Pre‐deployment programmes for building resilience in military and frontline emergency service personnel

Abstract

Background

Military personnel and frontline emergency workers may be exposed to events that have the potential to precipitate negative mental health outcomes such as depression, symptoms of post‐traumatic stress and even post‐traumatic stress disorder (PTSD). Programmes have been designed to build psychological resilience before staff are deployed into the field. This review presents a synthesis of the literature on these “pre‐deployment resilience‐building programmes”.

Objectives

The objective of this review was to assess the effectiveness of programmes that seek to build resilience to potentially traumatic events among military and frontline emergency service personnel prior to their deployment. These resilience programmes were compared to other interventions, treatment as usual or no intervention.

Search methods

Studies were identified through searches of electronic databases including Ovid MEDLINE, Embase, PsycINFO, Web of Science and Google Scholar. The initial search took place in January 2019, with an updated search completed at the end of September 2020.

Selection criteria

Only studies that used a randomised controlled trial (RCT)/cluster‐RCT methodology were included. The programmes being evaluated must have sought to build resilience prior to exposure to trauma. Study participants must have been 18 years or older and be military personnel or frontline emergency workers.

Data collection and analysis

Studies that met the inclusion criteria were assembled. Data extracted included methods, participants’ details, intervention details, comparator details, and information on outcomes. The primary outcomes of interest were resilience, symptoms of post‐traumatic stress and PTSD. Secondary outcomes of interest included acute stress disorder, depression, social support, coping skills, emotional flexibility, self‐efficacy, social functioning, subjective levels of aggression, quality of sleep, quality of life and stress. Assessment of risk of bias was also completed. A total of 28 studies were included in a narrative synthesis of results.

Main results

All 28 included studies compared an experimental resilience building intervention versus a control or no intervention. There was a wide range of therapeutic modalities used, including cognitive behavioural therapy (CBT) informed programmes, biofeedback based programmes, stress‐management programmes, mindfulness and relaxation programmes, neuropsychological‐based programmes, and psychoeducational‐informed programmes. The main outcomes are specified here, secondary outcomes such as depression, social support, coping skills, self‐efficacy, subjective levels of aggression and stress are reported in text. No studies reported on the following pre‐specified outcomes; acute stress disorder, emotional flexibility, social functioning, quality of sleep and quality of life.

Resilience

Eight studies reported resilience as an outcome. We narratively synthesised the data from these studies and our findings show that five of these interventions had success in building resilience in their respective samples. Two of the studies that reported significant results utilised a CBT approach to build resilience, while the other three successful programmes were mindfulness‐based interventions.

Symptoms of post‐traumatic stress

Our narrative synthesis of results included eight studies. Two of the eight studies produced significant reductions in symptoms of post traumatic stress compared to controls. These interventions used neuropsychological and biofeedback intervention models respectively.

PTSD caseness

Four studies reported PTSD caseness as an outcome. Our narrative synthesis of results suggests that evidence is mixed as to the effectiveness of these interventions in reducing clinical diagnosis of PTSD. One study of a neuropsychology‐orientated Attention Bias Modification Training (AMBT) programme had success in reducing both symptoms of post‐traumatic stress and numbers of participants receiving a diagnosis of PTSD. A stress‐management programme reported that, when baseline differences in rates of pre‐deployment mental health issues were controlled for, participants in the control condition were at 6.9 times the risk of a diagnosis of PTSD when compared to the intervention group.

Given the diversity of intervention designs and theoretical orientations used (which included stress‐management, neuropsychological and psychoeducational programmes), a definitive statement on the efficacy of pre‐deployment programmes at reducing symptoms of post‐traumatic stress and PTSD cannot be confidently offered.

Authors' conclusions

While a number of evaluations of relevant programmes have been published, the quality of these evaluations limits our ability to determine if resilience‐building programmes 'work' in terms of preventing negative outcomes such as depression, symptoms of post‐traumatic stress and diagnoses of PTSD. Based on our findings we recommend that future research should: a) report pre‐/post‐means and standard deviation scores for scales used within respective studies, b) take the form of large, RCTs with protocols published in advance, and c) seek to measure defined psychological facets such as resilience, PTSD and stress, and measure these concepts using established psychometric tools. This will provide more certainty in future assessments of the evidence base. From a clinical implications point of view, overall there is mixed evidence that the interventions included in this review are effective at safe guarding military personnel or frontline emergency workers from experiencing negative mental health outcomes, including PTSD, following exposure to potentially traumatic events. Based on this, practitioners seeking to build resilience in their personnel need to be aware of the limitations of the evidence base. Practitioners should have modest expectations in relation to the efficacy of resilience‐building programmes as a prophylactic approach to employment‐related critical incident traumas.

Plain language summary

How effective are military and frontline emergency service personnel pre‐deployment resilience building programmes?

Military and frontline emergency services personnel are at risk of developing PTSD (post‐traumatic stress disorder) and other trauma‐related psychological difficulties if they witness potentially traumatising events. Such events can include witnessing injuries or death or being exposed to situations where the personnel themselves are at risk of injury or death. Theoretically, it may be possible to build the psychological resilience of these personnel before they are faced with these types of events, thus reducing the occurrence and severity of distress after traumatic events. This review identified and collated the evidence for these type of resilience‐building programmes. Only studies that used an experimental group versus control group design (randomised controlled trial (RCT)/cluster‐RCT) were selected for the review. Over 6774 records were screened, with 28 studies selected for inclusion in the review. The programmes included in this review were informed by different theories (‘theoretical orientation’) and delivered in different ways (e.g. on‐line/off‐line; group‐based/individual). There is not yet enough evidence to support the assertion that such programmes can build resilience to symptoms of psychological stress and prevent a diagnosis of PTSD following critical incidents. This said, there are limitations to the existing evidence base. There is significant variety in the ways resilience‐building programmes are: theoretically orientated, populations targeted, how they are delivered, setting used, and outcomes measured (with further variety in scales used within specific outcomes). This has made drawing conclusions on how effective these programmes are, difficult as they are often not sufficiently similar to make fair comparisons. Future evaluations need to overcome these limitations, thus allowing us to determine if these programmes have value in pre‐deployment preparation and training.

Background

Military personnel and frontline emergency workers are at high risk of witnessing, or otherwise being involved in, potentially traumatic events (PTEs), also sometimes referred to as critical incident traumas (CITs) in the literature. For military personnel, these incidents can arise during humanitarian, peacekeeping or combat duties, and involve serious threat to the life of the personnel or those in their environment. For frontline emergency services workers (e.g. police officers, paramedics, firefighter), there can be similar risks to their own well‐being and that of others. In the wake of these events, some personnel will experience symptoms of post‐traumatic stress, and some will go on to develop post‐traumatic stress disorder (PTSD).

In an effort reduce the risk of developing mental health issues post exposure to a potentially traumatic event, programmes have been developed that seek to build the resilience of personnel prior to deploying them into situations where they may experience critical incidents. This review focuses on such programmes, and specifically those developed for military personnel and emergency first responders. The review is part of a wider programme of research requested by, and being completed in collaboration with, the Irish military (Defence Forces Ireland, DFI). It is intended that the research team will use the findings to design and pilot a novel pre‐deployment resilience‐building programme for military personnel being deployed on humanitarian and peacekeeping missions abroad.

Description of the condition

The World Health Organization (WHO) defines a CIT (critical incident trauma) as "an event outside the range of normal experience; one that is sudden and unexpected, makes you lose control, involves the perception of a threat to life, and can include elements of physical or emotional loss" (WHO 2006) Those who seek support following exposure to such CITs report symptoms of psychological trauma including helplessness, intense anxiety, intrusive thoughts, nightmares and difficulties with executive functioning (e.g. Bisson 2009; Janoff‐Bulman 1998). These symptoms can ultimately leave the individual profoundly distressed, with their lives “dominated by terror, silent humiliation, and visible pain” (Katsounari 2015)

For some, these symptoms will be short term (i.e. an ‘acute stress response’). For others; however, the symptoms of post‐traumatic stress will persist, and the presentation will meet the diagnostic criteria for PTSD. The classification of PTSD has changed over successive editions of the Diagnostic and Statistical Manual (DSM). Currently, the incident must have presented a threat of death or serious injury, and a range of other symptoms must be experienced including intrusion (e.g. nightmares), avoidance (e.g. of thoughts or feelings), change in mood and cognition (e.g. negative affect), and alterations in arousal and reactivity (e.g. heightened startle response) (APA 2013).

Research conducted with US soldiers returning from the Afghan War found that approximately 7% to 13.5% developed PTSD (Hines 2014) More variable rates have been reported for veterans of the Iraq War, where 4% to 17% of US veterans met the criteria for PTSD (Richardson 2010). The prevalence appears to be higher among Vietnam War veterans, where rates as high as 30.9% have been reported (Fisher 2014). These rates contrast with those in the general non‐military population, where a lifetime prevalence is estimated to be approximately 3.9% (Koenen 2018). High rates of PTSD have also been reported among emergency service personnel. For example, rates of PTSD are estimated to be four to six times higher among law enforcement personnel than the civilian community in the UK (Green 2004).

Description of the intervention

Resilience is a process where an individual displays positive adaptation despite the experience of significant stress in adverse situations (Luthar 2000; Richardson 2010). Fergus 2005 suggests that an individual’s resilience is made up of a combination of their internal “assets”, referring to an individual’s innate personality characteristics such as coping skills, and “resources” which refers to external protective factors such as a good quality social support structure. When an individual is exposed to severe adversity, such as witnessing human suffering during humanitarian or peacekeeping missions, resilience has been shown to have protective value against the harmful short‐term impacts of exposure to potentially traumatic events and can safeguard against the development of symptoms of post‐traumatic stress, PTSD and other negative mental health outcomes (Horn 2016).

Evidence would suggest that the risk of developing symptoms of post‐traumatic stress, acute stress responses and/or PTSD after a critical incident is determined by the interaction of pre‐trauma, peri‐trauma and post‐trauma risk and protective factors (e.g. Brewin 2000; Ozer 2003). Theoretically it may be possible to target some of these risk factors, or "assets" and "resources" prior to being exposed to a critical incident, and in doing so reduce the occurrence and severity of the post trauma response. Such programmes, for example, could seek to enhance frontline workers' ability to regulate emotions in general (a pre‐trauma risk factor); to manage dissociation (a peri‐trauma risk factor) and to harness social support (a post‐trauma factor). There may also exist a degree of flexibility, in terms of therapeutic modality, to build resilience. For example Mindfulness programmes may help build an individuals skills to enhance their ability to regulate emotions, while cognitive behavioural therapy (CBT) informed programmes may enhance an individual's ability to deal with intrusive thoughts which may follow exposure to a potentially traumatic event. Stress management programmes may decrease the risk of developing symptoms of post‐traumatic stress. Research by Maguen 2009 reported that routine work environment stress mediated the relationship between critical incident exposure and PTSD symptoms, whereby higher chronic stress increased the risk of developing symptoms of post‐traumatic stress. During an initial scoping exercise completed to inform this review, it was clear that approaches to building resilience to trauma among military and emergency service personnel have adopted a number of different therapeutic orientations. These include, but not limited to CBT; Horn 2016; Southwick 2015), behaviour therapy (e.g. stress exposure therapy) (Fava 2009), and biofeedback techniques (Reivich 2011). Programmes are delivered in different formats and through different media, including in group‐based (Padesky 2012) and individual (Cohn 2010) formats, and online (Castro 2006; Gonzalez 2014).

How the intervention might work

Interventions in this area are likely to adopt and integrate a range of different theoretical models, based on the specific identified needs of the target population. One example is the US Navy's Stress Resilience Training System (STRS) (Rose 2013). The SRTS integrates cognitive therapy and biofeedback training (de Vissier 2016) and is delivered via a tablet or computer (Cohn 2010). A central component of the programme involves training participants to regulate their physiological arousal in times of stress, with participants completing tasks that seek to enhance heart rate variability (HRV). High HRV is associated lower autonomic nervous system arousal and thus better stress resilience (Cohn 2010; Melillo 2011). The programme consists of a six‐ to eight‐week training phase incorporating student guided interaction and, in some cases, a weekly one‐hour mentoring session provided over the phone (de Vissier 2016).

The Master Resilience Training (MRT) is a second example. The MRT is a key part of the US Army’s pre‐deployment programme known as Comprehensive Soldier Fitness (Cornum 2011). Over a 10‐day period, non‐commissioned officers (junior leaders in the military) and are taught techniques and skills for building resilience among the soldiers they lead prior to deployment (Reivich 2011). The programme builds resilience through teaching mindfulness competencies, such as self‐awareness and self‐regulation, that facilitate effective coping in the face of stressful situations. The programme also incorporates aspects of CBT, for example the ABC model (adversity– belief– consequence) as developed by Ellis 1962 where soldiers are trained to identify thoughts that are triggered by activating events and to identify reactions that are driven by those thoughts. (Reivich 2011)

Also pertinent to this review are the resilience programmes utilised by emergency and frontline agencies, such as the police, fire service, and non‐governmental organisations (NGOs) involved in humanitarian work. Such responders can be subjected to comparable CITs to those experienced by military personnel. For example, one programme developed and tested with Swedish police seeks to desensitise the officers from stressors they may encounter during their duties (Arnetz 2009). Prior to stress inducing exposures, officers are provided with coping skills to manage their in‐the‐moment response to the stressor, and with desensitisation occurring over a period of repeated exposure. Arnetz 2009 and colleagues argue that such enhancement of stress‐specific adaptive responses reduces adverse psychological and physiological outcomes, such as over activation of amygdala‐hypothalamic‐pituitary axis, which has been shown to be a predictor of PTSD.

Why it is important to do this review

The best evidence would suggest that military personnel and frontline emergency workers are at higher risk of receiving a diagnosis of PTSD than the general population. This is likely to arise due to their increased likelihood of exposure to PTEs/CITs. Given this heightened risk, those responsible for the health and well‐being of staff must, where possible, act preventatively to protect their mental health and psychological well‐being. One part of this preventative work may involve developing and implementing pre‐exposure/pre‐deployment resilience building programmes that enhance the psychological resilience of staff to better enable them to manage highly stressful CITs.

A key part of the process in developing new interventions is the synthesis of evidence from those delivered in the past (Craig 2008). A number of reviews of relevant literature are available. Hourani 2011, for example provided a synthesis of the stress control literature and, investigated the interventions utilised by the US, UK, and UN forces. The review concluded that the most promising avenues for PTSD prevention lie in the domains of pre‐trauma exposure strategies and stress reduction training methodologies. Skeffington 2012, provided a broad synthesis of studies from a range of samples including police, military and civilian samples. The authors reported that their search quote: “yielded no trials that met stringent Cochrane Collaboration standards or controlled randomised trials exploring the impact of primary pre‐trauma programs on PTSD development”. Leppin 2014, reported limited evidence supporting the effectiveness of pre‐deployment resilience building interventions in civilian samples. However, there are limitations to these reviews. Hourani 2011 reviewed studies that used military samples only, excluding programmes used by emergency services. Skeffington 2012, in their synthesis, did not include any randomised controlled trials. Leppin 2014, did not include any military or emergency service pre deployment resilience programmes, opting for civilian programmes only. This Cochrane Review builds upon the work of Hourani 2011, Skeffington 2012, and Leppin 2014 by providing a detailed synthesis of randomised controlled trials, including military and emergency services samples. The first Cochrane Review of its kind, this review represents the most comprehensive review of pre‐deployment resilience building randomised controlled trials to date to our knowledge

In providing a comprehensive review of the evidence of direct relevance to military personnel and frontline emergency services workers, this review can help inform the design of novel resilience‐building programmes. This review is part of a larger body of research being completed at the request of, and in collaboration with, the Irish military. It is intended that the review, in conjunction with complementary studies (e.g. qualitative research with military personnel on deployment), will contribute towards the design of a novel pre‐deployment training programme that can enhance the resilience of military personnel to CITs.

The project team is composed of clinical and forensic psychologists and intervention methodologists based at the National University of Ireland Galway, who work closely with DFI. The work is being overseen by a steering group composed of military personnel (psychologists and employee‐assistance staff) and subject‐matter experts.

Objectives

The objective of this review was to assess the effectiveness of programmes that seek to build resilience to psychological trauma among military and frontline emergency service personnel prior to their deployment. These resilience programmes were compared to other experimental interventions, treatment as usual or no intervention comparators.

Methods

Criteria for considering studies for this review

Types of studies

We included randomised controlled trials (RCTs), cluster‐RCTs, and cross‐over trials, irrespective of their publication status, in our review. Quasi‐RCTs and other research designs were excluded.

Types of participants

Participant characteristics

To be included in the review the sample in the study needed to be:

a) military personnel, irrespective of rank, b) front line responders, such as policing, ambulance, and fire services or; c) emergency humanitarian workers. For each study, at least one group/condition participated in a pre‐deployment resilience‐building programme.

Exclusion criteria

We excluded studies that used non‐military or non‐frontline staff as their samples, e.g. army civilian support staff, secondary civilian medical personnel such as those based in a hospital.

Comorbidity

No restrictions were applied on the basis of comorbidity.

Setting

We applied no restrictions on the basis of setting.

Types of interventions

Experimental

We considered any intervention designed to build pre‐deployment resilience in military or emergency service personnel for inclusion in this review. The types of intervention which were included in this review comprised of a variety of therapeutic modalities, for example, cognitive behavioural therapy (CBT) programmes, Mindfulness programmes, Cognitive biofeedback interventions and stress inoculation training programmes, and delivery formats (online, in person group delivery etc). No explicit exclusion criteria was applied to the types interventions eligible for inclusion.

Comparator

Comparator interventions include any other intervention compared to the experimental intervention. We defined "control" comparator as a no intervention/treatment as usual control condition.

Types of outcome measures

We included studies that met the above inclusion criteria regardless of whether they reported the following outcomes. We describe narratively any studies that report outcomes not included here.

Primary outcomes

• Resilience: defined by resilience levels from pre‐intervention to post‐intervention, measured on standardised psychological scales including: Connor‐Davidson Resilience Scale (CD‐RISC) (Connor 2003), the Resilience Scale (RS) (Wagnild 1993), the Resilience Scale for Adults (RSA) (Hjemdal 2011), Dispositional Resilience Scale‐15 (DRS‐15) (Bartone 2007), and the Brief Resilience Scale (BRS) (Smith 2008), among others.

