Beyond first-line approaches: A scoping review of emerging operational stress interventions for military and public safety personnel

Abstract

Introduction:

Mental health conditions associated with military service, such as posttraumatic stress disorder (PTSD), can affect other high-risk public safety personnel (PSP) groups. Traditional psychotherapeutic and pharmaceutical approaches are effective for approximately 50%-60% of this population; thus, a broader range of treatment approaches needs to be identified. This scoping review aimed to identify and summarize programs available in Canada.

Methods:

Several databases were searched between 2011 and 2022, using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews to identify mental health programs for those at risk of developing occupation-based posttraumatic stress. Grey literature and a public web-based database were also searched.

Results:

After screening 599 records, 13 primary literature studies were identified. An additional seven programs were found by assessing 126 programs and services found in a public database search. Programs and services included a variety of prevention and intervention approaches, many of which used at least one complementary or alternative medicine modality.

Discussion:

Numerous therapeutic programs are available in Canada for military and PSP populations, many of which include a novel and holistic approach to treating mental health issues. However, there are few outcome studies, which may translate to the reluctance of some service providers to use or recommend these programs for mental health interventions or rehabilitation. More research is needed in these areas to better understand the utility of integrated approaches, which may help individualize and optimize mental health treatment in military and PSP populations.

Lay Summary

Mental health issues such as posttraumatic stress disorder (PTSD) are increasingly common among military Veterans and public safety personnel. Typical or traditional treatments such as therapy and medication work for only about 50%-60% of individuals, showing a clear need for more options. A search of PTSD treatment programs in Canada between 2011 and 2022 to identify available programs was conducted. The authors screened hundreds of records and found 13 studies, plus an additional seven programs through a search of a public database. These programs use many methods, some of which include complementary and alternative medicine, such as yoga and mindfulness. This review found that Canada has many novel mental health programs; however, very few of these programs have been evaluated for their effectiveness, which may lead some health care providers to be resistant to recommending them. The authors suggest that much more research needs to be conducted to better understand and improve programs that are effective for military and public safety personnel.

Introduction

Occupational-related trauma, often referred to as operational stress injury (OSI), is an umbrella term that describes the psychological injuries and disorders resulting from stressful situations, such as posttraumatic stress disorder (PTSD), depression, anxiety, sleep disorders, and anger and irritability.¹ PTSD related to military service can result from “combat, peace-keeping, and humanitarian deployments as well as non-deployment trauma.”^{2(p. 96)}

For years, PTSD research has focused on military personnel; however, public safety personnel (PSP) are also at risk of developing PTSD through their professional activities. The definition of PSP includes individuals working in firefighting, paramedic services, policing, corrections (security and non-security roles), and the community or playing supporting or administrative roles in those professions.^3–5 Much like the military, PSPs are frequently asked to step into harm’s way, risking their health and well-being to aid others. Most are shift workers, with long nights away from family, erratic schedules, and overtime hours, and they are often exposed to a host of potentially traumatic events,⁵ all of which can take a toll on their physical and mental health, frequently resulting in OSI.⁶

Recent studies have shown that PSP who work in potentially traumatic circumstances similar to those in which military personnel work have also seen increased rates of OSIs. One PSP study found that 14.9% of personnel met the criteria for a mental health disorder in the past year, and the prevalence of OSI among PSP ranges from 10.0% to 35.0%.⁷ However, relatively few studies have been carried out with Canadian PSP to gain an accurate estimate of national mental health issues among this population. One national study assessing the self- reported mental health of PSP found that 44.5% screened positive for at least one mental health issue,⁷ and another study found that prior military experience may increase the likelihood of PSP experiencing an OSI.⁷ However, few studies have focused on Canadian PSP to gain an accurate estimate of the prevalence of mental health issues in this population. With personal, societal, and economic stakes so high, gaps in our understanding of prevention, treatment, and resources related to the mental well-being of this high-risk group must be addressed.

