Wesemann et al., 2021; Published by Mary Ann Liebert, Inc.)

Emergency service personnel who respond to terrorist attacks may experience persistent stress following the event. This occupational stress must be examined in order to develop occupation-specific response preparation and follow-up measures. An explorative pilot study examined the occupational stress-related effects of the 2016 terrorist attack on Breitscheidplatz in Berlin on emergency service personnel. The present study examines whether the results of the pilot study can be replicated and whether the effects changed after 2 years. The participants were 60 emergency personnel (including 11 police officers and 24 firefighters) who were deployed to the attack, and a control group of 60 personnel (including 37 police officers and 21 firefighters) who were not deployed. Data on stress, quality of life, and current mental state were gathered 3 to 4 months after the attack and 18 to 21 months after the first survey. The data showed that police officers who responded to the attack had significantly higher levels of aggression and hostility at both time points, and firefighters had significantly lower levels of environmental quality of life at both time points. Quality of life in terms of physical health for firefighters could not be replicated. Due to the different types of stress experienced by emergency service personnel, a differentiated approach is necessary. More specific preparation and follow-up measures are necessary to counteract persistent stress. Further research in this area could lead to specific predeployment and postdeployment training measures.

In a pilot study, female emergency personnel showed increased paranoid ideation following a terror attack. This newly designed confirmatory study aims to replicate these previously found gender-specific results and investigate the progression of effects after 2 years. Participants were exposed and unexposed emergency personnel (n = 120). Exposed female versus exposed male personnel showed higher paranoid ideation at both time points. There was a group × time interaction effect in paranoid ideation: paranoid ideation increased over time in the exposed versus the unexposed female group. The same effect was observed with exposed female emergency personnel showing a significant 2-year post-deployment increase compared with the total group including unexposed female as well as exposed and unexposed male emergency personnel. There is, as yet, no conclusive explanation for this difference. Sexual harassment in a male-dominated profession may be a vulnerability factor. Differentiated preparation and follow-up for emergency responders is recommended moving towards health-related equality.

Background: The global rise of conflicts and catastrophes causes new challenges for western healthcare systems. There are obvious parallels between civilian disaster medicine and military combat care. The integration of disaster and deployment medicine into the medical curriculum thus seems necessary., Objective: What do medical students think about disaster and deployment medicine as part of the curriculum? Does participation in a voluntary disaster medicine course affect their view?, Material and Methods: While participating in an extracurricular lecture series on disaster and deployment medicine students (group 1) were asked about their personal views and prior experience in disaster medicine (20 questions). Students who did not attend the lecture (group 2) functioned as the control group. The statistical evaluation was performed descriptively and using Student's t test for independent subgroups., Results: The questionnaire was completed by 152 students (group 1: n = 78, group 2: n = 74). Only 10 students in group 1 and none in group 2 felt they had received an adequate amount of teaching in the field of disaster medicine. Medical students in both groups considered disaster medicine to be inadequately represented in the medical curriculum (group 1: 64% and group 2: 66%). Both groups were in favor of further expanding teaching in the field of disaster medicine (group 1: 72%, group 2: 54%, p = 0.001) and the development of e‑learning tools (group 1: 73%, group 2: 72%)., Discussion: The medical students questioned considered disaster and deployment medicine to be an integral part of the curriculum. Despite some statistical differences between the two groups, the survey showed that medical students possess a great interest in disaster medicine. Both groups were in favor of further integrating e‑learning tools. A regular inclusion of disaster and deployment medicine into the spectrum of medical student teaching is warranted.

Objective: The most common crisis intervention used with German rescue workers is Critical Incident Stress Management (CISM). Results regarding its effectiveness are inconsistent. A negative reinforcement of avoidance, due to premature termination of strong emotions during the Critical Incident Stress Debriefing (CISD), may explain this. The effectiveness of the CISD after terror attacks in Germany has not yet been investigated., Methods: All emergency responders deployed at the terror attack on Breitscheidplatz in Berlin were invited to take part in the study; 37 of the N = 55 participants had voluntarily participated in CISD; 18 had not., Results: Participants with CISD showed lower quality of life in psychological health and higher depressive symptomatology. Of these, females had lower quality of life in social relationships, whereas males showed more posttraumatic stress symptoms. Emergency responders from non-governmental organizations had higher phobic anxiety. Emergency medical technicians showed more somatic and depressive symptoms., Conclusion: There is no conclusive explanation for why rescue workers with CISD score worse on certain measures. It is possible that CISD has a harmful influence due to negative reinforcement, or that there was a selection effect. Further research differentiating occupational group, sex, and type of event is necessary.