• Symptoms of post traumatic stress e.g. PTSD‐8 (Hansen 2010), Clinically Administered PTSD Scale (CAPS‐1) (Weathers 2001).

• PTSD caseness (defined in this review as a participant reaching the clinical threshold on the following scales, or other, to be eligible for a diagnosis of post traumatic stress disorder) e.g. PTSD‐8 (Hansen 2010), Clinically Administered PTSD Scale (CAPS‐1) (Weathers 2001).

Secondary outcomes

• Acute stress disorder e.g. Acute Stress Disorder Scale (ASDS) (Bryant 2000).

• Depression e.g. Center for Epidemiological Studies Depression Scale (CES‐D) (Radloff 1977).

• Social Support e.g. Personal Resource Questionnaire (PRQ) (Brandt 1981).

• Coping skill e.g. Ways of Coping Checklist (WCCL) (Lazarus 1984).

• Emotional flexibility e.g. the Emotional Flexibility Scale (Fu 2018).

• Self‐efficacy e.g. the Self‐Efficacy Scale (Sherer 1982).

• Social functioning e.g. the Social Adaptation Self‐evaluation Scale (Bosc 1997).

• Subjective levels of aggression e.g. the Aggression Questionnaire (Buss 1992).

• Quality of sleep e.g. Pittsburg Sleep Quality Index (PSQI) (Buysse 1989).

• Quality of life e.g. Quality of Life scale (QLS) (Heinrichs 1984).

• Stress e.g. Perceived Stress scale (PSS) Cohen 1994

Timing of outcome assessment

We recorded outcome measurement pre‐ and post‐intervention. Where there was data recorded at long‐term follow‐up e.g. three months, we recorded this also.

Hierarchy of outcome measures

Where studies used multiple measures for one outcome, then the measure we deemed to have the highest reliability and validity was used as the measure included in the review. For PTSD the CAPS (Weathers 2001) is considered the gold standard for assessment of PTSD by the US Veterans Association (Watson 2002). For resilience there is no firm consensus on a gold standard measure. However, the CD‐RISC (Connor 2003), is one of the most cited measures in the area and a methodological review of resilience scales gave it a high psychometric rating (Windle 2011). As such, the CD‐RISC was used where available in the review. Where there was no obvious 'best' measure, then this was identified through discussion among members of the research team and with reference to the reliability and validity of each scale.

Search methods for identification of studies

Electronic searches

The studies included in this review were identified through searches of the following electronic databases (Appendix 1):

• Cochrane Central Register of Controlled Trials (CENTRAL; 2020, issue 9) in the Cochrane Library (searched 29 September 2020);

• Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) (all years to June 2016);

• Embase Ovid (1974 to 28 Sept 2020);

• MEDLINE ALL Ovid (1946 to 28 Sept 2020);

• PsycINFO Ovid (all years to September Week 3 2020);

• Web of Science Core Collection (SCI‐EXPANDED, SSCI, A&HCI, CPCI‐S, CPCI‐SSH, ESCI) (1900  to 29 Sept 2020);

• Proquest PILOTS: Published International Literature On Traumatic Stress (all years to 30 Sept 2020).

We also searched international trial registries (i.e. ClinicalTrials.gov (https://clinicaltrials.gov/) and the WHO International Clinical Trials Registry Platform (ICTRP) (http://apps.who.int/trialsearch/) for unpublished or ongoing trials).

We applied no restrictions on date, language, or publication status.

Searching other resources

Grey literature

We used a robust and broad search strategy when searching the grey literature. This included a search of the following sources:

• Google Scholar

• OpenGrey

• The British Library Electronic Theses Online Service (EThOS)

• Digital Access to Research Theses (DART ‐ Europe) e‐theses Portal

• Networked Digital Library of Theses and Dissertations (NDLTD)

• Proquest Dissertations and Theses (PQDT) Open ‐ open access dissertations and theses

• Proquest Dissertations & Theses Global

Handsearching

We handsearched abstracts from the following conferences from 2013 to 2018

• The Military Health System Research Symposium (MHSRS)

• The British Psychological Society Military Psychology conference

• Division 19 Society for Military Psychology APA Convention

• The International Applied Military Psychology Symposium

• The International Conference on Building Resilience (ICBR)

Reference lists

We assessed the reference lists of all included studies and relevant systematic reviews (both Cochrane and non‐Cochrane) to identify additional studies not captured in the original searches (e.g. unpublished or in‐press citations).

Correspondence

We contacted trial authors and subject experts for information on unpublished or ongoing studies, or to request additional trial data, where appropriate.

Updated search

An updated search of electronic databases and grey literature sources (less WHO ICTRP trials register as it is currently under maintenance) was completed between 29 September and 6 October 2020. Initial searches were conducted in January 2019. 

Data collection and analysis

Selection of studies

Two review authors (CD and KC) independently assessed the titles and abstracts of studies identified by the literature search, based on the predefined inclusion criteria. These were coded as either ‘retrieve' (eligible or potentially eligible/unclear) or ‘do not retrieve'. We assessed the full text of studies coded as ‘retrieve'. We resolved any disagreement through consensus or, if required, by consultation a third review author (KS). We identified and excluded duplicate records and collated multiple reports that related to the same study so that each study, rather than each report, is the unit of interest of the review. We have listed all studies excluded after full‐text assessment and their reasons for exclusion in a ‘Characteristics of excluded studies' table. We have presented the study selection process in a PRISMA flow chart (see Figure 1).

1.

2018 ‐ 2020 updated second search study flow diagram.

Data extraction and management

Two review authors (CD and KC) independently extracted data from the included studies using a pre piloted data extraction form. Any discrepancies were resolved by discussion or by consulting a third review author (KS). We extracted the following data from each study.

Methods

Author, year of publication, study design, number of study centres and geographic location, study setting (army base, psychologists office, etc.), type of profession targeted in the study and recruitment strategy.

Participants

Standard demographic and descriptive statistics such as number, age, gender, length of service in military/emergency response, nationality, inclusion and exclusion criteria.

Intervention details

Name of intervention, rationale/theory, materials used, procedures used, modes of delivery (individual/group), who delivers intervention (training), location, duration/frequency, and any other facets deemed notable (tailoring of intervention, modifications etc.)

Comparator details

Type of comparator (intervention, no treatment), name of intervention, rationale/theory, materials used, procedures used, modes of delivery (e.g. individual/group), who delivers the intervention, location, duration/frequency, and any other facets deemed notable (tailoring of intervention, modifications)

Outcomes

Outcomes and measurement tools for each relevant outcome measured in the trial.

Notes in relation to funding for trials and notable conflicts of interests.

Main comparisons

1) Experimental resilience intervention versus control or no intervention.

2) Experimental resilience intervention versus experimental resilience intervention.

Assessment of risk of bias in included studies

Two review authors (CD and KC) independently assessed the risk of bias for each included study following the guidance of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We used the Cochrane tool for assessing risk of bias in RCTs according to the following domains:

1. Random sequence generation (selection bias)

2. Allocation concealment (selection bias)

3. Blinding of participants and personnel (performance bias)

4. Blinding of outcome assessment (detection bias)

5. Incomplete outcome data (attrition bias)

6. Selective outcome reporting (reporting bias)

7. Other bias

We judged each potential source of bias as either high, low, or unclear. We have provided a brief justification for our judgement in the risk of bias table. We have summarised the risk of bias judgements across different studies for each of the domains listed (see Figure 2)

2.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

We addressed any disagreements through discussion and consulted a third review author (KS) if necessary. In the case of military resilience programmes, it may be the case that programme design and evaluation is undertaken either internally by military personnel or through third parties where funding is provided by military sources. This may create an additional risk of bias in these cases, which we have considered carefully.

Measures of treatment effect

Dichotomous

As recommended in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011), we planned to calculate a risk ratio (RR) and its 95% confidence interval (CI) for dichotomous data. For statistically significant results, we planned to calculate the number needed to treat for an additional beneficial outcome (NNTB), or the number needed to treat for an additional harmful outcome (NNTH) and 95% CIs.

Continuous

Where trials used similar scales and outcome measures for comparison, we planned to pool data by calculating the mean difference (MD) and 95% CIs.

We anticipated that outcome measures for military resilience programmes would be diverse. As such, we planned to use standardised mean difference (SMD) values, effect sizes (Cohen’s d), and their 95% CIs for treatment effect measurement, where appropriate.

Unit of analysis issues

Cluster‐randomised controlled trials

We included cluster‐RCTs in this review (e.g. organisation by platoon or company). Failing to adjust for the effects of clustering may result in underestimating standard errors and P values. For example, soldiers in the same unit are likely to be more similar to each other, due to shared experience and training style, than soldiers assigned at random (Higgins 2011; Kahan 2016). Where research had not controlled for clustering effects, we planned to contact the study authors for participant data to allow the analysis of intra‐cluster correlation coefficient (ICC). This would have allowed the variance within and between clusters to be assessed (McLaughlin 2014).

Cross‐over trials

We planned to include trials employing a cross‐over design, but we did not find any such trials in our search of the literature.

Dealing with missing data

We contacted investigators in order to verify key study characteristics and obtain missing numerical outcome data where appropriate (e.g. where pertinent intervention details were not provided). We have documented all correspondence with trial authors and report which trial authors responded to our information requests. Similarly, if standard deviations (SDs) were missing, we attempted to obtain these data by contacting trial authors. If SDs were not available from trial authors, we attempted to calculate from P values, t‐values, confidence intervals or standard errors, if these were reported in the trials.

Dichotomous data

We planned to deal with missing dichotomous data through an intention‐to‐treat (ITT) analysis, where we assumed that dropouts in the active treatment group have positive outcomes and those in the control group have negative outcomes (best‐case scenario), and that dropouts in the active treatment group have negative outcomes and those in the control group have positive outcomes (worst‐case scenario). We had planned to conduct a sensitivity analysis to assess how sensitive the results were to reasonable changes in assumptions made.

Continuous data

We planned, where available, to give greater priority to data where principled statistical methods had been used to deal with missing data (e.g. mixed‐effects models, multiple imputation). If these data were not imputed, we intended to use a last observation carried forward approach (LOCF) or completer data, where reported.

Assessment of heterogeneity

We used Chi² tests and I² statistics to assess heterogeneity. A forest plot was created to graphically display heterogeneity. Thresholds for interpreting the I² statistic value are as follows (Higgins 2011).

• 0% to 40%: might not be important.

• 30% to 60%: may represent moderate heterogeneity.

• 50% to 90%: may represent substantial heterogeneity.

• 75% to 100%: considerable heterogeneity

We found considerable heterogeneity between studies and, based on this finding, we have discussed the results of studies in a descriptive format (see Analysis 1.1).

Assessment of reporting biases

In order to minimise the risk of reporting bias, the authorship team devised a comprehensive search strategy. Our searches primarily included large databases of peer‐reviewed, published articles. To specifically address and minimise the potential impact of publication bias on this review, we searched several "grey" literature databases, reference lists of included articles, thesis databases and conference proceedings. These forms of databases may be more likely to include works which failed to produce "positive" significant findings. Their inclusion provides a more complete picture of the field as it currently stands

Data synthesis

We planned to pool data from more than one study, if appropriate, in a random‐effects meta‐analysis. However, given the level of heterogeneity identified in the studies sampled, valid outcome comparisons could not be made, and we have thus presented a narrative synthesis below (Higgins 2011). To support our narrative synthesis, we have provided relevant statistical output, means, standard deviations (SDs), P values and effect sizes where these were available.

Tables and figures

We entered data into Review Manager 5 (RevMan 2014), and have presented this information graphically, so that the area to the left of the 'line of no effect' indicates a favourable outcome for pre‐emptive resilience building.

Subgroup analysis and investigation of heterogeneity

Different therapies may have different effect sizes and acceptability to participants. We planned to explore clinical heterogeneity by examining the characteristics of studies that may be associated with this diversity. The selection of specific areas for subgroup analysis was based on experiences from previous reviews (Helmrich 2017) and a recent meta‐analysis where these subgroups (programme sample, delivery format and study design), were found to account for 47.7% of the variance in reported d values (Vanhove 2015).

We planned to conduct the following subgroup analyses.

• Setting of programme (e.g. military base, hospital, other).

• Type of comparator (control intervention, no intervention).

• Delivery format (e.g. group, individual, online).

• Type of approach to resilience building (e.g. CBT, mindfulness, stress management); we intended to develop categories of approaches on the basis of a thematic analysis of the interventions described in the included studies.

• Length of programme (e.g. number of sessions).

Sensitivity analysis

Where there was an unclear or high risk of bias in any domain, we planned to perform a priori sensitivity analysis based on the following criteria.

• Study quality: we planned exclude studies at high risk of bias in any domain from our sensitivity analysis.

• We planned to exclude studies in which missing data were not imputed, as they are at potentially greater risk of bias.

Summary of findings and assessment of the certainty of the evidence

We planned to create a summary of findings table including the following primary outcomes: resilience level, PTSD prevalence, acute stress disorder (ASD) and depression.

We planned on using the five GRADE recommendations (study limitations, consistency of effect, imprecision, indirectness and publication bias) to assess the certainty of a body of evidence as it relates to the studies that contribute data to the meta‐analyses for the prespecified outcomes. We planned on using the methods and recommendations described in Section 8.5 and Chapter 12 of the Cochrane Handbook of Systematic Reviews of Interventions (Higgins 2011), and using GRADEpro software (GRADEpro GDT 2015). We planned on justifying all decisions to downgrade or upgrade the certainty of evidence using footnotes, and, where necessary, and on making comments to aid the reader's understanding of the review.

Results

Description of studies

Below, we have presented the results of our search which provides a break down of the core characteristics of the 28 studies included in this review. Next, the results of the risk of bias assessment are provided. Finally, results are presented for each outcome of interest, which we specified in the methods section of this paper.

Results of the search

Our search of the seven electronic databases and grey literature returned a total of 6774 studies excluding duplicates. Of the 6774 studies, 138 met the criteria for full‐text review. Following full‐text screening, 28 studies met the criteria for inclusion in this review (see the appended Prisma chart Figure 1).

Included studies

A comprehensive description of the interventions, and comparators, used in the 28 studies included in this review can be found in thesection Characteristics of included studies. Below, please see a global summary of the main characteristics of the studies included in this review.

Types of interventions 

Of the 28 studies that met the criteria for inclusion in this review, there were several theoretical approaches to building pre‐trauma resilience. Three studies used CBT‐based programmes (Cacioppo 2015; Chongruska 2015; Wild 2016), seven studies utilised biofeedback‐based programmes (Bouchard 2012; Janka 2017; Lewis 2015; McCraty 2012; Pyne 2018; Trousselard 2015; Wessemann 2016), five studies were focused on stress inoculation/management (Digliani 1994; Hourani 2016; Hourani 2018; Rosmith 2013; Wild 2017), seven studies used mindfulness and relaxation‐based training (Chitra 2018; Christopher 2018; Crane 2019; Fikretoglu 2019; Joyce 2019; Ranta 2008; Taylor 2011), three studies used neuropsychological‐based programmes (Keynan 2019; Shipley 2002; Wald 2016), and the final three studies used a psychoeducational‐based approach (Adler 2015; Jones 2019; Skeffington 2016). See Table 1 for study details.

1. Study descriptive table.

Study ID	Title of Intervention	Comparator (as titled in each respective paper)	Population	Setting
CBT informed programmes
Cacioppo 2015	Social Resilience Training (SRT)	Active control condition (Cultural Awareness Training CAT)	US Army Soldiers	Military base
Chongruska 2015	Integrated Group Counselling	"informational control" active control condition	Thai Army Rangers	NS (Not specified)
Wild 2016	Resilience intervention	Control	Emergency services personnel	NS (several locations across UK)
Biofeedback based programmes
Bouchard 2012	Immersion and Practice of Arousla Control training	Training as usual control condition	Canadian Soldiers	Militay base
Janka 2017	Biofeedback training	Waiting list control	Crisis management personnel	Crisis management institutions
Lewis 2015	Predeployment stress inoculation therapy (PRESTINT)	Didactic control condition (Didactic lecture on Stress management)	US Army Paratroopers	NS
McCraty 2012	Coherence Advantage Stress Resilience and Performance Enhancement Program (CASRPEP)	Waiting list control	US Law Enforcement Officers	Police station
Pyne 2018	Heart rate variability biofeedback (HRVB) & Cognitive Bias modification for interpretation (CBM I)	Training as usual control condition	US National Guard Soldiers	NS
Trousselard 2015	Tactics to optimised the potential (sic) (TOP) & Cardio Biofeedback training	Training as usual control condition	French Army Firefighters	Military base
Wessemann 2016	Chaos Driven Situations Management Retrieval System (Charly)	Training as usual control condition	German army medical unit personnel	Military base
Stress management programmes
Hourani 2016	PRESIT (Pre‐deployment Stress Inoculation Training)	Active control condition ("current best practice" brochure + lecture on stress management)	USMC Marines	Military base
Hourani 2018	PRESIT	Active control condition (Stress management training)	US Army Soldiers	Military base
Digliani 1994	Stress inoculation training protocol	Delayed treatment control condition	US Law Enforcement Officers	Police station
Rosmith 2013	Stress inoculation training	Delayed treatment control condition	US Law Enforcement Officers	Police station
Wild 2017	Mixed Format Resilience Intervention	Online placebo	Emergency services personnel	NS ( Several locations in the UK)
Mindfulness and relaxation based training
Crane 2019	Self reflection training	Active control condition (Coping skills training)	Australian Army Cadets	Military base
Christopher 2018	Mindfulness‐Based Resilience Training	No intervention control (NIC)	US Law Enforcement Officers	NS
Ranta 2008	Multidimensional intervention	Active control condition (Relaxation training)	Indian Police Officers	NS
Taylor 2011	Psychological skills training (PST)	No treatment control condition	US Navy personnel	Military base
Fikretoglu 2019	Road to Mental Readiness (R2MR)	Delayed intervention control condition	Canadian military recruits	Military base
Chitra 2018	Resilience training	No treatment control condition	Female Indian police officers	Police station
Joyce 2019	Resilience@Work	Active control condition (Healthy Living Programme)	Australian Firefighters	Fire station
Shipley 2002	Visuo‐motor behaviour rehearsal (VMBR)	No treatment control	Canadian Police Recruits	Police training facility
Neuropsychological programmes
Keynan 2019	Repeated Amyg‐EFP‐Neurofeedback training	Active (Control EEG‐NF) & Passive (NoNF) control conditions	Israeli Soldiers	Military base
Wald 2016	Attention Bias Modification Training	Attention control condition (Active control) & No training control condition	Israeli Soldiers	NS
Psycho‐educational programmes
Adler 2015	Resilience training	Active control condition (Military History Lectures)	US Army Soldiers	Military base
Jones 2019	SPEAR training	Training as usual Condition	UK RAF recruits	NS
Skeffington 2016	Mental Agility and Psychological Strength training programme (MAPS)	Treatment as usual (TAU) condition	Trainee firefighters	Fire Fighter academy

Comparators

Please see Table 1 for a comprehensive list of comparator interventions. The majority of interventions included in this review were compared with active control conditions, no treatment control conditions, treatment as usual conditions, wait‐list or delayed treatment control comparators.