Treatments

Treatments for PTSD can include trauma-focused psychotherapy and pharmacotherapies.² Research suggests that psychotherapy and pharmacotherapy have different strengths in treating PTSD;⁸ however, psychotherapy generally results in greater overall recovery and longer-term effects.^9,10 Primary psychotherapies include trauma- focused cognitive behavioural therapies (CBTs), such as cognitive processing therapy,¹¹ prolonged exposure,¹² and eye-movement desensitization and reprocessing.^13,14

Primary pharmaceutical treatments include selective serotonin reuptake inhibitors and serotonin- norepinephrine reuptake inhibitors, but fewer than 60% of patients have a clinically meaningful response, and as many as 50%–60% of patients with PTSD are non-responders to pharmacological treatment alone.^15–17

Novel psychopharmaceuticals

Methylenedioxymethamphetamine (MDMA) has re-emerged as an effective therapeutic pharmaceutical in conjunction with psychotherapy. By reducing the fear response in the amygdala, MDMA can facilitate and enhance the therapeutic process.¹⁶ Ketamine (an N-methyl-D-aspartate antagonist) has traditionally been used for sedation, analgesia, and anesthesia.¹⁸ Recently, ketamine has been used at lower levels, producing a rapid-acting anti-depressant effect, and it has been used to effectively treat patients with unipolar and bipolar depression as well as suicidal thoughts.^18,19 Medical cannabis use has increased significantly among Veterans; it has been prescribed to treat both physical and mental symptoms of PTSD and found to help with relaxation and sleep.²⁰

Complementary and alternative medicine

The recent increase in novel psychopharmaceuticals has signalled an openness among the medical community to explore alternative approaches to mental health treatment. Complementary and alternative medicine (CAM) has varying definitions but generally refers to complementary and integrative approaches to health care that are “holistic and patient-focused … including mental, emotional, functional, spiritual, social and community aspects.”^{21(p. 343)} In the United States, CAM use has been reported to be higher among the military (37%-72%) than the civilian population (36%-38%).^22,23 CAM is being used to treat a wide range of physical and psychological conditions, including high cholesterol, arthritis, joint pain, anxiety, and depression, as well as to promote general health and well-being.^22,23 The increased availability of CAM programs may reflect the need for novel interventions and treatment modalities for managing and preventing OSIs, including PTSD.

Many new or emerging modalities are breaking away from traditional or first-line interventions by focusing on more holistic, patient-centred practices that do not emphasize a single outcome.²¹ For example, in their review of the neurological processes and efficacy of mindfulness in PTSD treatment, Boyd et al. describe personalized approaches as becoming the gold standard,²⁴ whereby clinicians view patients more holistically, considering the range and scope of each individual’s symptoms and experiences to help guide and prescribe individualized treatments.

Although many programs seem to be available that address a broad range of needs, from intensive long-term in-house programs for the treatment of PTSD and addictions to informal peer-support programs, wilderness and adventure programs, yoga and meditation, and equine therapy, there is little to no evidence that such programs have been empirically studied or evaluated. Without an evaluation process, it is impossible to know what programs are working and for which populations or to share knowledge about best practices and emerging programs to better address individual needs.²¹

Previous systematic reviews on this topic have addressed program availability internationally. However, they have focused on a different population, such as first responders only,²⁵ at-risk workers, which includes counsellors, first responders,²⁶ and PSP, and front-line health care workers.²⁷ The current study seeks to expand on findings from these reviews and to narrow the focus to Canadian programs that provide services for the military and PSP community.

Objectives

This scoping review aimed to identify and describe programs available for military personnel and PSP (police, firefighters, corrections, and paramedics) in Canada who have an OSI such as PTSD. We aimed to 1) explore the extent of the available research, 2) identify research gaps and where more work needs to be done, and 3) make recommendations for knowledge users.

Methods

Like systematic reviews, scoping reviews follow a structured guideline for evidence synthesis but diverge in their methodological process and are undertaken for different reasons.²⁸ Although systematic reviews are generally conducted by teams to critically appraise evidence and synthesize results, a scoping review is more suitable to exploring a broad scope or topic about which little is known by identifying and mapping the available evidence, regardless of the quality of that evidence.^28,29

This review used the Population, Intervention, Comparator or Control, and Outcome (PICO) framework (Table 1) to frame this research.³⁰ Population describes the population of interest, the research question, or both. Intervention is the intervention or interventions under consideration. Comparator or control asks for an alternative to the intervention, and the outcome is the relevant outcome or outcomes that reflect the line of inquiry. This scoping review follows best practices for using scoping reviews to preliminarily explore a topic or field.²⁹

Table 1.

