Management of Acute Stress Reactions in the Military: A Stepped Care Approach

Abstract

Purpose of the review: This review highlights knowledge gaps surrounding the development and use of interventions for Acute Stress Reactions (ASRs). First, we propose that a stepped care approach to intervention for ASR be developed and utilized in military operational environments. A stepped care approach would include detection and assessment, followed by behavioral intervention, and then medication intervention for ASRs. Second, we discuss potential strategies that can be taken for the development of safe and effective ASR medications.

Recent findings: ASRs commonly occur in operational environments, particularly in military populations. ASRs impact the safety and performance of individual service members and teams, but there are currently limited options for intervention. Efforts to improve ASR detection and assessment, and development and delivery of ASR interventions for implementation in operational environments, will be critical to maintaining the safety and performance of service members.

Keywords: Acute traumatic stress; Assessment; Intervention; Medication; Pharmacologic; iCOVER.

Fig. 1

Timeline of post-traumatic event symptoms. Post-trauma symptoms can occur at any time following a traumatic event. Symptoms may resolve at any point, spontaneously or with treatment. The presence of symptoms at one point does not necessarily predict future symptoms. Theoretically, interventions to manage symptoms can be applied at any point during or following the traumatic event. Although an ASR can be present up to 30 days following trauma exposure, the first 72 hours are of critical importance for military operations, are the least well- understood or studied, and occur within a period that ASD or PTSD cannot be diagnosed

Fig. 2

Stepped Care Approach to ASR symptom management. (1) ASR symptoms emerge. (2) ASR symptoms are detected and may be assessed by a peer or medic. (3) A behavioral intervention such as iCOVER is utilized. (4a) If symptoms do not resolve and an individual is unable to self-administer medication or a battalion aid station is not available, medication can be provided by a medic. (4b) If a battalion aid station is available and medic intervention is not urgently needed, step 4a may be skipped and assessment and intervention may occur at a battalion aid station. Throughout steps 2–4, monitoring by medic or provider for performance improvement or degradation should occur as much as feasible. If performance is still impaired in a previously treated individual, additional assessment and intervention may be applied at the battalion aid station. All steps may be repeated if symptoms re-emerge or, if available, the patient may need to be elevated to higher levels of care. As described in Fig. 1, symptoms may emerge immediately or up to 1 month following the traumatic event

Fig. 3

Downselection process for testing medications to be applied to individuals who are unable to self-administer. Downselection process for medications currently available in US Army battalion aid stations or medic bags to test for performance effects and ASR symptom management efficacy. Downselection criteria were fast absorption rate, ease of administration, and mechanism of action. Of 127 medications available, 28 medications were found to be worthy of consideration for performance testing. Preferred criteria were administration routes that are (1) rapid and (2) relatively easy for providers to administer and (3) mechanisms of action previously implicated in the stress response

Fig. 4

Downselection process for testing medications to be applied to individuals who are able to self-administer. Downselection process for medications currently available in US Army battalion aid stations or medic bags to test for performance effects and ASR symptom management efficacy. Downselection criteria were fast absorption rate, ease of administration, and mechanism of action. Of 127 medications available, 56 medications were found to be worthy of consideration for performance testing. Preferred criteria was a mechanism of action previously implicated in the stress response