Study populations

There were two general study populations reported in our included studies. Fifteen studies were conducted in military personnel (Adler 2015; Bouchard 2012; Cacioppo 2015; Chongruska 2015; Crane 2019; Fikretoglu 2019; Hourani 2016; Hourani 2018; Jones 2019; Keynan 2019; Lewis 2015; Pyne 2018; Taylor 2011; Wald 2016; Wessemann 2016) and 13 studies were conducted in frontline emergency workers (Chitra 2018; Christopher 2018; Digliani 1994; Janka 2017; Joyce 2019; McCraty 2012; Ranta 2008; Rosmith 2013; Shipley 2002; Skeffington 2016; Trousselard 2015; Wild 2016; Wild 2017). All studies, regardless of population, were synthesised under the same narrative synthesis, as presented below.

Of the 15 studies conducted in military personnel, seven studies were conducted with US military personnel including; US Army Soldiers (Adler 2015; Cacioppo 2015; Hourani 2018; Lewis 2015), US Marines (Hourani 2016), US National Guard personnel (Pyne 2018) and US Navy Personnel (Taylor 2011). The remaining eight studies were conducted with Israeli soldiers (Keynan 2019; Wald 2016), Canadian military personnel (Bouchard 2012; Fikretoglu 2019), Thai army rangers (Chongruska 2015), UK Royal Air Force recruits (Jones 2019), Australian army officer cadets (Crane 2019), and German military personnel (Wessemann 2016) .

Of the 13 studies conducted in frontline emergency services personnel, four studies were in a US Law Enforcement Officer (LEO) sample (Christopher 2018; Digliani 1994; McCraty 2012; Rosmith 2013). Outside of the US, three studies used a LEO sample; one in Canadian police recruits (Shipley 2002) and two in Indian police populations (Ranta 2008; Chitra 2018). Three studies were conducted in firefighters (Joyce 2019; Skeffington 2016; Trousselard 2015), and one was conducted in crisis managers (comprised of Rescue service, Fire service, Police and rescue services personnel; Janka 2017). Two studies used a mixed sample, comprising of police, fire & rescue, ambulance and search and rescue personnel (Wild 2016; Wild 2017)

Design

This review included randomised controlled trials (RCTs) or cluster‐RCTs.

Twenty‐three studies included in this review utilised a two‐arm intervention versus control condition study design. As specified in the protocol for this review, we defined control conditions as no intervention, treatment as usual and active control conditions such as waiting list controls. Four studies used a three‐arm design (Keynan 2019; Pyne 2018; Trousselard 2015; Wild 2017), whereby these studies compared an experimental intervention against a comparator intervention and a control condition. One study had a total of four arms, where an experimental intervention was compared against a control condition, and two comparator interventions (Wald 2016).

Programmes varied in duration and session length. The longest intervention (including long‐term follow‐up) took place over 18 months (Hourani 2018). The shortest programmes began and ended on the same day (Shipley 2002; Taylor 2011).

Programme session length also varied. The longest sessions took circa two hours to complete (Christopher 2018; Digliani 1994), in contrast to the shortest sessions which ran for five minutes (McCraty 2012).

Location

Geographically, the majority of included studies were conducted in the USA (n = 13; Adler 2015; Cacioppo 2015; Christopher 2018; Crane 2019; Digliani 1994; Hourani 2016; Hourani 2018; Lewis 2015; McCraty 2012; Pyne 2018; Rosmith 2013; Skeffington 2016; Taylor 2011). The remaining studies took place in Canada (n = 3 Bouchard 2012; Fikretoglu 2019; Shipley 2002), Europe, (n = 5 Janka 2017; Jones 2019; Trousselard 2015; Wild 2016; Wild 2017), Israel (n = 2 Keynan 2019; Wald 2016), Thailand (Chongruska 2015), India (n = 2 Chitra 2018; Ranta 2008) and Australia (n = 2 Crane 2019; Joyce 2019).

Setting

This review includes interventions that were delivered in several different settings. Nine studies took place in active duty US military bases, one in a Canadian military base (Fikretoglu 2019), one took place in a German army base Wessemann 2016), one was conducted in an Australian army training institution (Crane 2019), and one was set in a crisis management institution (Janka 2017). Five programmes were carried out in police facilities (Chitra 2018; Digliani 1994; McCraty 2012; Ranta 2008; Rosmith 2013). One study was implemented in a US firefighter training academy (Skeffington 2016), one in a French Army firefighter facility (Trousselard 2015), and the final study took place in several Australian fire stations (Joyce 2019). Five studies did not specify their study locations (Chongruska 2015; Christopher 2018; Jones 2019 Pyne 2018; Wald 2016).

Delivery

Five interventions were delivered by psychologists (Crane 2019; Janka 2017; Taylor 2011; Trousselard 2015; Wessemann 2016), one by former army non‐commissioned officers (Cacioppo 2015) and two programmes were solely computer‐delivered (Pyne 2018; Joyce 2019). Seven interventions were delivered by researchers (Digliani 1994; Fikretoglu 2019; Rosmith 2013; Skeffington 2016; Shipley 2002; Wald 2016 and one by public safety office personnel (McCraty 2012). The delivery team in Adler 2015 comprised of psychologists, active/retired army medics and mental health technicians. Hourani 2016 used "trained personnel", while  Chitra 2018, Jones 2019, Wild 2016 and Wild 2017 used "trainers" to deliver their respective resilience programmes. Bouchard 2012 stated that a "coach" instructed on their resilience intervention. The remaining six studies did not provide details as to who delivered their respective programmes (Chongruska 2015; Christopher 2018; Hourani 2018; Keynan 2019; Lewis 2015; Ranta 2008).

Outcomes

Primary outcomes

• Resilience which was reported in a total of eight studies (Cacioppo 2015; Chitra 2018; Chongruska 2015; Christopher 2018; Fikretoglu 2019; Joyce 2019; Wild 2016; Wild 2017) was predominately reported using the Connor‐Davidson Resilience scale (CD‐RISC). One study used an adapted Thai version of the CD‐RISC (Chongruska 2015), another study used the Resilience Scale (RS) (Wild 2017) while the final study used a scale adapted from Dolan 2006 to assess "military hardiness" (Chongruska 2015).

• Symptoms of post‐traumatic stress was reported in a total of eight studies (Hourani 2018; Lewis 2015; Pyne 2018; Skeffington 2016; Taylor 2011; Wald 2016; Wild 2016). The majority of studies measured symptoms of post traumatic stress using the PTSD checklist, with three using the military version (PCL‐M) (Hourani 2018; Pyne 2018; Wald 2016) and two using the civilian version (Lewis 2015; Skeffington 2016). One study used the Post Traumatic Stress Diagnosis Scale (PDS) (Wessemann 2016) and another the Impact of Event Scale Revised (Taylor 2011).

• PTSD caseness, defined as by reaching/surpassing a clinical threshold on a PTSD assessment scale, was reported as an outcome in four studies (Hourani 2016; Hourani 2018; Jones 2019; Wald 2016). Four different scales were used to report a clinical diagnosis of PTSD, these were; Post Traumatic Stress Disorder Checklist ‐ Civilain version (PCL‐C) (Hourani 2016), PTSD checklist ‐ military version (PCL‐M) (Hourani 2018), Clinician Administered PTSD Scales (CAPS) (Wald 2016) and the Primary Care PTSD screen (PC‐PTSD‐5) (Jones 2019).

Secondary outcomes

• Acute stress disorder was not reported by any of the studies in this review.

• Depression was reported by a total of seven studies (Adler 2015; Cacioppo 2015; Crane 2019; Fikretoglu 2019; Rosmith 2013; Wald 2016; Wild 2016) The majority of studies measured levels of depression using the Patient Health Questionnaire (PHQ) (Fikretoglu 2019), with several variations such as the PHQ‐D (Adler 2015) PHQ‐8 (Crane 2019) and the PHQ‐9 (Cacioppo 2015; Wald 2016; Wild 2016) also being utilised. Finally, a sub scale from the Profile of Mood States ‐ Short Form, which captures depression levels, was also used in one study (Rosmith 2013).

• Social support was reported in two studies (Skeffington 2016; Wild 2016). This was measured by the Social Support Questionnaire (SSQ) in both cases.

• Coping skill was reported by four of the studies included in this review (Hourani 2016; Joyce 2019; Skeffington 2016; Wild 2016). Two measures were used to assess coping skills, the Brief COPE scale was used by three studies (Joyce 2019; Skeffington 2016; Wild 2016), while a single item from the Perceived Stress Scale was used to assess coping skill in the remaining study (Hourani 2016).

• Emotional flexibility was not reported by any of the studies in this review.

• Self‐efficacy was reported as an outcome in three studies included in this review. Digliani 1994 used the Self Efficacy Scale (SES), while Wild 2016 and Wild 2017 both used the General Self‐Efficacy Scale (GSE).

• Social functioning was not reported by any of the studies in this review.

• Subjective levels of aggression was reported by one study included in this review (Christopher 2018). This was measured using the Buss Perry Aggression Questionnaire ‐Short form (BPAQ‐SF).

• Quality of sleep was not reported by any of the studies in this review.

• Quality of life was not reported by any of the studies in this review.

• Stress was reported by a total of nine studies included in this review (Chitra 2018; Christopher 2018; Crane 2019; Digliani 1994; Hourani 2018; Janka 2017; Ranta 2008; Rosmith 2013; Trousselard 2015). Three studies used the Personal Stress Scale (PSS) Hourani 2018; Janka 2017; Trousselard 2015) with one study using the PSS‐10 (Rosmith 2013). One study created their own measure for stress (Crane 2019), another used the Personal Stress Situation measure (Digliani 1994). Three studies used the Police Stress Questionnaire (Christopher 2018; Ranta 2008; Rosmith 2013). The final study reported on stress levels using the Occupational Stress Inventory (Chitra 2018).

Excluded studies

Please see table, Characteristics of excluded studies, for a list of all studies excluded after the full‐text review screening phase.

Risk of bias in included studies

For a detailed risk of bias assessment for each study, see the 'Characteristics of included studies' table. A graphical representation of risk of bias in included studies is presented in Figure 2 and Figure 3. The majority of studies, were assessed as low risk or unclear risk across most of the risk of bias categories described below. Given the nature of psychological research and the difficulties associated with truly blinding both participants and experimenters, a majority of studies were rated as being high risk of bias for blinding (performance bias and detection bias).

3.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Allocation

Out of the 28 studies included in this review, we assessed 11 at low risk of bias for random sequence generation. These 11 studies described, in adequate detail, their methodologies for generating random allocation sequences when assigning their participants to control versus experimental group (Chitra 2018; Christopher 2018; Digliani 1994; Fikretoglu 2019; Joyce 2019; Keynan 2019; Rosmith 2013; Skeffington 2016; Trousselard 2015; Wald 2016; Wessemann 2016). Fifteen studies did not provide specific detail on the randomisation process. One study was deemed at high risk of bias as there was a non‐random component in the sequence generation. i.e. randomisation was based on an assigned date and time of the training session and determined prior to the training (Lewis 2015). The final study (Jones 2019) was deemed at high risk of bias as they used an alternate number sequence method for randomisation.

Out of the 28 included studies, we assessed nine studies at low risk for selection bias, due to adequate reporting of allocation concealment (Chitra 2018; Digliani 1994; Fikretoglu 2019; Joyce 2019; Keynan 2019; Rosmith 2013; Skeffington 2016; Trousselard 2015; Wald 2016). Eighteen studies either did not provide specific details on allocation concealment, or provided insufficient information, and were judged to be at unclear risk of selection bias. The final study (Jones 2019) was deemed at high risk of selection bias as they used an alternate number sequence method for allocation.

Blinding

Performance bias

All studies included in this review assessed the efficacy of psychological interventions in mitigating negative psychological outcomes. We acknowledge that it is often not feasible to blind participants to conditions in applied psychological research where clinical interventions are the focus of enquiry. We assessed six studies to be at low risk of bias as these studies provided explicit details of steps taken to blind participants and/or experimenters to trial condition (Adler 2015; Cacioppo 2015; Fikretoglu 2019; Joyce 2019; Keynan 2019; Wald 2016). We considered the remaining 22 studies have an unclear designation as the majority did not specifically address this issue.

Detection bias

The majority of included studies in this review utilised self‐report measures such as questionnaires and surveys. Three out of 28 studies have been designated low risk of bias in this domain due to the authors detailing measures to blind personnel involved in data collection and/or blinding of participants to trial condition (Bouchard 2012; Fikretoglu 2019; Wald 2016). We assigned seven studies an 'unclear' risk of bias designation: studies which used both outcome assessors and self‐report inventories, and details on participant/assessor blinding were not addressed (Cacioppo 2015; Christopher 2018; Hourani 2016; Keynan 2019; Rosmith 2013; Shipley 2002; Trousselard 2015). Eighteen studies were deemed to be at a high risk of bias as they used self‐report measures and no details were provided on strategies to address participant blinding (Adler 2015; Chitra 2018; Chongruska 2015; Crane 2019; Digliani 1994; Hourani 2018; Janka 2017; Jones 2019; Joyce 2019; Lewis 2015; McCraty 2012; Pyne 2018; Ranta 2008; Skeffington 2016; Taylor 2011; Wessemann 2016; Wild 2016; Wild 2017)

Incomplete outcome data

We assessed four studies as being at high risk of attrition bias due to high dropout rates and/or lack of relevant reporting on handling of missing data (Hourani 2018; McCraty 2012; Taylor 2011; Wild 2016). Nineteen studies reported attrition rates, explanations for attrition and missing data per study group. We assessed these at low risk of attrition bias. Five studies did not address this domain in sufficient detail. These were classified as 'unclear' (Crane 2019; Janka 2017; Lewis 2015; Ranta 2008; Rosmith 2013).

Selective reporting

We assigned a 'low' risk of bias designation to studies that provided details on pre‐published trial protocols. Five studies provided reference to their pre‐published study protocols, which we designated 'low' risk of bias because they adhered to the methods and outcome measurement they specified a‐priori (Christopher 2018; Fikretoglu 2019; Joyce 2019; Keynan 2019; Wild 2016) Two studies (Pyne 2018; Wild 2017) differed from their protocols on outcomes reported. We therefore assigned an 'unclear bias' designation to these studies. Twenty‐one studies did not provide details on pre‐published trial protocols, all of which were judged to be at high risk of bias.

Other potential sources of bias

As outlined in the method's section of this review, careful consideration was given to the potential for bias to that might arise due to study funding sources, or due to authors who were employed by the military. Seven studies received funding directly from military/frontline emergency services organisations (Fikretoglu 2019; Hourani 2016; Hourani 2018; Jones 2019; Lewis 2015; Wald 2016; Wessemann 2016). Five other studies had authors who were in direct employment of a military/frontline emergency services or a military research facility (Keynan 2019; McCraty 2012; Pyne 2018; Taylor 2011; Trousselard 2015). We designated all these studies as having an "unclear" risk of bias. A further three studies were deemed to be of unclear risk of bias because they provided no conflict of interest declaration in their reports (Adler 2015; Ranta 2008; Shipley 2002). We designated the remaining 13 studies to be at low risk of bias.

Effects of interventions

Following consultation with our Cochrane editorial team, it was decided to perform a narrative synthesis of included studies. This decision was taken based on the heterogenous nature of the resilience interventions in the included studies (theoretical orientation, samples, delivery etc), and the diversity of outcome measures used. Overall, given the lack of a formal statistical pooling and subsequent analysis of the data across the majority of outcomes captured in this review, caution most be taken with interpreting the following results.

Below, we present the recorded data for our outcomes specified a priori. We have provided supporting statistical output, means, standard deviations, P values and effect sizes where these were available. See Table 2 for a comprehensive list of outcomes.