Population, intervention, comparators, and outcomes

Population	Military, Veteran, and public safety personnel (firefighters, paramedics, correctional officers, police, and Royal Canadian Mounted Police)
Intervention	Therapeutic interventions for PTSD or OSI, including prevention, rehabilitation, coping, resiliency, stigma, and training, education, and management
Comparator or control	Treatment as usual
Outcome	Primary outcomes that involve PTSD or OSI impacts, harm or suicide prevention, symptom reduction (anxiety, sleep, depression, PTSD), coping, quality of life, prevention, rehabilitation, social support, recovery, stigma, treatment, intervention, inpatient and outpatient

PTSD = posttraumatic stress disorder; OSI = operational stress injury.

The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used to provide transparency about how searches were conducted, including screening and reporting.²⁹

By using these frameworks, we aimed to enhance the quality and reliability of this review. Scoping reviews are often used as a mapping process or reconnaissance to determine the lay of the land about a topic. See Figure 1 for the PRISMA flow diagram.

Figure 1.

PRISMA-ScR flow diagram for the primary and grey literatures (Population, Interventions, Comparators, and Outcomes process)

PRISMA = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews.

Inclusion and exclusion criteria

The inclusion criteria were as follows: publication between 2011 and 2022, English or French language, peer-reviewed primary research, including experimental and quasi-experimental designs and outcome measures, as described in Table 1, military or PSP target population, and PTSD or OSI as primary outcomes. Excluded studies were those using first-line therapies (pharmaceuticals and CBT only), couples or family therapy, and a non-Canadian population of interest, protocols, dissertations, and reviews.

Search strategy

The goal of this stage was only to identify programs; therefore, primary research and grey literature were included. Programs were only included if they described a program that primarily targeted community PSP, military personnel, or both. For example, programs that listed several services in a clinic-like setting were not included because individual outcomes could vary depending on which services were selected. Several studies were excluded as they lacked a comprehensive program plan and outcomes. An academic librarian was consulted throughout the search process.

The initial search identified primary literature using CINAHL, EMBASE, the American Psychological Association’s PsycINFO, and MEDLINE in April 2021. One reviewer conducted a search and consulted with and discussed results with a second member of the author team. All citations were imported to Covidence; they were first screened by title and abstract, then by full review for those selected against protocol, see Table 2 for sample search. The search was extended to include hand searches of reference lists to identify studies.

Table 2.

Primary literature search sample: APA PsyclNFO <1806 to April Week 2, 2021>

Search no.	Search terms	No. of records
1	exp military personnel/	31,478
2	military veterans/	14,287
3	military psychology/ or military psychiatry/	2,205
4	military measures/	105
5	military.mp.	45,059
6	law enforcement/	4,386
7	police personnel/ or exp emergency personnel/ or exp law enforcement personnel/	15,381
8	first responders/	317
9	firefighters/	989
10	1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9	65,519
11	exp occupational stress/	22,653
12	exp posttraumatic stress disorder/ or acute stress disorder/	34,851
13	emotional trauma/ or acute stress disorder/	16,138
14	exp major depression/	138,042
15	exp mental health/	71,384
16	or/11–15	265,778
17	Military Psychology/	1,936
18	Military Psychiatry/	307
19	exp Drug Therapy/	149,147
20	Cognitive Behavior Therapy/	2,0854
21	exp Treatment/	1,089,476
22	Workplace Intervention/	1,004
23	exp Group Intervention/ or exp Crisis Intervention Services/ or exp Crisis Intervention/ or exp Intervention/	115,654
24	or/17–23	1,091,367
25	10 and 16 and 24	4,364
26	Canada.mp.	40,955
27	Canadian.mp.	24,984
28	26 or 27	5,3695
29	25 and 28	62

Note: AII searches were done in consultation with academic librarian. Search terms across databases may have varied slightly (additional databases include CINAHL, MEDLINE, and EMBASE).

APA = American Psychological Association.

A second search for primary research was conducted using Google Scholar with the following search terms: military, Veteran, public safety personnel, firefighters, paramedics, correctional officers, police and RCMP, intervention, rehabilitation, treatment, peer support, programs, posttraumatic stress, operational stress/injury, prevention, rehabilitation, social support, recovery, stigma, and treatment. For each search combination, only programs with reported and published outcome measures were included.