Background: The last 10 years have seen an increase in the number of suicides in the US Armed Forces. Accordingly, the topic of suicides in the German military has received a lot of attention in media and science alike., Methods: This study retrospectively examined all suicides (N = 107) committed by active, nonretired German military personnel from 2010 to the end of 2014, analyzing archived medical records. In a second step, these data were compared to a representative German Armed Forces survey conducted in 2012 (N = 1,549)., Results: The following risk groups for suicide were identified: male (OR = 9.6), single (OR = 7.8), aged over 45 years (OR = 4.0), short period of service (<2 years; OR = 2.7), and low level of education (OR = 2.2). Surprisingly, military personnel with little experience in deployments abroad (<2 missions) showed double the risk (OR = 2.0) compared to those who had been deployed more than once., Discussion: Multiple robustness checks show that being single, aged over 45 years, and having obtained a low level of education exhibit the most robust effects on suicide risk., Conclusion: Efforts should be made to develop and evaluate risk group-focused prevention programs. We conclude, that further studies should be initiated to show differences of risk groups between lethal and nonlethal suicidal behavior., (© 2018 The American Association of Suicidology.)

As a result of scientific publications indicating that the last two decades have seen an increase in the number of suicides in the US Armed Forces, the topic of suicide in the military of other countries, such as Germany, has also received a lot of attention in media and science alike. Risk factors for suicidal behaviour and suicide were identified in several research projects in the US, Canada, the UK, and Germany. Until now, German suicide research among military service personnel has mainly focused on epidemiological aspects of suicides and suicidality, individual risk factors, sub-groups at risk for suicide, suicides and deployment abroad, and associations of suicide and suicide attempts with acute mental disorders. The key findings are summarized in this review article. Efforts should be made to develop and evaluate risk group-focused and occupation-focused prevention and intervention programs. Future multinational studies should address potential differences between risk groups for fatal and non-fatal suicidal behaviour.

The aim of the present study was to investigate the effect of experiencing potentially traumatic events during deployment on post-deployment sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI) and the Addendum for Post-Traumatic Stress Disorder (PTSD) of the Pittsburgh Sleep Quality Index (PSQI-A). Deployment related experiences were quantified on a standardised list of the Mental Health Advisory Team of the U.S. armed forces. The original sample consisted of 118 soldiers of the German armed forces who were deployed to Afghanistan for six months. The present analyses focused on data assessed after deployment (n = 70) and in a three-month follow-up (n = 51). Results indicate that immediately after return experiences during deployment had an independent significant effect on sleep quality but not three months later. Immediately after return depressive and stress symptoms significantly affected sleep quality while three months later somatic symptoms were significant. At both time points sleep prior to deployment was a significant predictor of sleep quality following deployment. Given the importance of sleep quality prior to deployment as a known independent risk factor for newly occurring mental disorders after deployment, these results underline the need to improve sleep quality already at an early stage., (Copyright © 2018 Elsevier B.V. All rights reserved.)

In cases of suspected violations of rules, regulations or the law by armed forces personnel, investigations are invariably mandatory. Military investigations differ from well-researched civilian criminal investigations. Differing from civilian police detectives, most military investigators - as disciplinary supervisors and military police personnel - have a number of tasks to accomplish, which include leading in combat and ensuring military readiness. Military investigations can lead to substantive negative or positive consequences for military readiness, including mental health, unit cohesion and subjective legal certainty. This impact on unit cohesion and mental health is influenced by any prior history of distress or trauma; military investigations are often preceded by contravention of internal disciplinary acts, complaints and traumatic events. This study explores factors in the differing military and legal systems of Germany and the United Kingdom (UK) that might help military personnel to successfully conduct investigations while ensuring deployment readiness and maintaining human rights., Competing Interests: A. Buehler has declared no conflicts of interest. G. E. Oxburgh has declared no conflicts of interest. P. Zimmermann has declared no conflicts of interest. G.-D. Willmund has declared no conflicts of interest. U. Wesemann has declared no conflicts of interest., (© 2018 The Australian and New Zealand Association of Psychiatry, Psychology and Law.)