2. Table of pertinent outcomes.

Study ID	Outcome 1	Outcome 2	Outcome 3	Outcome 4	Outcome 5	Outcome 6	Outcome 7	Outcome 8	Outcome 9
CBT based programmes
Cacioppo 2015	Hardiness	Loneliness	Empathy	Alcohol misuse	Anxiety	Depression	Life Satisfaction	Perceived Stress	Sleep Quality
Chongruska 2015	Resilience	Mental Well‐being	Somatic Symptoms
Wild 2016	Resilience	Depression	Self Efficacy	Coping	Symptoms of Post Traumatic Stress
Biofeedback based programmes
Bouchard 2012	Cortisol	Heart rate
Janka 2017	Perceived stress	Changes in sympathetic tone
Lewis 2015	Symptoms of Post traumatic stress	Heart rate
McCraty 2012	Heart rate variability	Blood pressure
Pyne 2018 (1)	Symptoms of Post traumatic stress	Heart rate variability (HRV)
Trousselard 2015	Perceived stress	Mood
Wessemann 2016	Symptoms of Post traumatic stress	Current mental state
Stress management programmes
Hourani 2016	PTSD	Perceived stress	Heart period
Hourani 2018	Symtpoms of post traumatic stress	Perceived stress	PTSD
Digliani 1994	Personal stress	stress level	Trait anger	Self‐efficacy	Trait anxiety
Rosmith 2013	Organisational stress	Operational stress	Mood states ( mood disturbance, depression, anger)
Wild 2017	Resilience	Self‐effiacy	Depression	Symptoms of Post Traumatic Stress	Coping
Mindfulness and relaxation based training
Crane 2019	Stressor frequency	Depressive symptoms	Anxiety
Christopher 2018	Resilience	Operational and Organisational stress	Suicidal Ideation	Aggression and Anger	Cortisol Awakening Response	Self compassion	Psychological health & psychological flexibility	Burnout	Mindfulness
Ranta 2008	Occupational stress	Burnout
Taylor 2011	Symptoms of Post traumatic stress	Dissociation
Fikretoglu 2019	Psychological distress	Subjective levels of distress	Resilience	Anxiety	Depression	Mental health service use
Chitra 2018	Occupational stress	Resilience	Psychological wee‐being	Job satisfaction
Joyce 2019	Resilience	Mindfulness	Cognitive fusion	Experiential avoidance and psychological inflexibility	Self‐compassion	Optimism	Coping	Sense of Purpose
Shipley 2002	Anxiety (several sub categories)
Neuropsychological programmes
Keynan 2019	Emotional regulation	Anxiety	Alexithymia
Wald 2016	Symptoms of Post traumatic stress	PTSD Diagnosis (yes/no)	Depressive symptoms
Pyne 2018 (2)	Symptoms of Post traumatic stress
Psycho‐educational programmes
Adler 2015	Anxiety problems	Depression
Jones 2019	Symptoms of common mental disorder	Symptoms of PTSD (Caseness)	Alcohol Use
Skeffington 2016	Symptoms of Post traumatic stress	Other mental health symptoms	Coping strategies	Perceived social supports

Comparision 1 ‐ Experimental resilience building intervention versus control or no intervention

Resilience

A total of eight studies reported resilience as an outcome (Cacioppo 2015; Chongruska 2015; Christopher 2018; Chitra 2018; Fikretoglu 2019; Joyce 2019; Wild 2016; Wild 2017).

Cacioppo 2015 reported that their CBT informed programme, "Social Resilience Training" intervention appeared to improve military hardiness compared to cultural awareness training (mean difference (MD) 0.16; n = 581, P = 0.01). Hardiness was measured using a scale adapted from Dolan 2006 to assess military hardiness. Confidence intervals (CIs) were not reported for this effect size and there were insufficient data to calculate them.

Chongruska 2015 reported an increase in resilience in their CBT informed programme, "integrated group counselling", compared to controls (MD 9.61, 95% CI 4.43 to 14.79; n = 60, P = 0.003). Resilience was measured using an adapted version of the CD‐RISC.

Joyce 2019 conducted a mindfulness‐based intervention "Resilience@work (RAW)". The authors reported that there appeared to be no evidence of a difference at six weeks (P = 0.09), although the resilience scores (measured by CD‐RISC) were not reported at this time point.  At six months follow‐up, the resilience at work group appeared to show a higher level of resilience, with an average resilience score increase of 1.3 compared to 0.73 in the control group (95% CI 0.38 to 1.06, P = 0.09). 

Chitra 2018 reported on their mindfulness‐based "resilience training" intervention, The authors reported that participants who received the training intervention had higher levels of resilience (measured by CD‐RISC), with a magnitude of change in resilience score of 43% compared to just under 2% in the control group (P = 0.00).

Fikretoglu 2019 conducted a mindfulness‐based stress reduction programme "R2MR", with Canadian soldiers. At five weeks, the MD in the resilience (CD‐RISC) total score was ‐0.14 (P = 0.54), and at nine weeks, the mean difference in the resilience (CD‐RISC) total score was ‐0.31 (P = 0.41), where the intervention group displayed lower levels of resilience compared to control.

Christopher 2018 conducted a mindfulness‐based training programme with US LEOs. Resilience, measured by CD‐RISC, trended higher in the mindfulness group both immediately post‐training (MD 6.59, 95% CI 0.84 to 12.33, P = 0.02) and at three months compared to the control group (MD 5.72, 95% CI 0.48 to 11.92, P = 0.07).

Wild 2016 conducted a CBT informed "resilience intervention" with a mixture of police, fire, ambulance, and search and rescue personnel. Resilience, as measured by the CD‐RISC, was found to have increased marginally in both the intervention and control conditions over time, however this difference was non significant immediately post intervention (MD 0.58, 95% CI ‐3.21 to 4.37, P = 0.07) and at follow up (MD 1.56, 95% CI ‐2.05 to 5.17, P = 0.40).

Wild 2017 conducted a stress management "Mixed format resilience intervention" with a mixture of police, fire, ambulance, and search and rescue personnel. Resilience, as measured on the Resilience Scale (RS), increased in both the intervention and online control conditions at post intervention (MD ‐1.47, 95% CI ‐10.06 to 7.12, P = 0.73). At follow up assessment, resilience scores were higher in the intervention group compared to the control group (MD ‐6.13, 95% CI ‐15.78 to 3.52, P = 0.21).

A total of eight studies reported resilience as an outcome of interest. Of these eight interventions, five reported that their interventions increased participant resilience compared to participants in their respective control conditions. Two of the three CBT‐informed programmes produced significant results. While three out of the four programmes which used a mindfulness‐based interventions, evidenced increased resilience in their participants. Both Wild 2016 and Wild 2017, who utilised CBT and stress management modalities respectively, reported that resilience was increased by their interventions, but a similar effect was also observed in their control conditions.

Symptoms of post‐traumatic stress

A total of eight studies reported symptoms of post‐traumatic stress as a study outcome (Hourani 2018; Lewis 2015; Pyne 2018; Skeffington 2016; Taylor 2011; Wald 2016; Wessemann 2016; Wild 2016).  However, the studies were too heterogenous to combine in a meta‐analysis. Of the seven studies which included symptoms of post traumatic stress as an outcome, five failed to produce significant decrease in symptoms.

Hourani 2018 conducted a stress management programme, 'Predeployment Stress Inoculation Training Programme' with US army soldiers; they reported that their intervention did not significantly reduce symptoms of post traumatic stress.

Pyne 2018 reported on a biofeedback based programme, "heart rate variability biofeedback", with US National Guard soldiers. They reported no significant overall effect of the interventions on post‐deployment symptoms of post traumatic stress. At 12‐months post‐deployment, there was no significant difference between intervention and the control arms.

https://revman.cochrane.org/#/210318062013075493/dashboard/htmlView/1.117?revertEnabled=false&versionWithProductionChanges=false#STD‐Lewis‐2015 reported that symptoms of post traumatic stress were not significantly reduced by their PRESTINT programme compared to controls but specific data were not reported.

https://revman.cochrane.org/#/210318062013075493/dashboard/htmlView/1.117?revertEnabled=false&versionWithProductionChanges=false#STD‐Taylor‐2011 conducted a mindfulness programme, "psychological skills training", with US Navy personnel. Their programme did not significantly reduce symptoms of post traumatic stress versus a control condition; there was a decrease in symptoms of post traumatic stress from 24 hours to 1 month post trial (P < 0.0017) and 3 months (P < 0.017) however the difference in recovery between intervention and control, relative to one another, was not significant.

Skeffington 2016 conducted a CBT based programme, "Mental agility and Psychological Strength Training Programme (MAPS)" with trainee firefighters. They reported that the intervention was no more effective than control in the primary prevention of symptoms of post traumatic stress at 6‐months follow up (MD 1.98, 95% CI ‐0.48 to 4.44) nor at 12‐months follow‐up (MD 0.90, 95% CI ‐1.71 to 3.51). The authors also reported that there was no evidence to suggest that the intervention was effective in the primary prevention of mental health issues.

Wessemann 2016 conducted a biofeedback based programme, 'Chaos Driven Situations Management Retrieval Systems' (CHARLY) programme with German military medical personnel. They reported a significant difference between the intervention (CHARLY) group and the control group in a measure of global impairment; whereby impairment was reduced in the CHARLY group vs control (P = 0.028). The groups also differed significantly in all three sub scales of the PDS scale for PTSD (re‐experiencing (MD ‐ 0.42, P = 0.02), avoidance (MD ‐0.38, P = 0.04), and arousal (MD ‐0.47, P = 0.03) following deployment. However the PDS was not administered pre‐deployment. Finally, the CHARLY group showed a significantly lower level of traumatic stress on the PDS scale following deployment than the control group.

Wald 2016 conducted an attention bias modification training (ABMT) programme with Israeli soldiers. High dose ABMT (8 sessions) was compared with low dose ABMT (4 sessions), attention control training (ACT) and no training. Following a 6‐month low‐intensity deployment, there were no significant between‐group differences in the PCL scores. At 10 days following intense combat, there were no significant differences in PCL scores between interventions. However, at the 4‐month follow‐up, soldiers in the four‐session ABMT group had significantly lower incidence of PCL scores ⩾ 40 than the no‐training control group (OR 2.40, 95% CI 1.01 to 5.71, P < 0.05), but not than the eight‐session ABMT or ACT groups, neither of which differed from the no‐treatment group.

Wild 2016 conducted a CBT informed "resilience intervention" with a mixture of police, fire, ambulance, and search and rescue personnel. Symptoms of post traumatic stress, as measured by the PCL‐5, appeared to decrease in both the intervention and control groups post intervention (MD 1.68, CI 95% ‐0.92 to 4.28, P = 0.20) and follow up (MD 2.14, 95% CI ‐0.07 to 4.96, P = 0.14).

Two of the eight studies reported that their interventions were successful in reducing symptoms of post traumatic stress in their participants. The interventions which evidenced a successful decrease in symptoms of post traumatic stress compared to controls, utilised biofeedback and neuropsychology therapeutic modalities respectively.

PTSD caseness

Four studies reported PTSD caseness as an outcome (Hourani 2016; Hourani 2018; Jones 2019; Wald 2016).  

Hourani 2016 reported that their stress management intervention, Pre‐Deployment Stress Inoculation Training (PRESIT), was not successful at reducing PTSD diagnosis (measured using the PCL‐C) compared to the control condition (odds ratio (OR) 0.79, 95% CI 0.28 to 2.23, P > 0.05). However, when baseline differences in rates of pre‐deployment mental health issues were controlled for, participants in the control condition were at 6.9 times the risk of a diagnosis of PTSD when compared to the intervention group (OR 6.93, 95% CI 1.63 to 29.55, P < 0.05)

Hourani 2018 reported no group differences (P = 0.39) between their stress management "PRESIT" intervention (34 participants met PCL threshold for PTSD) and control conditions (21 participants met PCL threshold for PTSD); both groups had almost identical PTSD levels at baseline. The results indicate that the intervention was not effective in reducing the number of subsequent clinical diagnosis of PTSD. 

Wald 2016 reported that four sessions of a neuropsychological‐based programme, attention modification bias training (AMBT), reduced CAPS‐PTSD diagnosis compared to no‐training control group (OR 3.21, 95% CI 1.01 to 9.22, P < 0.05). Eight session AMBT intervention training did not significantly reduce PTSD diagnosis compared to four‐session group or a control. Results suggest that in order to reduce the incidence of PTSD by one, 19.2 soldiers would need to receive treatment instead of treatment as usual.

Jones 2019 reported that the psychoeducational programme "SPEAR" did not reduce PTSD caseness, measured using the PL‐PTSD 5 inventory, compared to the control condition at post intervention (16 intervention cases versus 16 control cases) or at three‐month follow‐up (15 intervention cases versus 13 control cases).

These studies all used recognised scales which are used as screening/diagnostic tools for post‐traumatic stress disorder. Only one study, which utilised neuropsychological approach, produced results which indicated it was effective in reducing the risk of participants meeting the threshold for a diagnosis of PTSD. However, given the limited number of studies which assessed PTSD caseness as an outcome, and the inconsistent findings, these results must be interpreted with caution.

Secondary outcomes

Acute stress disorder

Acute stress disorder was not reported as an outcome in any of the included studies.

Depression

A total of seven studies reported depression as an outcome (Adler 2015; Cacioppo 2015; Crane 2019; Fikretoglu 2019; Rosmith 2013; Wald 2016; Wild 2016).

Adler 2015 conducted a psychoeducational programme, "resilience training", with US Army soldiers. It was rated as less useful than military history classes (control condition) by participants. There was no difference in PHQ‐D scores between intervention (MD 1.63 (SD 0.57) and control (MD 1.64 (SD 0.55) at three‐weeks follow‐up.

Cacioppo 2015 reported on their CBT informed "Social resilience training" (SRT) programme. They measured depression using the PHQ‐9 and reported no difference between SRT and control groups (MD 0.01, P = not significant). Confidence intervals for this effect size were not reported.

Rosmith 2013 conducted a stress management programme, "Stress Inoculation Training (SIT) with US LEOs. Results suggested that, immediately post‐intervention, neither the SIT program (MD 9.51, 95% CI 1.57 to 17.45, P = 0.02) nor the SIT + booster (MD 7.92, 95% CI 0.26 to 15.58, P = 0.04) were more effective than control in reducing depressive symptoms as measured using a sub scale of the POMS‐SF inventory.  Furthermore, there was no difference between the SIT programmes when the booster was added (MD 1.59, 95% CI ‐5.75 to 8.93, P = 0.67).  At follow‐up, SIT versus control (MD 4.99, 95% CI ‐2.49 to 12.47, P = 0.19) showing no difference between the SIT and control condition in reduction of depressive symptoms. There was no significant reduction in depressive symptoms when SIT + booster participants were compared with those in the control condition (MD ‐2.24, 95% CI ‐9.46 to 4.98, P = 0.54). In contrast, the SIT booster programme appeared more effective than standard SIT intervention at reducing depressive symptoms at follow‐up (MD 7.23, 95% CI 0.31 to 14.15, P = 0.04).

Wald 2016 conducted an neuropsychological‐based intervention, attention bias modification training, with Israeli soldiers. They reported that symptoms of depression (measured using the PHQ‐9) increased from baseline (assessment 1) to the low‐intensity combat (assessment 2), and then decreased 10 days following high‐intensity combat (assessment 3), and decreased further four months post‐combat (assessment 4), revealing significant quadratic trends in all the groups. No statistical results were reported in the paper for this outcome.

Fikretoglu 2019 conducted a mindfulness‐based stress reduction programme "R2MR", with Canadian soldiers. They reported no difference in levels of depression as measured by the PHQ‐9 scale at first follow‐up (MD ‐0.03, P = 0.89) or at second follow‐up (MD 0.08, P = 0.79).  Specific data on PHQ‐9 scores in intervention and control groups were not presented and confidence intervals around these effects sizes were not reported.  

Crane 2019 reported results on a mindfulness‐based, self reflection training programme with Australian army cadets. They demonstrated that at longer‐term follow‐up (+3 months) the intervention group (SRT) had lowered mean depression symptoms compared to the control group (MD 2.36, 95% CI 1.25 to 3.47, P < 0.001) using the PHQ‐8 questionnaire. However, there was no difference in depression symptoms at initial follow‐up (MD ‐0.01, 95% CI ‐1.07 to 1.05, P = 0.99). At long‐term follow‐up, symptoms in the SRT group declined by 2% (95% CI ‐11% to 9%). Meanwhile, the control group experienced an increase in symptoms by a further 32% (95% CI ‐0.76 to ‐0.15).

Wild 2016 conducted a CBT informed "resilience intervention" with a mixture of police, fire, ambulance, and search and rescue personnel. The authors reported that although there was a decrease in levels of depression (measured using the PHQ‐9) from pre (MD 0.33, 95% CI ‐0.48 to 1.14, P = 0.42) to post intervention (MD ‐0.07 95% CI ‐0.93 to 0.79, P = 0.87), this effect was observed in both the intervention and control groups.

A total of seven studies reported depression as an outcome. The intervention that reported significant findings used a mindfulness‐based intervention with army cadets. Overall, the results presented here show little evidence to suggest that the included interventions were effective in decreasing depression symptoms in military/front ine emergency services personnel compared to controls

Social support

Two studies reported social support as an outcome (Skeffington 2016).

Skeffington 2016 conducted a CBT‐based programme, "Mental Agility and Psychological Strength Training Programme (MAPS)" with trainee firefighters. They reported that, relative to the control group, participants in the CBT‐based programme reported no increase in social support overall, as measured by the SSQ, (P = 0.08), however at six months follow‐up, there appeared to be a significant difference in social support between groups, favouring the intervention MD ‐0.50 (95% CI ‐0.68 to ‐0.32, P < 0.0001).

Wild 2016 conducted a CBT informed "resilience intervention" with a mixture of police, fire, ambulance, and search and rescue personnel. They reported on two aspects of social support, operationalised as "home" and "work" social support. Both were measured using an adapted version of the SSQ Scale. For levels of home social support, scores decreased in both the intervention and control group from baseline to post intervention (MD ‐ 0.80, 95% CI ‐2.31 to 0.71, P = 0.30) and at follow up (MD ‐0.89, 95% CI ‐2.46 to 0.68, P = 0.27). However there was no significant difference observed between groups. For work social support, a similar non significant difference between intervention and control was observed at both post intervention (MD ‐0.006, 95% CI ‐1.60 to 1.48, P = 0.94) and follow up (MD ‐ 0.88, 95% CI ‐2.42 to 0.66, P = 0.26).

Coping skill

Four studies reported coping skill as an outcome (Hourani 2016; Joyce 2019; Skeffington 2016; Wild 2016)

Coping skill was reported across three subsets.

i) Adaptive coping

Skeffington 2016 reported that adaptive coping improved from baseline in the sample as a whole, using the Brief COPE scale (P = 0.02). At T2 there was an MD ‐0.38 (95% CI ‐2.36 to 1.47, P = 0.69) suggesting that the MAPS intervention was not more effective than control for improving adaptive coping in participants. 

Joyce 2019 conducted a mindfulness‐based programme "Resilience@Work" with Australian firefighters. They reported that there was a sustained improvement in adaptive coping among the intervention group when compared with the control group at six‐month follow‐up (P = 0.46) (measured using the Brief COPE scale)

ii) Maladaptive coping

Skeffington 2016 reported that the MAPS intervention was not more effective than control for reducing maladaptive coping in participants (MD 0.84, 95% CI ‐3.53 to 5.21, P = 0.71), also using the Brief COPE scale

Hourani 2016 conducted a stress inoculation therapy programme, "PRESIT," with US marines. They reported no differences in self‐reported Perceived Stress Scale (PSS) scores post deployment. For those who had no self‐reported mental health problems, marines in the control group were almost twice as likely to have had recent coping problems than Marines in the intervention PRESIT group. 

iii) Active coping

Wild 2016 conducted a CBT informed "resilience intervention" with a mixture of police, fire, ambulance, and search and rescue personnel. They reported no significant differences in levels of active coping (Brief COPE scale) between the intervention and control groups either immediately post intervention (MD ‐0.07, 95% CI ‐0.42 to 0.28, P = 0.70) or at longer term follow up (MD 0.29 95% CI ‐0.07 to 0.65, P = 0.11).