Finally, grey literature was also included. Although there can be considerable variation in agreement or consensus, grey literature has been described as any source generally not intended for publication, including conference proceedings or websites.^31,32 We used the Respect Forum database, Google, and hand searches of reference lists. In addition, a database search for available programs was conducted using a draft of the RESPECT Map, which aims to connect individuals in uniform with services across Canada.³³ Programs were identified and screened using the PICO criteria described previously. Most programs that were excluded offered services or treatment to a broad community, not specifically to military or PSP. See Table 2.

Table 3.

Database search of programs and services available in Canada for the military and PSP (RESPECT; N = 126)

Program type or service	n
Community-based	14
Housing or homelessness	12
Financial	3
Counselling and clinical	10
Crisis or support groups	6
Medical service	10
Research and education	10
Military resources	18
Religious or spiritual	4
Fundraising and charity	3
Mental health and well-being	5
Unclassified	5
Duplicates (national programs listed in multiple locations)	36

Note: Resources listed are as of May 2021 and may not reflect more recent database updates.

PSP = public safety personnel.

Results

Search results: primary research

The primary search found 519 studies, 89 of which were duplicates and were removed. The remaining 430 were screened by title and abstract, and 370 were found to be not relevant. A secondary search was conducted by searching the reference lists of studies previously extracted in the primary search: 16 articles were screened with no duplicates, and 1 was found to be relevant to the review and included. Finally, a Google Scholar search was also conducted. In total, 64 studies were identified, and 13 were included in this review.

Most studies found in the primary and secondary searches were designed for military and Veterans (n = 9), firefighters (n = 1), police (n = 1), PSP (n = 1), and military, Veteran, and PSP (n = 1). The studies included a total of 5,232 individuals, 31.8% (n = 1,664) females. The types of intervention included were psychoeducational (n = 3), wilderness and adventure programs (n = 2), group therapy (n = 1), therapeutic enactment (n = 1), yoga (n = 1), and animal therapy (n = 1). In addition, four studies included more than one type of intervention. Similarly, the studies had a range of reported outcomes, including symptom management (n = 9), personal growth (n = 2), resiliency and stigma (n = 1), and goal setting (n = 1).

Search results: program search

The RESPECT Map database (Mapping of Services to Personnel in Uniform) was used to identify available programs not found in the primary search. As of May 2021, the database reflected 126 unique titles representing services and programs available to the military and PSP.

Programs and services were grouped into thematic categories by the first author on the basis of the program’s stated primary delivery format (e.g. a wilderness-based peer support program was classified as wilderness/adventure) and the categorization process of previous systematic reviews on similar topics.^27,33 From this list, seven programs were identified on the basis of previously described criteria. For example, programs that did not primarily serve the population of interest were excluded, as were those based on financial assistance and housing services. In addition, programs were included in this study if they clearly described a mental well-being program with targeted outcomes.

Multimodal programs that included interventions with several strategies or modalities were the largest program type found in this review (four total^34–37) and included a minimum of three therapeutic approaches, such as peer support, animal therapy, nature, or wilderness training. Programs were mostly short term and immersive, ranging from three days up to four weeks at remote or isolated locations. Among those reporting outcomes, immediate positive effects were described; however, no long-term follow-up was conducted, and these studies had small sample sizes, limiting their generalizability.

Discussion

Military and PSP members may be at higher risk of developing operational and posttraumatic injuries because of the nature of their work. Pharmaceutical agents have long been relied on to treat the associated mental health conditions, with moderate success. The increased interest in and use of novel psychopharmaceuticals signals the importance of finding and adapting new interventions that may help to address the gap when patients do not respond to first-line interventions. Despite an apparent increase in mental health programming, little is known about the effectiveness of these programs and how they may be able to treat or mitigate the effects of OSIs.

This scoping review identified 13 programs through a methodical search of current literature, supplemented by a thorough search of grey literature, including a new public database that yielded an additional seven programs. There was significant heterogeneity among studies and programs in design, type, population, and outcomes.