Background: There are a high number of soldiers with deployment-related and non-deployment-related mental health problems in the German Armed Forces (Bundeswehr): This has led to an increase in mental disorders and a decrease in quality of life. To tackle these problems and to strengthen resources among the Bundeswehr personnel, this study aims at developing a screening instrument for assessing the psychological fitness of soldiers on the basis of questionnaire scales. In this approach, psychological fitness describes a soldier's ability to integrate and enhance his/her mental and emotional capabilities using resources and trainable skills., Methods: Bundeswehr combat soldiers (N = 361) answered questionnaires about resilience (RS-11), sense of coherence (SOC-L9), quality of life (WHOQOL-BREF), mental disorders (PHQ-D) and post-traumatic growth (PTG). Additionally, they were interviewed by trained troop psychologists both before and after their deployment in Afghanistan from January to June 2014. The screening model is based on self-report data; the psychological fitness in the standardized interview serves as a validation standard., Findings: A linear logistic regression model was performed that includes the social relationship and the psychological scale from WHOQOL-BREF and the somatoform and the stress scale from PHQ. This model allows specialists a first assessment between participants who are psychologically fit before and after deployment and those who are less so. The chosen cutoff for sensitivity is between 70% and 79% and for specificity between 70% and 85%., Discussion: This screening approach is still not applicable to large populations like that of the Bundeswehr, which currently has about 170,000 soldiers but it is limited to deployed combat troops. Classifying psychological fitness allows specialists to differentiate between people in need of special training or additional diagnostic measures and those in need of sustaining their fitness regularly at the earliest possible stage. A follow-up study that is representative of deployed and non-deployed military personnel will examine whether these results can be transferred to the entire Bundeswehr and whether the validity of the interview can be established.

Background: Terrorist attacks induce various responses in emergency responders. Addressing this range of responses in individual workers is of central interest., Aims: To assess the gender- and occupation-specific effects of a terrorist attack, particularly in emergency responders., Methods: This was a pilot study. Emergency responders present during the 2016 terrorist attack at Breitscheidplatz in Berlin were asked to participate. Measures for crisis management had been previously implemented. Stress (Patient Health Questionnaire [PHQ]), quality of life (The World Health Organization Quality of Life [WHOQOL-BREF]), post-traumatic stress disorder (PTSD Checklist for DSM-5 [PCL-5]) and current psychological symptoms (Brief Symptom Inventory [BSI]) were assessed., Results: Thirty-seven subjects were included, 11 female and 26 male. The occupational groups included 16 firefighters, six police officers, five psychosocial health care personnel and nine members of aid organizations. Three months after the attack, female workers showed higher scores in stress and paranoid ideation, police officers showed higher scores in hostility and firefighters scored lower quality of life in environment and physical health., Conclusions: The mental health burden identified in this study plays an important role for emergency responders after terrorist attacks. Differences between occupational groups may be attributable to differences in tasks that responders perform during acute incidents. The presence of these differences 3 months after the incident suggests that these are at least medium-term conditions. This study may inform the development of treatments and policies and it thus recommended to develop a multi-level assessment and treatment programme that is gender- and occupation-specific., (© The Author(s) 2017. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Pro-inflammatory cytokines, such as interleukin (IL)-1β, have been implicated as underlying pathophysiological mechanisms and potential biomarkers of post-traumatic stress disorder (PTSD). This systematic review examines data regarding IL-1β production/concentration in human and animal studies of PTSD. In accordance with PRISMA guidelines, relevant articles from PubMed were reviewed from inception until July 10, 2017. Nineteen studies were eligible for inclusion. Animal studies demonstrated increased hippocampal IL-1β in rodent models of PTSD. Several immunomodulatory drugs were shown to reduce elevated IL-1β levels and anxiety-like behaviors in animals. Human cross-sectional studies showed contradictory results; serum and plasma IL-1β concentrations in PTSD patients were either elevated or did not differ from control groups. In vitro IL-1β production by stimulated cells demonstrated no difference between PTSD and control participants, although spontaneous in vitro production of IL-1β was increased in the PTSD group. The findings from 2 longitudinal studies were inconsistent. Given the conflicting findings, it is premature to consider IL-1β as a biomarker of PTSD. Anti-inflammatory agents may reduce IL-1β, and be a potential basis for future therapeutic agents in PTSD treatment. More longitudinal research is needed to better understand the role of IL-1β in the development and/or maintenance of PTSD.