Overall, we found limited evidence to suggest that the above interventions were successful in increasing coping skill compared to controls.

Emotional flexibility

This outcome was not reported in any of the included studies

Self‐efficacy

Three studies reported self‐efficacy as an outcome.

Digliani 1994 conducted a stress inoculation training programme, with US LEOs. Authors reported that participants in the intervention group did not report higher levels of social self‐efficacy, measured using the SES (MD ‐1.00, 95% CI ‐3.57 to 1.57, P = 0.45) nor general self‐efficacy (MD ‐1.66, 95% CI ‐6.9 to 3.58, P = 0.53)

Wild 2016 conducted a CBT informed "resilience intervention" with a mixture of police, fire, ambulance, and search and rescue personnel. As measured by the GSE scale, both intervention and control groups reported increases in subject levels of self efficacy, this difference between groups was not significant either post intervention (MD 0.17, 95% CI ‐0.87 to 1.21, P = 0.75) or at longer term follow up (MD 0.56, 95% CI ‐0.47 to 1.59, P = 0.28).

Wild 2017 conducted a Stress management "Mixed format resilience intervention" with a mixture of police, fire, ambulance, and search and rescue personnel. Self‐efficacy, as measured using the GSE, was not significantly different in either group compared to control immediately post intervention (MD 1.16, 95% CI ‐0.32 to 2.64, P = 0.12). Similarly, there was no difference between control and intervention in self reported levels of self‐efficacy at longer follow up (MD 0.59, 95% CI ‐1.18 to 2.36, P = 0.51).

Overall, we found no evidence to suggest these included interventions were effective in increasing levels of self‐efficacy in participants compared to controls.

Social functioning

This outcome was not reported in any of the included studies

Subjective levels of aggression

Christopher 2018 conducted a mindfulness‐based training programme with US LEOs. They reported that participants in the intervention group had lower levels of aggression compared to a control group. The mean difference was a 0.27 point reduction on a two‐point sub‐scale for aggression (95% CI ‐0.55 to 0.01, P = 0.06). This was measured using the BPAQ‐SF

Quality of sleep

This outcome was not reported in any of the included studies

Quality of life

This outcome was not reported in any of the included studies

Stress

Nine studies in the review reported stress as an outcome measures. Stress was conceptualised in several ways e.g. Operational, Organisational and Personal Stress.

Crane 2019, reported results on a self reflection training programme with Australian army cadets. They reported that participants in the Social Resilience Training programme reported lower levels of perceived stressed compared to participants in the control condition, at initial follow‐up (MD ‐11.06, 95% CI ‐15.1 to ‐7.02, P < 0.00001).  The authors created their own 23‐item scale to measure stress.

Hourani 2018 conducted a stress inoculation therapy programme with US army soldiers They reported that participants in the intervention group did not report lower perceived stress score on the PSS, compared to the control group (P = 0.51).

Christopher 2018 conducted a mindfulness‐based training programme with US LEOs. They reported that at post‐training, MBRT (intervention) participants reported a significant improvement in organisational stress scores, as measured by the PSQ, compared to those at baseline (MD ‐0.60, 95% CI ‐1.23 to 0.03, P = 0.05).

Digliani 1994 measured two facets of stress, 'personal stress' and 'stress level'.  Personal stress was measured using the Personnal Stress Situation (PSS), which asked participants to report their two most stressful ongoing life events and rate them on a scale from 1 to 100, with a higher score indicating a higher stress event. According to the PSS event 1 there was no difference post‐training (MD ‐11.42, 95% CI ‐24.34 to 1.50, P = 0.08).  However, at follow‐up the SIT stress inoculation program was associated with reduced stress (MD ‐21.32, 95% CI ‐35.71 to ‐6.93, P = 0.04).  Similarly, for PSS event 2, post training there was no difference (MD ‐4.12, 95% CI ‐17.79 to 9.55, P = 0.55) but at follow‐up, the SIT program was associated with reduced stress (MD ‐15.6, 95% CI ‐30.25 to ‐0.95, P = 0.04).  Stress level was measured using the LSR or Level of Stress Rating, whereby participants were asked to rate their overall stress in the past week, on a scale from 1 to 20 with a higher number indicating higher stress. The authors report that no significant effects were found for treatment, trials or interaction on this measure of subjective stress, suggesting the intervention had no measurable impact on overall subjective stress compared to the control condition.

Ranta 2008 conducted a mindfulness‐based training programme, "multidimensional intervention", with Indian police officers. They reported a lower stress score (P < 0.001) in the intervention (mean 79.92) than control group (mean 98.15). Standard deviations for these means were not reported. The authors used the Police Stress Questionnaire to measure levels of stress.

Rosmith 2013 conducted a stress management training programme, "Stress Inoculation Training (SIT) ", with US LEOs. For 'operational stress', they reported no difference between SIT and control (F = 1.63, P = 0.186). However, authors only reported F‐statistics and p‐values. For the 'organisational stress' outcome, Rosmith 2013, the delayed training (control) group (M = 63.86) had significantly higher follow‐up PSQ‐Org scores than the SIT (intervention) group (M = 42.11). These results suggest that the intervention was more effective than control condition for reducing organisational stress. For the 'perceived stress' outcome, Rosmith 2013 reported that follow‐up PSS‐10 scores were not different between the two groups (F = 1.10, P = 0.352). However, authors only reported F‐statistics and p‐values.

Trousselard 2015 conducted two biofeedback‐based programmes. They reported that perceived stress change differed among the groups (P = 0.05). The TOP (intervention group A) group had a higher stress decrease than the controls (P = 0.05). No differences were observed in PSS sub factors change. However, at six‐month follow‐up,participants in the TOP program tended to have lower scores on PSS sub factors than participants in the CBF program (comparator intervention) (P = 0.09). The number of fire fighters (FFs) decreasing their scores under the clinical threshold was higher in the intervention groups (TOP & CBF programmes) (7.8%) than in the control group (7 FFs from the TOP group; and 7 FFs from the CBF group versus 0 FFs in the control group, v2 = 4.45; P = 0.03; i.e. a 12%‐reduction of perceived stress occurred in the intervention groups, compared with the control group. 

Janka 2017 conducted a biofeedback‐based programme, "biofeedback training", with crisis management personnel. They reported lower stress scores immediately post‐test (P = 0.007) and at later follow‐up (P = 0.036) in the intervention group. The results showed that there was a gradual increase in PSS stress score from pre‐test to follow‐up in the control group. Post hoc analysis found that there appeared to be no difference in PSS score observed between time points. However, no analysis is reported to confirm whether the overall difference in PSS score between interventions and control groups was conducted. 

Chitra 2018 conducted a "resilience training" programme underpinned by a blend of mindfulness, CBT and relaxation techniques, with female Indian police officers. They reported a 43% decrease in occupational stress scores (as measured on the OSI inventory) across the trials for the experimental group compared to only 1% in the control group.  The resilience training program appeared to be more effective in reducing occupational stress (MD ‐23.55, 95% CI ‐38.01 to ‐9.09, P = 0.01)

Studies operationalised stress as personal stress, stress levels, operational stress, organisational stress, perceived stress and occupational stress. Two studies failed to reduce stress levels in their participants compared to a control condition. Both studies used perceived stress as their operationalization of stress. Seven studies reported that their respective interventions were successful in reducing participant stress levels compared to a control condition. Overall, it would appear that our included interventions were effective at reducing stress in their participants compared to controls.

Comparison 2 ‐ Experimental resilience building intervention versus another experimental resilience building intervention

As per our protocol we planned to report "experimental intervention versus experimental intervention" as our first main comparison. However, we found no studies that directly compared two experimental interventions against one another.

Subgroup analysis

We planned to conduct the following subgroup analyses.

Setting of programme

Due to lack of suitable data and we were unable to conduct this analysis.

Type of comparator

Due to lack of suitable data we were unable to conduct this analysis.

Delivery format

Due to lack of suitable data we were unable to conduct this analysis.

Type of approach to resilience building

Due to lack of suitable data we were unable to conduct this analysis.

Length of programme

Due to lack of suitable data and we were unable to conduct this analysis.

Sensitivity analysis

We planned to conduct the following sensitivity analyses.

Study quality

Due to lack of suitable data we were unable to conduct this analysis.

We planned to exclude studies in which missing data were not imputed, as they are at potentially greater risk of bias.

Due to lack of suitable data we were unable to conduct this analysis.
 

Summary of findings

As we performed a narrative synthesis of the results, we did not produce a summary of findings table.

Discussion

Summary of main results

This systematic review examined pre‐deployment programmes for building resilience in military and frontline emergency service personnel. The findings are based on 28 randomised controlled trials (RCTs) with a combined sample of 11847 participants. Below we present a brief summary and discussion of the results of each outcome assessed in this review.

Primary outcomes

Resilience

Eight studies reported resilience as an outcome (Cacioppo 2015; Chitra 2018; Chongruska 2015; Christopher 2018; Fikretoglu 2019; Joyce 2019:Wild 2016; Wild 2017). Overall, the results shows that five interventions had success in building resilience in their respective samples. These programmes, consisted of cognitive behavioural therapy (CBT)‐based interventions (n = 2) and mindfulness informed programmes (n = 3). A stress management and a CBT informed programme, displayed trend higher levels of resilience in intervention vs controls but similar changes were observed in the respective control groups. The programme which reported a decrease in resilience in intervention versus control, utilised a mindfulness therapeutic modality (Fikretoglu 2019)

Symptoms of post‐traumatic stress

Our narrative synthesis of results included eight studies. Two of the seven studies produced significant reductions in symptoms of post traumatic stress compared to controls (Wald 2016 & Wessemann 2016). These interventions used a Neuropsychological and biofeedback intervention models respectively.

PTSD

Four studies reported PTSD as an outcome (Hourani 2016; Hourani 2018; Jones 2019; Wald 2016). The evidence was mixed as to the effectiveness of these interventions in reducing clinical diagnosis of PTSD. Hourani 2016 reported that their stress management programme, when baseline differences in rates of pre‐deployment mental health issues were controlled for, that participants in the control condition were at 6.9 times the risk of a diagnosis of PTSD when compared to the intervention group.  Wald 2016 using a neuropsychological‐based Attention Bias Modification Training (AMBT) programme had success in reducing both symptoms of post‐traumatic stress and numbers of participants receiving a diagnosis of PTSD.

Overall, given the diversity of intervention designs and theoretical orientations used, a definitive statement on the efficacy of pre‐deployment programmes at reducing symptoms of post‐traumatic stress and PTSD cannot be confidently offered. However, based on our results, it would appear that the evidence in favour of these programmes effectively preventing a clinical diagnosis of PTSD is limited.

Secondary outcomes

Acute stress disorder

Acute stress disorder was not reported as an outcome in any of the included studies.

Depression

We found little evidence to suggest that the interventions assessed in this review were effective in decreasing depression symptoms in military/frontline emergency services personnel compared to controls. A total of seven studies reported depression as an outcome. The intervention that reported significant findings used a mindfulness‐based programme with army cadets.

It is difficult to make a firm statement on the efficacy of pre‐deployment programmes for reducing depression given the small subset of five studies included in this review which measured depression. However, based on our results, it would appear that the impact of the programmes on levels of depression is limited, with the majority of included programmes failing to produce positive reductions in levels of depression.

Social support, coping skill, self‐efficacy and subjective levels of aggression

Social support, coping skills, and self‐efficacy were examined in just one to three studies each. With the exception of subjective levels of aggression (Christopher 2018), the interventions had no significant positive effects on these outcomes. It is notable that these would theoretically be viewed as protective factors for reducing the harmful after effects of witnessing a potentially traumatic event and developing PTSD, and yet are not routinely targeted or measured in interventions. While a main research focus on the primary outcomes as listed above is important, these secondary outcomes conceptualised some of the potential 'mechanisms of change' in resilience‐building programmes. Without further focus on these secondary factors, it is difficult to categorically determine what facets of psychological resilience are being reinforced by these pre‐deployment programmes.

Quality of life and quality of sleep

No studies reported this outcomes.

Stress

A total of nine studies reported stress as an outcome. Previous reviews in the area of pre deployment psychological preparedness training have highlighted stress reduction and stress inoculation programmes as being effective. Our findings are in line with the work of Hourani 2011. The majority of studies found their programmes effective in reducing stress, with two out of nine studies finding insignificant results. Stress management, mindfulness and biofeedback‐based interventions all proved to be successful methods at reducing and safeguarding against stress. There appears to be a degree of flexibility regarding intervention method/theoretical orientation and effective stress reduction.

Overall completeness and applicability of evidence

Population

A priori, we set out to include all eligible RCTs for military and frontline emergency services personnel within this review. We expected the majority of studies included to be from military samples given the stereotypical association of PTSD, trauma and resilience with military populations. We also expected to have a large representation from frontline emergency services subgroups such as the police, fire service, civil defence organisations etc. Aside from US law enforcement officers and a small subset of firefighter and crisis manager samples, there appears to be a distinct lack of trials in the frontline emergency services cohort in general. For example, we found a very limited number RCTs focused on pre‐deployment resilience in frontline emergency medical staff such as paramedics and emergency medical technicians (EMTs), constituting a significant gap for future research to explore.

Intervention

Our review, based on 28 studies, found that approaches to building resilience could be conceptualised under six different headings (See Table 1)

1) CBT‐informed programmes

2) Biofeedback‐based programmes

3) Stress management‐based programmes

4) Mindfulness‐ and relaxation‐based training

5) Neuropsychological‐informed programmes

6) Psychoeducational‐based programmes

A wide variety of theoretical approaches exists in the field. Within these subgroups, there is further variation in the methods of delivery, duration of programme and what/how outcomes are measured.

A recent meta‐analysis conducted by Kitchiner 2019, reported that of all the interventions types included in their review, CBT with a trauma focus was shown to be the most effective for treating PTSD. The question of whether the most effective treatment of PTSD could also be used as a tool to proactively protect against it is an interesting one. Two of the three CBT programmes included in this review were both successful in significantly increasing the resilience of their participants compared to controls. A future direction of resilience training could lie in the domain of CBT‐based programmes. However, given the small CBT sub‐sample reported in this review, we offer this suggestion with caution. Biofeedback interventions included in this review had success in reducing the symptoms of post‐traumatic stress and stress. Given the implication of stress in PTSD (Maguen 2009), biofeedback may be another intervention domain warranting further exploration. Similar to biofeedback interventions, we have found evidence to suggest that mindfulness‐based programmes may be effective at reducing stress.

Comparisons

Given the wide variety of interventions, direct comparisons have proven difficult, if not impossible in many cases. We were unable to conduct a meta‐analysis on the data for PTSD due to considerable heterogeneity between studies.

Outcomes

We prespecified twelve outcomes of interest in our protocol that we would investigate in this review. Upon review of included studies, we subdivided PTSD in two subcategories, post‐traumatic stress symptoms and PTSD (where scores fell above/below clinical thresholds). We also included stress as an outcome measure given its important role in resilience mechanisms, whereby long‐term chronic stress is implicated in burnout and increased susceptibility to PTSD.

Five of our pre‐specified outcomes, ASD, emotional flexibility, social functioning, quality of sleep and quality of life, were not included as outcomes in any of our included studies.

Quality of the evidence

Owing both to the variety of outcomes and inconsistency of reporting standards, the evidence is not complete. Many studies reported outcomes that could not be synthesised, and reporting was such that we could often not calculate effect sizes or synthesise findings across studies. For that reason, it is difficult to draw firm conclusions from the current evidence base.

We had the a‐priori goal of completing a meta‐analysis of the primary outcomes, however over the course of completing this review, several important issues arose.

1) There was a wide variety of resilience‐building approaches, samples, types of facilitators, modes of delivery and settings observed between all studies, creating substantial clinical and methodological heterogeneity.

2) There were significant discrepancies in the reporting of outcomes between studies, with several authors not responding to requests for additional data/ information (see Appendix 2 "Author Correspondence").

As can be seen in Table 1, there is significant variety in the ways resilience‐building programmes are; theoretically/therapeutically orientated, populations targeted, how they are delivered, setting used, and outcomes measured (with further variety in scales used within specific outcomes). This has made drawing conclusions on efficacy of interventions difficult, as they are often not sufficiently similar to make fair comparisons.

Regarding risk of bias issues as the overall certainty of evidence, the highest levels of bias were observed in selective reporting (21 studies rated as high risk), detection bias (16 studies rated as high risk) and incomplete outcome data (three studies rated as high risk). These issues were primarily attributed to a general absence of blinding of participants and assessors, where applicable (detection bias), a general absence of pre‐published trial protocols (selective reporting) and inadequate detail on attrition rates and the handling of missing data (incomplete outcome data). See the section on risk of bias above and Figure 2; Figure 3 for more detail.

Given the relatively small numbers of studies included in this review, and in particular the small subset of studies that reported on our main outcomes of interest, there is not enough evidence to provide confident conclusion on the efficacy of resilience building programmes. Given the varied quality of studies included in this review, a small number, or even a single large, well‐conducted trial has the potential to greatly influence the direction of the field. With this in mind, we have outlined specific recommendations for future research below, which may serve to help standardise the field of pre‐exposure resilience training and strengthen the evidence base.

Potential biases in the review process

The authors declare that no biases exists through our own funding and employment. We acknowledge that this review will contribute to a larger body of work which is supported by Defence Forces Ireland, however no funding was received from this organisation in completion of this review.

Many of the studies included in this review have been conducted by authors employed by the military, or the studies have been funded by military directly or thorough military academic institutions, this potential source of bias received special attention during our risk of bias assessment.