Most empirically validated programs were delivered to military and Veteran populations or a single group, such as police or firefighters. The programs that did not report any published studies tended to include a wider range of populations, including military, Veterans, PSP, and health care workers, which may reflect a shift in studying these groups together as a result of the high-risk nature of their work, for which higher rates of OSIs are reported. Also not explicitly included in any of these studies or programs were services targeted at corrections personnel, which is consistent with previous reviews that found few intervention studies for this population, calling attention to a significant gap in our understanding of services and needs for this group.²⁵

Several wilderness-based or nature-based adventure training programs delivered to small groups for six to seven days (Tables 4 and 5) were found. Two studies showed some positive outcomes in the domains of stigma reduction, improved sense of empowerment, and overall well-being. Although there seem to be more programs of this type and significant literature supporting the benefits of nature-based programs for this population, there is, however, little if any evidence of long-term results or outcomes.⁴⁷ This may limit exposure to these programs and the dissemination of their outcomes to users, clinicians, and program planners.

Table 4.

Primary literature results (N = 13)

Study	Study type	Location	Ratio male/female	N	Intervention	Delivery	Population	Duration	Outcome measures
Richardson and colleagues8	Retrospective	London, Ontario	99/1	102	Psychotherapy Psychoeducation Pharmaceutical	Psychotherapist Psychologist	Military	60 min every 2–4 wk	Symptom management, CAPS, PCL-M, BDI, BAI, AUDIT, SF-36
Sommerfeld and colleagues38	Observational Mixed methods	Northwest Canada	91.7/8.3	72	Psychoeducation Wellness Kit	Researcher	Firefighters	60 min ×1	Goal setting, writing, role-playing, feasibility of training
Szeto and colleagues39	Meta-analysis Pre-post Surveys Nonrandomized quasi-experimental	Nationwide	65.2/33.2	4649	Road to Mental Readiness	Not stated	First responders Public safety personnel	4 or 8 h with follow-up at 3 mo	Stigma, help seeking, resilience, OMS-WA
van Reekum & Watt40	Nonrandomized Pre-post Interviews	Halifax, Nova Scotia	All male	20	Interpersonal group therapy	Psychologist Psychiatrist	Veterans RCMP	90 min × 12	Symptom reduction, alcohol use, PCL-5, DASS, ASI-3, MIQ-M, AUDIT, TAS
Belliveau and colleagues41	Interviews	British, Columbia	All male	6	Therapeutic enactment Group therapy	Researcher	Military	30–45 mins	Personal change, connection, identity
Cox and colleagues34	Pre-post	British Columbia	All male	56	Therapeutic enactment Group-based, emotional regulation, enactment, reducing barriers, goal setting	VTP Psychologists Psychiatrists Paraprofessionals (trained military)	Military	3 weekends, approx. 4 wk, total 80 h	BDI-II, TSI
Westwood and colleagues35	Pre-post, qualitative	British Columbia	All male	18	Group-based, emotional regulation, enactment, reducing barriers, goal setting	Psychologists Counsellors Physicians	Military	3 weekends, approx. 4 wk, total 80 h	TSI, BDI-II, SERS
Groll and colleagues42	Prospective longitudinal cohort	Ontario	77.8/22.1	57	Yoga	Not stated	Military Veteran	60 min weekly × 12	PCL-M, BDI-II, SF-12, DRRI-CES, PSQI, ASI-3, MPQ, STAXI
Vincent and colleagues43	Multiple time series	Canada	Not stated	15	Animal therapy (dogs)	Dog training school Assistance dog International guidelines	Military Veteran	Ongoing, 3 mo	PSQI, PCL-M, BDI-II, WHOQOL-BREF, LSA
Carleton and colleagues44	Times series	Canada	43.5/56.5	147	Road to Mental Readiness	Organizational	Police		AUDIT, DASS-21, BRS, MAKS, OMS-WA, PCL-5, UWES-9, R2MR-Specific, R2MR-Skills
Dentry and colleagues36	Mixed methods	Ontario	50/50	16	Peer support Individual Group Adventure Equine	Medical doctor Physiatrist	Military Public safety personnel	6 d, in residence	LCS, K-6
Harper and colleagues45	Longitudinal mixed methods	Canada	87/23	54	Wilderness adventures	Veterans	Military Veteran	6 d	OBOI
Forsyth and colleagues46	Longitudinal mixed methods	Canada	70/30	20	Wilderness adventures	Veterans	Military Veteran	6 d	EASI