Objective: Smoking is a highly preventable risk factor. The present study investigates whether military operations abroad, as compared to deployment preparation, increase the risk of starting to smoke, enhance tobacco dependence and moderator variables can be identified on smoking behavior., Method: The study was conducted at 2 mechanized infantry battalions with N=264 soldiers. The task force completed a deployment in Afghanistan, the control group performed a deployment training. Assessments of tobacco dependence, posttraumatic symptoms, depression and stress were done before (t1) and after (t3) deployment. In addition, one assessment was done at mid-point (t2) during deployment and during the pre-deployment training, respectively., Results: The prevalence rate of smoking soldiers was 56,4%. 51,1% (n=135) of all examined soldiers smoked more than 20 cigarettes per day. The results show a significant increase of tobacco dependence in the task force from t1 to t3 (p=0,040) as compared to the control group. For both groups, there was no increase in starting to smoke during the period of investigation (χ²<1; n. s.). Moderator variables on smoking were not found, but there was a significant increase in posttraumatic stress symptoms in the deployed group (p=0,006)., Conclusions: Perhaps the increase in tobacco dependence in the experimental group can be attributed to the specific burdens of deployment. If high smoking rates were to be found also in other branches of the armed services, effective smoking cessation programs should be offered more widely., Competing Interests: Interessenkonflikt:: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Recently, changes have been introduced to the diagnostic criteria for posttraumatic stress disorder (PTSD) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Objectives: This study investigated the effect of the diagnostic changes made from DSM-IV to DSM-5 and from ICD-10 to the proposed ICD-11. The concordance of provisional PTSD prevalence between the diagnostic criteria was examined in a convenience sample of 100 members of the German Armed Forces. Method: Based on questionnaire measurements, provisional PTSD prevalence was assessed according to DSM-IV, DSM-5, ICD-10, and proposed ICD-11 criteria. Consistency of the diagnostic status across the diagnostic systems was statistically evaluated. Results: Provisional PTSD prevalence was the same for DSM-IV and DSM-5 (both 56%) and comparable under DSM-5 versus ICD-11 proposal (48%). Agreement between DSM-IV and DSM-5, and between DSM-5 and the proposed ICD-11, was high (both p  < .001). Provisional PTSD prevalence was significantly increased under ICD-11 proposal compared to ICD-10 (30%) which was mainly due to the deletion of the time criterion. Agreement between ICD-10 and the proposed ICD-11 was low ( p  = .014). Conclusion: This study provides preliminary evidence for a satisfactory concordance between provisional PTSD prevalence based on the diagnostic criteria for PTSD that are defined using DSM-IV, DSM-5, and proposed ICD-11. This supports the assumption of a set of PTSD core symptoms as suggested in the ICD-11 proposal, when at the same time a satisfactory concordance between ICD-11 proposal and DSM was given. The finding of increased provisional PTSD prevalence under ICD-11 proposal in contrast to ICD-10 can be of guidance for future epidemiological research on PTSD prevalence, especially concerning further investigations on the impact, appropriateness, and usefulness of the time criterion included in ICD-10 versus the consequences of its deletion as proposed for ICD-11., Competing Interests: No potential conflict of interest was reported by the authors.

In this prospective study, subjective sleep quality and excessive daytime sleepiness prior to, during and after deployment of German soldiers in Afghanistan were examined. Sleep quality (Pittsburgh Sleep Quality Index; PSQI) and daytime sleepiness (Epworth Sleepiness Scale; ESS) were assessed in 118 soldiers of the German army, who were deployed in Afghanistan for 6 months (deployment group: DG) and in 146 soldiers of a non-deployed control group (CG) at baseline. Results of the longitudinal analysis are reported, based on assessments conducted prior to, during the deployment and afterwards in the DG, and in the CG in parallel. Sleep quality and daytime sleepiness in the DG were already impaired during the predeployment training phase and remained at that level during the deployment phase, which clearly indicates the need for more attention on sleep in young soldiers, already at this early stage. The percentage of impaired sleepers decreased significantly after deployment. Programmes to teach techniques to improve sleep and reduce stress should be implemented prior to deployment to reduce sleep difficulties and excessive daytime sleepiness and subsequent psychiatric disorders., (© 2017 European Sleep Research Society.)