Agreements and disagreements with other studies or reviews

In general, previous systematic reviews in this field have reported little evidence to support the effectiveness of pre‐deployment resilience‐building interventions. Leppin 2014 reported little evidence to suggest that resilience‐building programmes increase resilience in their participants. Hourani 2011 concluded that the most promising avenues for PTSD prevention lie in the domains of pre‐trauma exposure strategies and stress‐reduction training methodologies. A Cochrane review of resilience programmes for civilian medical professionals published by Kunzler 2021 reported some positive effects for resilience training but noted a high level of uncertainty surrounding this result: similar to the findings of this review. Skeffington 2012, provided a broad synthesis of studies from a range of samples including police, military and civilian samples. The authors reported that their search quote “yielded no trials that met stringent Cochrane Collaboration standards or controlled randomised trials exploring the impact of primary pre‐trauma programmes on PTSD development”. In contrast, we have collated a broad range of trials which meet RCT standards in this review, many of which have been published since the Skeffington review of 2012 (Skeffington 2016). This is testament to the targeted and invigorated focus placed on pre‐exposure resiliency programmes in the last decade.

The findings of our review, are generally in line with previous findings from other systematic reviews i.e. 1) limited results supporting pre‐deployment psychological preparedness interventions 2) findings indicating that stress‐management programmes have promising efficacy in reducing participant stress. The main limitation of this review compared to previous investigations, is that programmes not conducted to RCT/cluster‐RCT standards have not been included. While RCT trials provide the "gold standard" benchmark for making inferences on efficacy, they certainly do not make up the majority of research in this area. As such a true, global picture of pre‐deployment resilience programming, remains elusive. Despite its limitations, this review provides a bedrock from which the field of resilience can grow. The primary strength of this review compared to previous work, has been its ability to bring together a wide variety of programmes, with a significant spread of intervention types and therapeutic mechanisms. While it has been difficult to provide a firm statement of the usefulness of resilience programmes, this review has provided a snapshot of the field of pre‐deployment resilience training as it stands, in both the military and emergency services domains. The recommendations provided in the following sections will, if adopted, provide much needed consistency in both design and reporting standards in the field.

Authors' conclusions

Implications for practice.

Overall, there is mixed evidence that the resilience‐building interventions included in this review are effective at safe guarding frontline personnel from developing psychological trauma or PTSD later. Based on this, practitioners seeking to build resilience in their personnel need to be aware of the limitations of the evidence base and have modest expectations in relation to the efficacy of resilience‐building programmes in protecting against the potential impacts of trauma.

We have concluded that there is some promising evidence to suggest that these pre‐deployment programmes had success in building resilience. However, only six studies reported resilience as an outcome. These studies measured the impacts of cognitive behavioural therapy (CBT) and mindfulness‐informed interventions and no study using other therapeutic modalities reported resilience as an outcome. It is therefore not possible at this juncture, to provide a statement on the efficacy of these other approaches as regards their potential to increase resilience. Aside from resilience, the other primary outcomes of interest we included were PTSD caseness, and symptoms of post traumatic stress. Generally, it would appear that the interventions we have included in this review were not effective in reducing symptoms of post‐traumatic stress or significantly reducing the risk of participants meeting the threshold for a diagnosis of PTSD. Similarly, results for depression suggested the included interventions were no more efficacious than controls at reducing rate of depression.

This review also presents evidence that several programmes evidenced effectiveness at reducing both work‐related and personal stress. Research by Maguen 2009 reported that routine work environment stress mediated the relationship between critical incident exposure and PTSD symptoms. Therefore interventions that target stress reduction may reduce the risk of developing symptoms of post‐traumatic stress after exposure to potentially traumatic events. The inclusion of stress‐ building facets/modules into resilience‐building programmes, may prove a fruitful direction for the field. Given the complexity of resilience, with its myriad of sub‐factors, future resilience programmes may be well‐placed to utilise a blended/multi‐model approach. This may involve the implementation of modular‐based programmes, drawing on aspects of mindfulness, stress reduction and CBT skills (the modalities that appeared to be most efficacious as per the findings of this review) to target a range of outcomes such as resilience, stress, depression, symptoms of postraumatic stress etc.

It is also important to state that there is a significant body of evidence regarding resilience‐building interventions that has not been captured in this review. Many of the studies investigating pre‐deployment resilience building are not conducted as randomised controlled trials (RCTs) or cluster‐RCTs. The nature of military/frontline emergency services work, and the difficulties of applying strict RCT methodologies around operational environments may be a factor in the selection of more flexible quasi‐experimental research designs. Therefore, we recommend practitioners utilise the results of this study in conjunction with non RCT studies, whilst using caution, to gain a global picture of the field when selecting/developing interventions to use with their populations.

Implications for research.

It has become evident through the course of this review that there is a wide variety of approaches to building resilience, both from theoretical and methodological stand points. It has also become evident that there is no singular "gold standard" methodology or therapeutic underpinning for effectively building resilience. This review has drawn together a conglomerate collection of studies, including interventions aligned with the positive psychological school of thought; whereby the enhancement of strengths and an individual's social resources are the primary focus. These programmes contrast with the medical/disease model approaches which focus on the prevention of disease or disorder. As mentioned in the above "implications for practice" section, resilience is a dynamic and multifaceted phenomenon comprised of a range of sub factors and is influenced by both internal and external stimuli. From a trans diagnostic point of view, measuring the relative "success" or "failure" of resilience building interventions may not be best served by measuring simply diagnosis/no diagnosis of PTSD or other mental health issue in isolation. For example PTSD may be only diagnosed several years post exposure to a potentially traumatic event, which is likely not to be captured within a typical RCT study, but other co‐morbidities may present earlier and/or respond to intervention sooner. Future research should therefore seek to capture the variety of factors which contribute to an individual's resilience whilst also measuring an appropriate range of outcomes.

Specifically, our findings have allowed us to make the following recommendations for future research, with the aim of improving the quality and consistency of evidence produced within the field.

1) Through the course of this review it has become clear that reporting standards are varied and inconsistent. As a minimum, authors should seek to report pre‐ and post‐means and standard deviation (SD) scores for scales used within respective studies. This will facilitate data pooling and meta‐analyses in the future.

2) As regards source of funding, a significant portion of the studies included in this review were funded by military organisations. As a minimum, authors should include a declaration of funding source and transparent information regarding their employment relationship with host militaries. Sponsorship and research input from military or emergency service organisations should be well‐documented to safeguard the transparency of the research process.

3) The area of resilience‐building to reduce psychological trauma in a military or emergency services personnel population will be strengthened by high‐quality RCTs with a‐priori protocols. There are relatively few studies to this standard at present and the field will benefit hugely from a continued focus on this form of research.

4) There were many different theoretical and methodological approaches to building resilience reported in this review. The variety of approaches and reporting standards has made a full synthesis of the current body of evidence difficult. Our recommendation for future research is to work towards a common ground, specifically firm conceptualisations of resilience and standardised terminology surrounding it. Standardising outcome measurement across future studies will be important in building the knowledge base of this relatively novel field for psychological research/practice: For example, studies should seek to measure defined psychological facets such as resilience, symptoms of post‐traumatic stress, depressive symptoms, perceived social support, stress and measure these concepts using standardised inventories such as the Connor‐Davidson Resilience Scale (CD‐RISC), Clinician‐Administered PTSD Scale (CAPS) and Perceived Stress Scale (PSS). This will allow a more comprehensive comparison of future interventions whilst providing much needed consistency in the field. Such consistency, will facilitate the design, development and evaluation of effective, evidence‐based resilience building programmes into the future.

A strength of this review is that we have been able to bring such a wealth of interventions types together, which to our knowledge has not been done to this level before. However, as stated above, this review was focused with RCT/cluster‐CRCT studies and as such many studies in the field have not been captured. Future reviews should consider including non‐randomised controlled trials to gain the most complete picture of the body of evidence. It is also interesting to note that the overwhelming majority of included studies were conducted in "western" nations, with a marked dearth of programmes from Africa, Asia, South American and the Middle East. Future research encompassing the diversity of these regions can only help to develop our holistic understanding of resilience, trauma and the potential for effective intervention.

History

Protocol first published: Issue 1, 2019

Appendices

Appendix 1. Search strategies

Bibliographic Databases

Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library 
Search Name:   CCMD Predeployment P19 V05
Search Date: 29 September 2020

ID         Search

#1        MeSH descriptor: [Civil Defense] explode all trees
#2        MeSH descriptor: [Military Personnel] explode all trees
#3        MeSH descriptor: [Emergency Responders] explode all trees
#4        MeSH descriptor: [Relief Work] explode all trees
#5        MeSH descriptor: [Rescue Work] explode all trees
#6        ((military or soldier* or army or armies or combatant*)):ti,ab,kw (Word variations have been searched)
#7        ("national guard" or "civil defence" or "civil defense"):ti,ab,kw OR ("armed forces" or "armed personnel"):ti,ab,kw (Word variations have been searched)
#8        (marines or navy or naval or seamen* or sailors or submariners or submariners or "coast guard*" or coastguard*):ti,ab,kw OR (airforce* or "air force*"):ti,ab,kw OR ((air* or helicopter or flight or plane*) NEAR/3 (crew or pilots)):ti,ab,kw OR (airman or airmen or "air man" or "air men"):ti,ab,kw (Word variations have been searched)
#9        (firefighters or "fire fighters" or firemen or "fire crew"):ti,ab,kw OR (police* or policing or "enforcement officer*"):ti,ab,kw OR ("law enforcement" or "civil enforcement"):ti,ab,kw OR (security NEAR/1 (personnel or service* or staff)):ti,ab,kw OR (paramedic* or para‐medic*):ti,ab,kw (Word variations have been searched)
#10      (ambulance NEAR/2 (crew* or personnel or staff or nurs* or team* or technicians)):ti,ab,kw OR (peacekeepers or "peace keepers"):ti,ab,kw OR ((humanitarian or peacekeep* or "peace keep*" or "united nations" or NGO*) NEAR/3 (crew* or personn* or staff or nurs* or team* or technicians or volunteers or workers or workforce or work force)):ti,ab,kw OR ((aid or disasters or "disaster recovery" or relief) NEAR/1 (personnel or team* or volunteers or workers or workforce or work force)):ti,ab,kw OR ((emergency or "first respon*" or frontline or "front line" or rescue) NEAR/2 (crew* or personnel or staff or nurs* or team* or technicians or volunteers or workers or workforce or "work force")):ti,ab,kw (Word variations have been searched)
#11      ("relief work*" or "emergency responders"):ti,ab,kw OR (oxfam or "red cross" or "red crescent"):ti,ab,kw OR (((medic* or medec*) NEAR/1 "sans frontier*") OR "doctors without borders"):ti,ab,kw OR ("united nations" or "humanitarian organi*"):ti,ab,kw (Word variations have been searched)
#12      MeSH descriptor: [United Nations] explode all trees
#13      MeSH descriptor: [Voluntary Health Agencies] explode all trees
#14      #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13
#15      MeSH descriptor: [Adaptation, Psychological] explode all trees
#16      MeSH descriptor: [Resilience, Psychological] explode all trees
#17      (resilien* or preparedness):ti OR (resilien* NEAR/3 (foster* or improv* or increas* or build* or educat* or psychoeducat* or intervention* or management or program* or curriculum or skill* or train* or therap*)):ti,ab,kw (Word variations have been searched)
#18      MeSH descriptor: [Stress, Psychological] explode all trees and with qualifier(s): [prevention & control ‐ PC]
#19      MeSH descriptor: [Occupational Stress] explode all trees and with qualifier(s): [prevention & control ‐ PC]
#20      MeSH descriptor: [Stress, Psychological] explode all trees
#21      MeSH descriptor: [Occupational Stress] explode all trees
#22      MeSH descriptor: [Compassion Fatigue] explode all trees
#23      ((prevent* or reduc* or decreas* or risk*)):ti (Word variations have been searched)
#24      (#20 or #21 or #22) and #23
#25      (psychotrauma* or psycho‐trauma*):ti,ab,kw OR ((psychological NEAR/1 (trauma* or distress or stress)) NEAR/3 (prevent* or reduc* or decreas* or risk*)):ti,ab,kw (Word variations have been searched)
#26      MeSH descriptor: [Trauma and Stressor Related Disorders] explode all trees and with qualifier(s): [prevention & control ‐ PC]
#27      MeSH descriptor: [Adjustment Disorders] explode all trees and with qualifier(s): [prevention & control ‐ PC]
#28      MeSH descriptor: [Stress Disorders, Traumatic] explode all trees and with qualifier(s): [prevention & control ‐ PC]
#29      MeSH descriptor: [Combat Disorders] explode all trees and with qualifier(s): [prevention & control ‐ PC]
#30      MeSH descriptor: [Psychological Trauma] explode all trees and with qualifier(s): [prevention & control ‐ PC]
#31      MeSH descriptor: [Stress Disorders, Post‐Traumatic] explode all trees and with qualifier(s): [prevention & control ‐ PC]
#32      MeSH descriptor: [Stress Disorders, Traumatic, Acute] explode all trees and with qualifier(s): [prevention & control ‐ PC]
#33      MeSH descriptor: [Trauma and Stressor Related Disorders] explode all trees
#34      MeSH descriptor: [Adjustment Disorders] explode all trees
#35      MeSH descriptor: [Stress Disorders, Traumatic] explode all trees
#36      MeSH descriptor: [Combat Disorders] explode all trees
#37      MeSH descriptor: [Stress Disorders, Post‐Traumatic] explode all trees
#38      MeSH descriptor: [Stress Disorders, Traumatic, Acute] explode all trees
#39      (#33 or #34 or #35 or #36 or #37 or #38) and #23
#40      ("acute stress" or ((combat or adjustment or stress) NEAR/1 disorder*)):ti,ab,kw (Word variations have been searched)
#41      #40 and #23
#42      ((stress or pretrauma* or pre‐trauma*) NEAR/3 (psychotherap* or therap* or training)):ti,ab,kw OR ("critical incident*" NEAR/3 (educat* or psychoeducat* or intervention* or management or program* or skill* or train*)):ti,ab,kw OR (coping NEAR/3 (educat* or psychoeducat* or intervention* or program* or skill* or train*)):ti,ab,kw OR ("stress inoculation"):ti,ab,kw OR (exposure NEAR/1 (psychotherap* or therap* or training)):ti,ab,kw (Word variations have been searched)
#43      ((predeployment or pre‐deployment or pre‐exposure or pretrauma* or pre‐trauma*) NEAR/3 (service or duty or duties or deploy* or frontline or "front line" or exposure or war or wars or warfare or disaster* or crisis or crises or "critical incident*")):ti,ab,kw OR (((before or prior) NEAR/4 (service or duty or duties or deploy* or frontline or "front line" or exposure or war or wars or warfare or disaster* or crisis or crises or "critical incident*"))):ti,ab,kw (Word variations have been searched)
#44      (#15 OR #16 OR #17 OR #18 OR #19 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #39 OR #41 OR #42 OR #43)
#45     ( #14 AND #44)

***************************************************************************

Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) c/o CRS‐Web (current to June 2016)
#1 (military or soldier* or army or armies) AND INREGISTER
#2 "emergency responders" or "emergency medical technicians" AND INREGISTER
#3 "relief work*" or "rescue work*" AND INREGISTER
#4 ((armed adj (forces or personnel)) or "national guard" or "civil defense") AND INREGISTER
#5 (marines or navy or naval or seamen* or sailors or submariners or submariners or "coast guard*" or coastguard*) AND INREGISTER
#6 (airforce* or "air force" or ((air* or helicopter or flight or plane or planes) near crew)) AND INREGISTER
#7 (pilots or co‐pilots) AND INREGISTER
#8 (firefighters or "fire fighters" or firemen or "fire crew") AND INREGISTER
#9 (police* or policing or "enforcement officers" or ((law or civil) adj enforcement)) AND INREGISTER
#10 (security adj (personnel or service* or staff)) AND INREGISTER
#11 (paramedic* or para‐medic* or ((ambulance or ambulatory) adj2 (crew* or personnel or staff or nurs* or team* or technicians))) AND INREGISTER
#12 (peacekeepers or "peace keepers" or ((humanitarian or peacekeep* or peace keep* or "united nations") adj3 (crew or crews or personnel or staff or nurs* or team* or technicians or volunteers or workers or workforce or work force))) AND INREGISTER
#13 ((aid or disasters or "disaster recovery" or relief) adj (personnel or team* or volunteers or workers or workforce or "work force")) AND INREGISTER
#14 ((emergency or "first respon*" or frontline or "front line" or rescue) adj2 (crew or crews or personnel or staff or nurs* or team* or technicians or volunteers or workers or workforce or work force)) AND INREGISTER
#15 (oxfam or "red cross" or "red crescent") AND INREGISTER
#16 (((medic* or medec*) adj "sans frontier*") or "doctors without borders") AND INREGISTER
#17 "united nations" OR "voluntary health agenc*" OR UNESCO OR  "World Health Organi*" OR "Pan American Health Organi*" AND INREGISTER
#18 "humanitarian organi*" AND INREGISTER
#19 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18)
#20 (adaptation or resilien* or preparedness) AND INREGISTER
#21 (stress* near (prevent* or decreas* or reduc*)) AND INREGISTER
#22 "compassion fatigue" AND INREGISTER
#23 ((psychotrauma* or psycho‐trauma* or (psychological adj (trauma* or distress or stress))) near (prevent* or reduc* or decreas* or risk*)) AND INREGISTER
#24 "trauma and stress* related disorders" or "adjustment disorder*" or "combat disorders" or "psychological trauma" or "stress disorder*" or "acute stress" AND INREGISTER
#25 "acute stress*" AND INREGISTER
#26 "prevention & control" AND INREGISTER
#27 (prevent* or reduc* or decreas* or risk*):ti AND INREGISTER
#28 (#24 or #25) and (#26 or #27)
#29 (BattleMind or "Comprehensive Soldier" or "Resilience Training") AND INREGISTER
#30 ((stress or pretrauma* or pre‐trauma*) near (psychotherap* or therap* or training)) AND INREGISTER
#31 ("critical incident*" near (educat* or psychoeducat* or intervention* or management or program* or skill or skills or train*)) AND INREGISTER
#32 (coping near (educat* or psychoeducat* or intervention* or program* or skill or skills or train*)) AND INREGISTER
#33 "stress inoculation" AND INREGISTER
#34 (exposure adj (psychotherap* or therap* or training)) AND INREGISTER
#35 (predeployment or pre‐deployment or pre‐exposure or pretrauma* or pre‐trauma* or ((before or "prior to") near (service or duty or duties or deploy* or frontline or "front line" or exposure or war or wars or disaster* or crisis or crises or "critical incident*"))) AND INREGISTER
#36 (#20 OR #21 OR #22 OR #23 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 or #35)
#37 (#36 AND #19)
#38 rescuers AND INREGISTER
#39 (#37 OR #38) n=324