CAPS = Clinician-Administered PTSD Scale; PCL-M = PTSD Checklist-Military Version; BDI = Beck Depression Inventory; BAI = Beck Anxiety Inventory; AUDIT = Alcohol Use Disorders Identification Test; SF-36 = 36-item Short Form Survey; OMS-WA = Opening Minds Scale for Workplace Attitudes; RCMP = Royal Canadian Mounted Police; PCL-5 = PTSD Checklist for the DSM; DASS = Depression Anxiety Stress Scale; ASI-3 = Anxiety Sensitivity Index-3; MIQ-M = Moral Injury Questionnaire-Military Version; TAS = Trait Anger Scale; VTP = Veterans Transition Program; BDI-II = Beck Depression Inventory-II; TSI = Trauma Symptom Inventory; SERS = Self-Esteem Rating Scale; SF-12 = Short-Form Health Survey-12; DRRI-CES = Deployment Risk and Resilience Inventory–Combat Exposure Subscale; PSQI = Pittsburgh Sleep Index; MPQ = McGill Pain Questionnaire; STAXI = State-Trait Anger Expression Inventory; WHOQOL-BREF = Brief World Health Organization Quality of Life Questionnaire; LSA = Life Space Assessment; DASS-21 = Depression Anxiety Stress Scale-21; BRS = Brief Resilience Scale: MAKS = Mental Health Knowledge Schedule; UWES-9 = Utrecht Work Engagement Scale-9; R2MR-Specific = Road to Mental Readiness-Specific; R2MR-Skills = Road to Mental Readiness-Skills; LCS = Life Challenges Survey; K-6 = Kessler Psychological Distress Scale; OBOI = Outward Bound Outcomes Instrument; EASI = Endorsed and Anticipated Stigma Survey; PTSD = posttraumatic stress disorder.

Table 5.

RESPECT Map database search for programs: grey literature (n = 7)

Organization	Date	Location	Population	Intervention	Delivery	Outcomes	Duration	Measures
Camp My Way	2019	British Columbia	Military First responders	Wilderness Camping Exercise Nutrition Meditation Peer support	Not stated	OSI coping	Not stated	N/A
Canadian Women’s Wellness	2018	British Columbia, Nova Scotia	HCW Military PSP	Meditation	Practitioner	PTSD symptoms, other physical and mental conditions	Not stated	Research available on the website, program specific
Can Praxis	n.d.	Alberta	Military Veteran PSP	Equine therapy	Not stated Psychologist	Symptom reduction		Holster belt
Camp Aftermath	2017	Ottawa based	Military Veteran PSP	Volunteerism Yoga Meditation Animal care Farming Peer support Nature	Veterans, peer support	Management of OSI/PTSD	3 phases, 1 y screening, 6 d treatment, 1 y follow- up	N/A
Warrior Adventures	2018	Ottawa based	Military Veteran PSP	Peer support Nature Adventure Technical skills	Veterans Peer support	Prevent or reduce PTSD and OSI	6 d	N/A
Rogue Adventures	2018	Squamish based	Military Veteran PSP	Adventure Kiteboarding Yoga Mindfulness	Veterans	Prevent or reduce PTSD and OSI	7 d	N/A
Badge of Life Canada	2010	Bruce Peninsula	Police Corrections	Peer support Animal therapy Hiking Psychoeducation	Peer support Chaplains	Posttraumatic growth	2 wk virtual 1-wk retreat 16 wk virtual	N/A; – requested published research from the author, no response

OSI = operational stress injury; N/A = not available; HCW = health care workers; PSP = public safety personnel; PTSD = posttraumatic stress disorder.

Psychoeducation was the primary delivery format for three programs, and although not considered within the scope of CAM, psychoeducation was used as a prevention approach to mental-health-related issues. This approach is also not among first-line interventions; however, it was included in several programs as a complementary strategy. Psychoeducation is broadly defined as a health promotion education and training approach.^25,48

Additional programs included in this review were animal therapies (dog and equine), group therapy, and therapeutic enactment. Each of these programs reported data from small groups, with no or limited follow-up, limiting their generalizability. Several programs describing equine therapy were found during the search process of this review and were excluded because they lacked a clear program description and target population with measurable outcomes.

Other systematic reviews that have touched on a similar topic have produced far more studies and programs than found in this review that looked only at Canada.^25–27 In addition, although previous reviews did not primarily focus on novel or CAM interventions, they identified different approaches to mitigating the effects of OSIs and the variety of outcomes being addressed, which included psychoeducation, wellness capacity, mental health and stigma awareness,²⁶ psychological injury,²⁷ and mindfulness training.²⁵ Ultimately, this demonstrates that alternative approaches to managing OSIs are being used globally and highlights where Canada may be behind in testing these programs.