Introduction: Military surgeons must be prepared to care for severe and complex life-threatening injuries rarely seen in the civilian setting. Typical civilian training and practice do not provide adequate exposure to the broad set of surgical skills required. The German Bundeswehr Medical Service has developed and refined the War Surgery Course (WSC) to meet this training gap. This article describes the recent experience with this readiness curriculum., Methods: Run annually since 1998, WSC consists nowadays of 5 days with 20 theoretical modules. Four sessions with standardised practical skills training use a live tissue porcine model, and the recently added cadaver-based Advanced Surgical Skills for Exposure in Trauma course. Sixteen military surgeons who participated in the WSC in January 2016 completed a survey of their self-rated readiness for 114 predefined emergency skills before and after completion, and provided an overall evaluation of the course., Results: Self-assessed readiness improved significantly over baseline for all areas covered in both the practical skills and theoretical knowledge portions of the WSC curriculum. Additionally, all participants rated the course as important and universally recommended it to other military surgeons preparing for missions., Conclusions: The WSC course format was well received and perceived by learners as a valuable readiness platform. Ongoing evaluation of this course will enable data-driven evolution to ensure a maximum learning benefit for participants. With the increasing multinational nature of modern military missions, surgeons' training should follow international standards. Continuing evolution of military surgical training courses should further encourage the sharing and adoption of best educational practices., Competing Interests: Competing interests: None., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Changes in serum concentrations of tumor necrosis factor-α (TNF-α) and its soluble receptors (sTNF-R) p55 and p75 have been shown to be associated with various psychiatric treatments., Subjects and Methods: Before and after treatment, serum levels of TNF-α, sTNF-R p55 and sTNF-R p75 were measured in 38 German soldiers who had been deployed abroad and suffered from combat-related post-traumatic stress disorder (PTSD). Patients were randomized either to inpatient psychotherapy (N=21) including eye movement desensitization and reprocessing (EMDR) or to outpatient clinical management (N=17). Symptoms of PTSD were measured using the Post-traumatic Stress Diagnostic Scale (PDS)., Results: The PDS score significantly decreased across time in both groups. Serum concentrations of TNF-α increased, while sTNF-R p55 and sTNF-R p75 levels decreased significantly. After the treatment period, we could not detect any significant difference regarding TNF-α, sTNF-R p55 or sTNF-R p75 levels between the inpatient psychotherapy group and the outpatient clinical management control group., Conclusions: This relatively small clinical study suggests that specific inpatient psychotherapy but also non-specific supportive outpatient treatment for PTSD are associated with changes in the TNF-α system. This may represent an immunological effects or side effects of psychotherapy.

To prevent deployment-related disorders, Chaos Driven Situations Management Retrieval System (CHARLY), a computer-aided training platform with a biofeedback interface has been developed. It simulates critical situations photorealistic for certain target and occupational groups. CHARLY was evaluated as a 1.5 days predeployment training method comparing it with the routine training. The evaluation was carried out for a matched random sample of N = 67 soldiers deployed in Afghanistan (International Security Assistance Force). Data collection took place before and after the prevention program and 4 to 6 weeks after deployment, which included mental state, post-traumatic stress disorder (PTSD) symptoms, knowledge of and attitude toward PTSD, and deployment-specific stressors. CHARLY has been significantly superior to the control group in terms of psychoeducation and attitude change. As to the mental state, both groups showed a significant increase in stress after deployment with significant lower increase in CHARLY. For PTSD-specific symptoms, CHARLY achieved a significant superiority. The fact that PTSD-specific scales showed significant differences at the end of deployment substantiates the validity of a specifically preventive effect of CHARLY. The study results tentatively indicate that highly standardized, computer-based primary prevention of mental disorders in soldiers on deployment might be superior to other more personal and less standardized forms of prevention., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

Growing evidence suggests involvement of the tumor necrosis factor (TNF)-α system in the pathophysiology of psychiatric disorders. Research into post-traumatic stress disorder (PTSD) has investigated serum levels of TNF-α, but not to date its soluble receptors sTNF-R p55 and sTNF-R p75. We examined serum levels of TNF-α, sTNF-R p55 and sTNF-R p75 in 135 male German soldiers 70 of whom had been deployed abroad and 65 in Germany only. Post-traumatic stress symptoms were measured using the Post-traumatic Stress Diagnostic Scale (PDS) and the Trier Inventory for the Assessment of Chronic Stress (TICS). Correlational analysis controlling for multiple testing, showed no significant Spearman rank correlations between PDS or TICS scores and serum levels of TNF-α, sTNF-R p55 or sTNF-R p75, either in the full sample or in the group of soldiers who had been deployed abroad. ANCOVAs showed no significant differences between soldiers with or without a PDS-derived diagnosis of PTSD, or between soldiers with or without deployment abroad, after controlling for age, smoking and body mass index (BMI). These results suggest that the TNF-α system, as reflected by TNF-α, sTNF-R p55 and sTNF-R p75 serum levels, does not play a major role in the pathophysiology and development of PTSD symptoms as measured by the PDS and the TICS. However, several methodological and contextual issues have to be considered.