[The CCMDCTR is an archived database, current to June 2016]

***************************************************************************

Ovid Embase <1974 to 2020 September 28> 
Search Date: 29 Septemberr 2020
Search Strategy:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

1     Civil Defense/ (1616)
2     Soldier/ or Sailor/ or Airplane Pilot/ or Airplane Crew/ (34785)
3     Rescue Personnel/ (7800)
4     Relief Work/ or Rescue Work/ (2340)
5     Disaster/ (23082)
6     (military or soldier$ or army or armies).ti,ab,kw,hw. (95961)
7     ((armed adj (forces or personnel)) or national guard or civil defen?e).ti,ab,kw. (6518)
8     (marines or navy or naval or seamen? or sailors or submariners or submariners or coast guard$ or coastguard$).ti,ab,kw,hw. (9291)
9     (airforce? or air force?).ti,ab,kw. (4034)
10     ((air$ or helicopter or flight or plane?) adj3 (crew or pilots)).ti,ab,kw,hw. (3910)
11     (airman or airmen or air man or air men).ti,ab,kw. (310)
12     (pilots or co‐pilots).ti,sh. (1845)
13     (firefighters or fire fighters or firemen or fire crew).ti,ab,kw. (3257)
14     (police$ or policing or enforcement officers).ti,ab,kw,hw. (24573)
15     ((law or civil) adj enforcement).ti,ab,kw. (5755)
16     (security adj (personnel or service$ or staff)).ti,ab,kw. (613)
17     (paramedic? or para‐medic?).ti,ab,kw. (8190)
18     (ambulance adj2 (crew? or personnel or staff or nurs$ or team? or technicians)).ti,ab,kw. (1525)
19     (peacekeepers or peace keepers).ti,ab,kw. (168)
20     ((humanitarian or peacekeep$ or peace keep$ or united nations or NGO$) adj3 (crew? or personn$ or staff or nurs$ or team? or technicians or volunteers or workers or workforce or work force)).ti,ab,kw. (608)
21     ((aid or disasters or disaster recovery or relief) adj (personnel or team? or volunteers or workers or workforce or work force)).ti,ab,kw. (486)
22     ((emergency or first respon$ or frontline or front line or rescue) adj2 (crew? or personnel or staff or nurs$ or team? or technicians or volunteers or workers or workforce or work force)).ti,ab,kw. (15128)
23     (relief work$ or emergency responders).ti,ab,kw. (808)
24     (oxfam or red cross or red crescent).ti,ab,kw. (5841)
25     (((medic$ or medec$) adj sans frontier$) or doctors without borders).ti,ab,kw. (841)
26     United Nations/ (8942)
27     (united nations or humanitarian organi$).ti,ab,kw. (8422)
28     (1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27) (213465)
29     Psychological Adjustment/ (1218)
30     Psychological Resilience/ (3962)
31     (resilien$ or preparedness).ti,kw. (22167)
32     (resilien$ adj3 (foster$ or improv$ or increas$ or build$ or educat$ or psychoeducat$ or intervention$ or management or program$ or curriculum or skill? or train$ or therap$)).ti,ab,kw. (6266)
33     mental stress/pc, th or job stress/pc, th or compassion fatigue/pc, th (5579)
34     mental stress/ or job stress/ or compassion fatigue/ (92173)
35     (prevent$ or reduc$ or decreas$ or risk?).ti. (1489176)
36     34 and 35 (6382)
37     ((psychotrauma$ or psycho‐trauma$ or (psychological adj (trauma$ or distress or stress))) adj3 (prevent$ or reduc$ or decreas$ or risk$)).ti,ab,kw. (3280)
38     Posttraumatic Stress Disorder/pc or Acute Stress Disorder/pc or Psychotrauma/pc (1266)
39     Posttraumatic Stress Disorder/ or Acute Stress Disorder/ or Psychotrauma/ (67925)
40     (prevent$ or reduc$ or decreas$ or risk?).ti. (1489176)
41     39 and 40 (3964)
42     (acute stress or ((combat or adjustment or stress) adj disorder?)).ti,ab,kw. (50115)
43     (prevent$ or reduc$ or decreas$ or risk?).ti. (1489176)
44     42 and 43 (3172)
45     ((stress or pretrauma$ or pre‐trauma$) adj3 (psychotherap$ or therap$ or training)).ti,ab,kw. (6067)
46     (critical incident$ adj3 (educat$ or psychoeducat$ or intervention$ or management or program$ or skill$ or train$)).ti,ab,kw. (275)
47     (coping adj3 (educat$ or psychoeducat$ or intervention? or program$ or skill? or train$)).ti,ab,kw. (7109)
48     stress inoculation.ti,ab,kw. (282)
49     (exposure adj (psychotherap$ or therap$ or training)).ti,ab,kw. (2721)
50     (predeployment or pre‐deployment or pre‐exposure or pretrauma$ or pre‐trauma$ or ((before or prior to) adj3 (service or duty or duties or deploy$ or frontline or front line or exposure or war or wars or warfare or disaster? or crisis or crises or critical incident?))).ti,ab,kw. (42847)
51     (29 or 30 or 31 or 32 or 33 or 36 or 37 or 38 or 41 or 44 or 45 or 46 or 47 or 48 or 49 or 50) (103951)
52     randomized controlled trial/ (622555)
53     randomization.de. (88223)
54     Controlled clinical trial/ and (Disease management or Drug Therapy or Prevention or Rehabilitation or Therapy).fs. (254581)
55     *clinical trial/ (17634)
56     placebo.de. (355730)
57     placebo.ti,ab. (311831)
58     trial.ti. (309853)
59     (randomi#ed or randomi#ation or randomi#ing).ti,ab,kw. (938925)
60     (RCT or "at random" or (random* adj3 (administ* or allocat* or assign* or class* or cluster* or control* or determine* or divide* or division or distribut* or expose* or fashion or number* or place* or pragmatic* or recruit* or split or subsitut* or treat*))).ti,ab,kw. (763574)
61     ((singl$ or doubl$ or trebl$ or tripl$) adj3 (blind$ or mask$ or dummy)).mp. (313944)
62     (control* and (trial or study or group) and (placebo or waitlist* or wait* list* or ((treatment or care) adj2 usual))).ti,ab,kw,hw. (361722)
63     or/52‐62 (1766221)
64     ((animal or nonhuman) not (human and (animal or nonhuman))).de. (5759050)
65     63 not 64 (1606257)
66     28 and 51 and 65 (410)
67     (BattleMind or Comprehensive Soldier or Master Resilience Training or Stress Resilience Training System).ti,ab,kw. (40)
68     66 or 67 (447)

***************************************************************************

Ovid MEDLINE(R) ALL <1946 to September 28, 2020>
Search Date: 29 September 2020
Search Strategy:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

1     Civil Defense/ (2962)
2     Military Personnel/ (40007)
3     exp Emergency Responders/ (12614)
4     Relief Work/ or Rescue Work/ (5973)
5     (military or soldier$ or army or armies).ti,ab,kf,hw. (99124)
6     ((armed adj (forces or personnel)) or national guard or civil defen?e).ti,ab,kf. (8438)
7     (marines or navy or naval or seamen? or sailors or submariners or submariners or coast guard$ or coastguard$).ti,ab,kf,hw. (15732)
8     (airforce? or air force?).ti,ab,kf. (3952)
9     ((air$ or helicopter or flight or plane?) adj3 (crew or pilots)).ti,ab,kf. (1757)
10     (airman or airmen or air man or air men).ti,ab,kf. (299)
11     (pilots or co‐pilots).ti,sh. (2225)
12     (firefighters or fire fighters or firemen or fire crew).ti,ab,kf,hw. (2842)
13     (police$ or policing or enforcement officers).ti,ab,kf,hw. (17987)
14     ((law or civil) adj enforcement).ti,ab,kf,hw. (7568)
15     (security adj (personnel or service$ or staff)).ti,ab,kf. (460)
16     (paramedic? or para‐medic?).ti,ab,kf. (5306)
17     (ambulance adj2 (crew? or personnel or staff or nurs$ or team? or technicians)).ti,ab,kf. (1078)
18     (peacekeepers or peace keepers).ti,ab,kf. (151)
19     ((humanitarian or peacekeep$ or peace keep$ or united nations or NGO$) adj3 (crew? or personn$ or staff or nurs$ or team? or technicians or volunteers or workers or workforce or work force)).ti,ab,kf. (469)
20     ((aid or disasters or disaster recovery or relief) adj (personnel or team? or volunteers or workers or workforce or work force)).ti,ab,kf. (440)
21     ((emergency or first respon$ or frontline or front line or rescue) adj2 (crew? or personnel or staff or nurs$ or team? or technicians or volunteers or workers or workforce or work force)).ti,ab,kf. (11622)
22     (relief work$ or emergency responders).ti,ab,kf. (700)
23     (oxfam or red cross or red crescent).ti,ab,kf,sh. (4715)
24     (((medic$ or medec$) adj sans frontier$) or doctors without borders).ti,ab,kf. (769)
25     exp United Nations/ (41381)
26     *Voluntary Health Agencies/ (2279)
27     (united nations or humanitarian organi$).ti,ab,kf. (7174)
28     or/1‐27 (218550)
29     Adaptation, Psychological/ (94938)
30     Resilience, Psychological/ (5960)
31     (resilien$ or preparedness).ti,kf. (18926)
32     (resilien$ adj3 (foster$ or improv$ or increas$ or build$ or educat$ or psychoeducat$ or intervention$ or management or program$ or curriculum or skill? or train$ or therap$)).ti,ab,kf. (5169)
33     stress, psychological/pc, th or occupational stress/pc, th or compassion fatigue/pc, th (14188)
34     stress, psychological/ or occupational stress/ or compassion fatigue/ (123119)
35     (prevent$ or reduc$ or decreas$ or risk?).ti. (1166102)
36     34 and 35 (8020)
37     ((psychotrauma$ or psycho‐trauma$ or (psychological adj (trauma$ or distress or stress))) adj3 (prevent$ or reduc$ or decreas$ or risk$)).ti,ab,kf. (2488)
38     "trauma and stress related disorders"/pc or adjustment disorders/pc or stress disorders, traumatic/pc or combat disorders/pc or psychological trauma/pc or stress disorders, post‐traumatic/pc or stress disorders, traumatic, acute/pc (1467)
39     "trauma and stress related disorders"/ or adjustment disorders/ or stress disorders, traumatic/ or combat disorders/ or psychological trauma/ or stress disorders, post‐traumatic/ or stress disorders, traumatic, acute/ (40220)
40     (prevent$ or reduc$ or decreas$ or risk?).ti. (1166102)
41     39 and 40 (2166)
42     (acute stress or ((combat or adjustment or stress) adj disorder?)).ti,ab,kf. (39491)
43     (prevent$ or reduc$ or decreas$ or risk?).ti. (1166102)
44     42 and 43 (2474)
45     ((stress or pretrauma$ or pre‐trauma$) adj3 (psychotherap$ or therap$ or training)).ti,ab,kf. (4498)
46     (critical incident$ adj3 (educat$ or psychoeducat$ or intervention$ or management or program$ or skill$ or train$)).ti,ab,kf. (204)
47     (coping adj3 (educat$ or psychoeducat$ or intervention? or program$ or skill? or train$)).ti,ab,kf. (5004)
48     stress inoculation.ti,ab,kf. (192)
49     (exposure adj (psychotherap$ or therap$ or training)).ti,ab,kf. (2010)
50     (predeployment or pre‐deployment or pre‐exposure or pretrauma$ or pre‐trauma$ or ((before or prior to) adj3 (service or duty or duties or deploy$ or frontline or front line or exposure or war or wars or warfare or disaster? or crisis or crises or critical incident?))).ti,ab,kf. (31722)
51     (29 or 30 or 31 or 32 or 33 or 36 or 37 or 38 or 41 or 44 or 45 or 46 or 47 or 48 or 49 or 50) (175971)
52     controlled clinical trial.pt. (93863)
53     randomized controlled trial.pt. (514087)
54     (randomi#ed or randomi#ation or randomi#ing).ti,ab,kf. (652948)
55     (RCT or "at random" or (random* adj3 (administ* or allocat* or assign* or class* or cluster or control* or determine* or divide* or division or distribut* or expose* or fashion or number* or place* or pragmatic or quasi or recruit* or split or subsitut* or treat*))).ti,ab,kf. (556152)
56     placebo*.ab,ti,kf. (219193)
57     trial.ab,ti,kf. (616145)
58     groups.ab. (2099332)
59     (control* and (trial or study or group*) and (placebo or waitlist* or wait* list* or ((treatment or care) adj2 usual))).ti,ab,kf,hw. (201935)
60     ((single or double or triple or treble) adj2 (blind* or mask* or dummy)).ti,ab,kf. (175880)
61     double‐blind method/ or random allocation/ or single‐blind method/ (281536)
62     52 or 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 (3110005)
63     exp animals/ not humans.sh. (4738878)
64     62 not 63 (2646262)
65     28 and 51 and 64 (1008)
66     (BattleMind or Comprehensive Soldier or Master Resilience Training or Stress Resilience Training System).ti,ab,kf. (38)
67     65 or 66 (1038)

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Ovid APA PsycInfo <1806 to September Week 3 2020>
Search Date: 29 September 2020
Search Strategy:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

1     Emergency Preparedness/ (1239)
2     exp Military Personnel/ (30521)
3     exp Emergency Services/ (10871)
4     First Responders/ (278)
5     exp Rescue Workers/ (254)
6     (military or soldier$ or army or armies).ti,ab,hw,id. (47272)
7     ((armed adj (forces or personnel)) or national guard or civil defen?e).ti,ab,hw,id. (2497)
8     (marines or navy or naval or seamen? or sailors or submariners or submariners or coast guard$ or coastguard$).ti,ab,hw,id. (4600)
9     (airforce? or air force?).ti,ab,hw,id. (3037)
10     ((air$ or helicopter or flight or plane?) adj3 (crew or pilots)).ti,ab,hw,id. (3247)
11     (airman or airmen or air man or air men).ti,ab,hw,id. (367)
12     (pilots or co‐pilots).ti,sh. (830)
13     (firefighters or fire fighters or firemen or fire crew).ti,ab,hw,id. (1553)
14     (police$ or policing or enforcement officers).ti,ab,hw,id. (25264)
15     ((law or civil) adj enforcement).ti,ab,hw,id. (9183)
16     (security adj (personnel or service$ or staff)).ti,ab,hw,id. (347)
17     (paramedic? or para‐medic?).ti,ab,hw,id. (670)
18     (ambulance adj2 (crew? or personnel or staff or nurs$ or team? or technicians)).ti,ab,hw,id. (118)
19     (peacekeepers or peace keepers).ti,ab,hw,id. (176)
20     ((humanitarian or peacekeep$ or peace keep$ or united nations or NGO$) adj3 (crew? or personn$ or staff or nurs$ or team? or technicians or volunteers or workers or workforce or work force)).ti,ab,hw,id. (358)
21     ((aid or disasters or disaster recovery or relief) adj (personnel or team? or volunteers or workers or workforce or work force)).ti,ab,hw,id. (325)
22     ((emergency or first respon$ or frontline or front line or rescue) adj2 (crew? or personnel or staff or nurs$ or team? or technicians or volunteers or workers or workforce or work force)).ti,ab,hw,id. (3403)
23     (relief work$ or emergency responders).ti,ab,hw,id. (339)
24     [(oxfam or red cross or red crescent).ti,ab,kf,sh.] (0)
25     (((medic$ or medec$) adj sans frontier$) or doctors without borders).ti,ab,hw. (97)
26     International Organizations/ (2916)
27     [(united nations or humanitarian organi$).ti,ab,kf.] (0)
28     (1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27) (101689)
29     exp Adjustment/ (51802)
30     Emotional Adjustment/ (16405)
31     "Resilience (Psychological)"/ (14474)
32     Coping Behavior/ (48133)
33     "Stress and Coping Measures"/ (190)
34     (resilien$ or preparedness).ti,hw. (19132)
35     (resilien$ adj3 (foster$ or improv$ or increas$ or build$ or educat$ or psychoeducat$ or intervention$ or management or program$ or curriculum or skill? or train$ or therap$)).ti,ab,hw,id. (5296)
36     Psychological Stress/ or Occupational Stress/ or Compassion Fatigue/ (30493)
37     (prevent$ or reduc$ or decreas$ or risk?).ti. (170409)
38     36 and 37 (1471)
39     ((psychotrauma$ or psycho‐trauma$ or (psychological adj (trauma$ or distress or stress))) adj3 (prevent$ or reduc$ or decreas$ or risk$)).ti,ab,hw,id. (1973)
40     Post‐Traumatic Stress/ or Posttraumatic Stress Disorder/ (33804)
41     (prevent$ or reduc$ or decreas$ or risk?).ti. (170409)
42     40 and 41 (1715)
43     (acute stress or ((combat or adjustment or stress) adj disorder?)).ti,ab,hw,id. (48297)
44     (prevent$ or reduc$ or decreas$ or risk?).ti. (170409)
45     (43 and 44) (2480)
46     ((stress or pretrauma$ or pre‐trauma$) adj3 (psychotherap$ or therap$ or training)).ti,ab,hw,id. (3431)
47     (critical incident$ adj3 (educat$ or psychoeducat$ or intervention$ or management or program$ or skill$ or train$)).ti,ab,hw,id. (362)
48     (coping adj3 (educat$ or psychoeducat$ or intervention? or program$ or skill? or train$)).ti,ab,hw,id. (8585)
49     stress inoculation.ti,ab,hw,id. (569)
50     (exposure adj (psychotherap$ or therap$ or training)).ti,ab,hw,id. (3727)
51     (predeployment or pre‐deployment or pre‐exposure or pretrauma$ or pre‐trauma$ or ((before or prior to) adj3 (service or duty or duties or deploy$ or frontline or front line or exposure or war or wars or warfare or disaster? or crisis or crises or critical incident?))).ti,ab,hw,id. (8524)
52     (29 or 30 or 31 or 32 or 33 or 34 or 35 or 38 or 39 or 42 or 45 or 46 or 47 or 48 or 49 or 50 or 51) (138400)
53     clinical trials.sh. (11768)
54     (randomi#ed or randomi#ation or randomi#ing).ti,ab,id. (88340)
55     (RCT or at random or (random* adj3 (administ* or allocat* or assign* or class* or cluster* or control* or determine* or divide* or division or distribut* or expose* or fashion or number* or place* or recruit* or split or subsitut* or treat*))).ti,ab,id. (104841)
56     (control* and (trial or study or group) and (placebo or waitlist* or wait* list* or ((treatment or care) adj2 usual))).ti,ab,id,hw. (29693)
57     ((single or double or triple or treble) adj2 (blind* or mask* or dummy)).ti,ab,id. (26518)
58     trial.ti. (31143)
59     placebo.ti,ab,id,hw. (40589)
60     treatment outcome.md. (20767)
61     treatment effectiveness evaluation.sh. (24801)
62     mental health program evaluation.sh. (2140)
63     (53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62) (200256)
64     28 and 52 and 63 (404)
65     (BattleMind or Comprehensive Soldier or Master Resilience Training or Stress Resilience Training System).ti,ab,hw,id. (65)
66     (64 or 65) (466)