Strengths and limitations

This scoping review explored mental health programming for the Canadian military and PSP over the past 10 years. The search focused primarily on programs that produced peer-reviewed literature; however, to gain a broader overview, we also included many programs that had not undergone full evaluation. This approach allowed for a more comprehensive picture of availability and emerging trends. Another strength of this review was using a database that provided a more up-to-date and inclusive list of programming that might otherwise have gone undetected.

This review was limited by having a single reviewer performing the search, data extraction, and quality assessment; therefore, there is risk of bias. However, an additional reviewer was consulted at each step of the review process. Because of the wide range of programs and study types included, generalizability and assessment of effectiveness are difficult. Although this review aimed to provide as complete a picture as possible, programming is rapidly developing and reflects only what was found at the time of the search process.

Future directions

This review reiterates previous findings and recommendations that call for evidence-based programming and focuses on some areas of further development. Future studies should use validated outcome measures and formal reporting methods such as peer-reviewed publications. Testing programs with a diverse population that includes military and PSP is also recommended. On the basis of this scoping review, a systematic review of the effectiveness of Canadian programs is warranted. There is also need for larger, more robust studies, such as randomized controlled trials, with longer-term follow-ups to assess the stability and maintenance of outcomes. Finally, with the increase in emerging novel programs, further investigation is warranted into the use of CAM services available in Canada for military and PSP and their role as adjunctive therapies.

Conclusions

Currently, the literature on novel or holistic treatment programs and services available for military and PSP in Canada is limited. Although it is a positive sign that new programs are on the rise, they largely lack peer-reviewed studies. This may limit what clinicians are willing to recommend for patients to help inform, mitigate, or even prevent the effects of OSIs. The increase in the availability of therapeutic and intervention programs that take a holistic or alternative approach to OSIs may signify that these methods are becoming more broadly accepted and used among the military and PSP. Future studies that focus on longer-term outcomes may help ensure the quality and integrity of programs and the health and safety of program participants.

Biographies

Ashleigh Forsyth, BA (psychology), MSc (rehabilitation science), is currently completing a PhD in neuroscience and holds degrees from Thompson Rivers University and Queen’s University. In 2015 she received the Royal Canadian Legion Master’s Scholarship for her research on stigma. Ashleigh’s research interests are military, Veteran and public safety personnel mental health, resiliency, and novel programming, including adventure and wilderness training.

Anees Bahji, BSc(H), MD, CISAM, CCSAM, DABPN, FRCPC, is a psychiatrist and PhD candidate at the University of Calgary, specializing in addiction medicine and health services research. His work focuses on cannabis use disorders, psychiatric comorbidities, and health administrative data. He is co-chair of the Section of Addiction Psychiatry of the Canadian Psychiatric Association and has a strong interest in leveraging evidence-based practices to improve public health outcomes.

Jeremy G. Stewart, PhD, CPsych, is an associate professor in the Department of Psychology at Queen’s University. His research aims to understand and quantify vulnerability to suicidal and self-injurious behaviour among youth across distinct units of analysis (e.g., environmental circumstances, behaviour, physiology). He teaches advanced courses focused on child and adolescent mental health and cognitive-behavioural treatment approaches. Furthermore, Stewart internationally trains research groups and programs in life stress assessment and procedures for responding to suicide risk.

Maj. (retd) Matthew Simpson, MSc, MD, CCFP, FCFP, CD2, is a family physician and Assistant Professor of Medicine at Queen’s University. Raised in a military family, he served in both the Primary Reserves (1990-2003) and the Regular Force (2003-15) and deployed to Afghanistan in 2010 as a physician. He teaches in the family medicine residency program and provides primary care to Veterans and military families. He was recently made honorary colonel for the base hospital in Kingston.

Dianne Groll, PhD, is an adjunct associate professor of psychiatry and psychology at Queen’s University in Kingston, Ontario. She has been engaged in population health research for more than 25 years, focusing on mental health, posttraumatic stress disorder, and population health research. Her expertise is in quality-of-life research, research methodology, and statistics. Her research is funded by the Canadian Institutes of Health Research and other agencies.

Funding Statement

No funding was received for this article.