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Web of Science Search History
Indexes=SCI‐EXPANDED, SSCI, A&HCI, CPCI‐S, CPCI‐SSH, ESCI Timespan=1900‐2020
Search Date:: 29 September 2020

# 19    657   (#18 OR #17)
# 18    57   TOPIC: (BattleMind or "Comprehensive Soldier" or "Master Resilience Training" or "Stress Resilience Training System") 
# 17   607   #16 AND #15 
# 16    2,858,791   TITLE: (trial) OR TOPIC: (random*) OR TOPIC: (placebo) OR TOPIC: (control* NEAR/2 (trial or study or group*) )  OR TOPIC: ((treatment or care) NEAR/2 usual) OR TOPIC: ((single or double or triple or treble) NEAR/2 (blind* or mask* or dummy) ) 
# 15    5,532   (#14 AND #10)
# 14   716,684   (#13 OR #12 OR #11 )
# 13   46,284   TOPIC: (((aid or disasters or "disaster recovery" or relief) NEAR/1 (personnel or team? or volunteers or workers or workforce or "work force") )) OR TOPIC: (((emergency or "first respon*" or frontline or "front line" or rescue) NEAR/2 (crew? or personnel or staff or nurs* or team? or technicians or volunteers or workers or workforce or "work force") )) OR TOPIC: (("relief work*" or "rescue work*" or "emergency responders") ) OR TOPIC: ((oxfam or "red cross" or "red crescent") ) OR TOPIC: (("med* sans frontier*" or "doctors without borders") ) OR TOPIC: ("united nations" or "humanitarian organi*") 
# 12   88,291    TOPIC: (("civil defence" or "civil defense") ) OR TOPIC: ((firefighters or "fire fighters" or firemen or "fire crew") ) OR TOPIC: (police* or policing or "enforcement officers") OR TOPIC: (("law enforcement" or "civil enforcement") ) OR TOPIC: ((security NEAR/1 (personnel or service* or staff) )) OR TOPIC: (paramedic? or para‐medic?) OR TOPIC: ((ambulance NEAR/2 (crew? or personnel or staff or nurs* or team? or technicians) )) OR TOPIC: ((peacekeepers or "peace keepers") ) OR TOPIC: ((humanitarian or peacekeep* or "peace keep*" or "united nations" or NGO*) NEAR/3 (crew? or personn* or staff or nurs* or team? or technicians or volunteers or workers or workforce or "work force") ) 
# 11   591,822   TOPIC: ((military or soldier* or army or armies) ) OR TOPIC: (("armed forces" or "armed personnel" or "national guard" or "civil defence" or "civil defense") ) OR TOPIC: ((marines or navy or naval or seamen? or sailors or submariners or submariners or "coast guard*" or coastguard*) ) OR TOPIC: ((airforce? or "air force?") ) OR TOPIC: ((air* or helicopter or flight or plane?) NEAR/3 (crew or pilots) ) OR TOPIC:((airman or airmen or "air man" or "air men") ) 
# 10   117,343   (#9 OR #8 OR #7 OR #6 OR #5 OR #4 OR #3 OR #2 OR #1)
# 9   41,618   TOPIC: ((before or prior) NEAR/3 (service or duty or duties or deploy* or frontline or "front line" or exposure or war or wars or warfare or disaster* or crisis or crises or "critical incident*") ) 
# 8   14,552   TOPIC: (exposure NEAR/1(psychotherap* or therap* or training) ) OR TOPIC: ((predeployment or pre‐deployment or pre‐exposure or pretrauma* or pre‐trauma*) NEAR/3 (service or duty or duties or deploy* or frontline or "front line" or exposure or war or wars or warfare or disaster* or crisis or crises or "critical incident*") ) 
# 7   16,070    TOPIC: ((stress or pretrauma* or pre‐trauma*) NEAR/3 (psychotherap* or therap* or training) ) OR TOPIC: ("critical incident*" NEAR/3 (educat* or psychoeducat* or intervention* or management or program* or skill* or train*) ) OR TOPIC: (coping NEAR/3 (educat* or psychoeducat* or intervention? or program* or skill? or train*) ) OR TOPIC: ("stress inoculation") OR TOPIC: ("stress vaccination") 
# 6   2,227  TOPIC: ("adjustment disorders*" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) OR TOPIC: ("traumatic stress" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) OR TOPIC: ("posttraumatic stress" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) OR TOPIC: ("post‐traumatic stress" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) 
# 5    3,125   TOPIC: ("psychological distress" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) OR TOPIC: ("psychological stress" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) OR TOPIC: ("combat disorder*" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) OR TOPIC: ("stress related disorder*" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) 
# 4   569   TOPIC: ("occupational stress" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) OR TOPIC: ("compassion fatigue" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) OR TOPIC: ((psychotrauma* or psycho‐trauma*) NEAR/3 (prevent* or reduc* or decreas* or risk*) ) OR TOPIC: ("psychological trauma*" NEAR/3 (prevent* or reduc* or decreas* or risk*) ) 
# 3   18,147   TOPIC: (resilien* NEAR/3 (foster* or improv* or increas* or build* or educat* or psychoeducat* or intervention* or management or program* or curriculum or skill? or train* or therap*) ) 
# 2   1,873   TOPIC: (Resilien* NEAR/2 Psycholog*) 
# 1   22,472   TS=((Adaptation or adaptivity) NEAR/3 (foster* or improv* or increas* or build* or educat* or psychoeducat* or intervention* or management or program* or curriculum or skill? or train* or therap*) ) 

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PILOTS via Proquest
Search Date: 30 September 2020

Six separate searches were conducted (573 records loaded into EndNote, de‐duplicated=263)

MAINSUBJECT.EXACT.EXPLODE("Randomized Clinical Trial") OR noft(trial*) OR noft(placebo) OR noft(RCT OR "at random" OR (random* NEAR/3 (administ* OR allocat* OR assign* OR class* OR cluster OR control* OR determine* OR divide* OR division OR distribut* OR expose* OR fashion OR number* OR place* OR pragmatic OR quasi OR recruit* OR split OR subsitut* OR treat*))) OR (noft((control* AND (trial OR study OR group*) AND (placebo OR waitlist* OR "wait* list*"))) OR oft((treatment OR care) NEAR/2 usual)) OR noft((single OR double OR triple OR treble) NEAR/2 (blind* OR mask* OR dummy))
Combine searches: 1 and 13

S14       (((MAINSUBJECT.EXACT.EXPLODE("Military Personnel") OR MAINSUBJECT.EXACT.EXPLODE("Emergency Personnel") OR MAINSUBJECT.EXACT.EXPLODE("United Nations Personnel")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR armed personnel " or " national guard " or " civil defence " or civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR "armed personnel" OR "national guard" OR "civil defence" OR "civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(peacekeepers OR "peace keepers") OR noft((humanitarian OR peacekeep* OR "peace keep*" OR "united nations" OR NGO*) NEAR/3 (crew? OR personn* OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft((aid OR disasters OR "disaster recovery" OR relief) NEAR/1 (personnel OR team? OR volunteers OR workers OR workforce OR "work force")) OR noft((emergency OR "first respon*" OR frontline OR "front line" OR rescue) NEAR/2 (crew? OR personnel OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft("relief work*" OR "emergency responder?") OR noft(oxfam OR "red cross" OR "red crescent") OR noft("medicin sans frontier*" OR "medecin sans frontier*" OR "doctors without borders") OR noft("united nations" OR "humanitarian organi*"))) AND ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing")) OR ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing"))) OR (MAINSUBJECT.EXACT("Burnout") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT("Vicarious Traumatization") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("Anxiety Disorders") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("PTSD") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR ti(resilien* OR preparedness) OR noft(resilien* NEAR/3 (foster* OR improv* OR increas* OR build* OR educat* OR psychoeducat* OR intervention* OR management OR program* OR curriculum OR skill* OR train* OR therap*)) OR noft((psychotrauma* OR psycho‐trauma*) NEAR/3 (prevent* OR reduc* OR decreas* OR risk*)) OR noft((stress OR pretrauma* OR pre‐trauma*) NEAR/3 (psychotherap* OR therap* OR training)) OR noft("critical incident*" NEAR/3 (educat* OR psychoeducat* OR intervention* OR management OR program* OR skill* OR train*)) OR noft(coping NEAR/3 (educat* OR psychoeducat* OR intervention? OR program* OR skill? OR train*)) OR noft("stress inoculation" OR "stress vaccination") OR noft(exposure NEAR/1 (psychotherap* OR therap* OR training)) OR noft((predeployment OR pre‐deployment OR pre‐exposure OR pretrauma* OR pre‐trauma*) NEAR/3 (service OR duty OR duties OR deploy* OR frontline OR "front line" OR exposure OR war OR wars OR warfare OR disaster? OR crisis OR crises OR "critical incident?")))) AND ((single OR double OR triple OR treble) NEAR/2 (blind* OR mask* OR dummy)) PTSDpubs         18

S13       (single OR double OR triple OR treble) NEAR/2 (blind* OR mask* OR dummy) PTSDpubs         375 

S12       (((MAINSUBJECT.EXACT.EXPLODE("Military Personnel") OR MAINSUBJECT.EXACT.EXPLODE("Emergency Personnel") OR MAINSUBJECT.EXACT.EXPLODE("United Nations Personnel")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR armed personnel " or " national guard " or " civil defence " or civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR "armed personnel" OR "national guard" OR "civil defence" OR "civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(peacekeepers OR "peace keepers") OR noft((humanitarian OR peacekeep* OR "peace keep*" OR "united nations" OR NGO*) NEAR/3 (crew? OR personn* OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft((aid OR disasters OR "disaster recovery" OR relief) NEAR/1 (personnel OR team? OR volunteers OR workers OR workforce OR "work force")) OR noft((emergency OR "first respon*" OR frontline OR "front line" OR rescue) NEAR/2 (crew? OR personnel OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft("relief work*" OR "emergency responder?") OR noft(oxfam OR "red cross" OR "red crescent") OR noft("medicin sans frontier*" OR "medecin sans frontier*" OR "doctors without borders") OR noft("united nations" OR "humanitarian organi*"))) AND ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing")) OR ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing"))) OR (MAINSUBJECT.EXACT("Burnout") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT("Vicarious Traumatization") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("Anxiety Disorders") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("PTSD") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR ti(resilien* OR preparedness) OR noft(resilien* NEAR/3 (foster* OR improv* OR increas* OR build* OR educat* OR psychoeducat* OR intervention* OR management OR program* OR curriculum OR skill* OR train* OR therap*)) OR noft((psychotrauma* OR psycho‐trauma*) NEAR/3 (prevent* OR reduc* OR decreas* OR risk*)) OR noft((stress OR pretrauma* OR pre‐trauma*) NEAR/3 (psychotherap* OR therap* OR training)) OR noft("critical incident*" NEAR/3 (educat* OR psychoeducat* OR intervention* OR management OR program* OR skill* OR train*)) OR noft(coping NEAR/3 (educat* OR psychoeducat* OR intervention? OR program* OR skill? OR train*)) OR noft("stress inoculation" OR "stress vaccination") OR noft(exposure NEAR/1 (psychotherap* OR therap* OR training)) OR noft((predeployment OR pre‐deployment OR pre‐exposure OR pretrauma* OR pre‐trauma*) NEAR/3 (service OR duty OR duties OR deploy* OR frontline OR "front line" OR exposure OR war OR wars OR warfare OR disaster? OR crisis OR crises OR "critical incident?")))) AND noft((treatment OR care) NEAR/2 usual) PTSDpubs         26

S11       noft((treatment OR care) NEAR/2 usual) PTSDpubs         335

S10       (((MAINSUBJECT.EXACT.EXPLODE("Military Personnel") OR MAINSUBJECT.EXACT.EXPLODE("Emergency Personnel") OR MAINSUBJECT.EXACT.EXPLODE("United Nations Personnel")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR armed personnel " or " national guard " or " civil defence " or civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR "armed personnel" OR "national guard" OR "civil defence" OR "civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(peacekeepers OR "peace keepers") OR noft((humanitarian OR peacekeep* OR "peace keep*" OR "united nations" OR NGO*) NEAR/3 (crew? OR personn* OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft((aid OR disasters OR "disaster recovery" OR relief) NEAR/1 (personnel OR team? OR volunteers OR workers OR workforce OR "work force")) OR noft((emergency OR "first respon*" OR frontline OR "front line" OR rescue) NEAR/2 (crew? OR personnel OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft("relief work*" OR "emergency responder?") OR noft(oxfam OR "red cross" OR "red crescent") OR noft("medicin sans frontier*" OR "medecin sans frontier*" OR "doctors without borders") OR noft("united nations" OR "humanitarian organi*"))) AND ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing")) OR ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing"))) OR (MAINSUBJECT.EXACT("Burnout") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT("Vicarious Traumatization") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("Anxiety Disorders") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("PTSD") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR ti(resilien* OR preparedness) OR noft(resilien* NEAR/3 (foster* OR improv* OR increas* OR build* OR educat* OR psychoeducat* OR intervention* OR management OR program* OR curriculum OR skill* OR train* OR therap*)) OR noft((psychotrauma* OR psycho‐trauma*) NEAR/3 (prevent* OR reduc* OR decreas* OR risk*)) OR noft((stress OR pretrauma* OR pre‐trauma*) NEAR/3 (psychotherap* OR therap* OR training)) OR noft("critical incident*" NEAR/3 (educat* OR psychoeducat* OR intervention* OR management OR program* OR skill* OR train*)) OR noft(coping NEAR/3 (educat* OR psychoeducat* OR intervention? OR program* OR skill? OR train*)) OR noft("stress inoculation" OR "stress vaccination") OR noft(exposure NEAR/1 (psychotherap* OR therap* OR training)) OR noft((predeployment OR pre‐deployment OR pre‐exposure OR pretrauma* OR pre‐trauma*) NEAR/3 (service OR duty OR duties OR deploy* OR frontline OR "front line" OR exposure OR war OR wars OR warfare OR disaster? OR crisis OR crises OR "critical incident?")))) AND (noft(control*) AND noft((trial OR study OR group)) AND noft((placebo AND waitlist* OR wait* list*))) PTSDpubs         14 

S9        noft(control*) AND noft((trial or study or group)) AND noft((placebo and waitlist* or wait* list*)) PTSDpubs         243 

S8        (((MAINSUBJECT.EXACT.EXPLODE("Military Personnel") OR MAINSUBJECT.EXACT.EXPLODE("Emergency Personnel") OR MAINSUBJECT.EXACT.EXPLODE("United Nations Personnel")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR armed personnel " or " national guard " or " civil defence " or civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR "armed personnel" OR "national guard" OR "civil defence" OR "civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(peacekeepers OR "peace keepers") OR noft((humanitarian OR peacekeep* OR "peace keep*" OR "united nations" OR NGO*) NEAR/3 (crew? OR personn* OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft((aid OR disasters OR "disaster recovery" OR relief) NEAR/1 (personnel OR team? OR volunteers OR workers OR workforce OR "work force")) OR noft((emergency OR "first respon*" OR frontline OR "front line" OR rescue) NEAR/2 (crew? OR personnel OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft("relief work*" OR "emergency responder?") OR noft(oxfam OR "red cross" OR "red crescent") OR noft("medicin sans frontier*" OR "medecin sans frontier*" OR "doctors without borders") OR noft("united nations" OR "humanitarian organi*"))) AND ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing")) OR ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing"))) OR (MAINSUBJECT.EXACT("Burnout") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT("Vicarious Traumatization") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("Anxiety Disorders") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("PTSD") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR ti(resilien* OR preparedness) OR noft(resilien* NEAR/3 (foster* OR improv* OR increas* OR build* OR educat* OR psychoeducat* OR intervention* OR management OR program* OR curriculum OR skill* OR train* OR therap*)) OR noft((psychotrauma* OR psycho‐trauma*) NEAR/3 (prevent* OR reduc* OR decreas* OR risk*)) OR noft((stress OR pretrauma* OR pre‐trauma*) NEAR/3 (psychotherap* OR therap* OR training)) OR noft("critical incident*" NEAR/3 (educat* OR psychoeducat* OR intervention* OR management OR program* OR skill* OR train*)) OR noft(coping NEAR/3 (educat* OR psychoeducat* OR intervention? OR program* OR skill? OR train*)) OR noft("stress inoculation" OR "stress vaccination") OR noft(exposure NEAR/1 (psychotherap* OR therap* OR training)) OR noft((predeployment OR pre‐deployment OR pre‐exposure OR pretrauma* OR pre‐trauma*) NEAR/3 (service OR duty OR duties OR deploy* OR frontline OR "front line" OR exposure OR war OR wars OR warfare OR disaster? OR crisis OR crises OR "critical incident?")))) AND noft(RCT OR "at random" OR (random* NEAR/3 (administ* OR allocat* OR assign* OR class* OR cluster OR control* OR determine* OR divide* OR division OR distribut* OR expose* OR fashion OR number* OR place* OR pragmatic OR quasi OR recruit* OR split OR subsitut* OR treat*))) PTSDpubs         167 

S7        noft(RCT OR "at random" OR (random* NEAR/3 (administ* OR allocat* OR assign* OR class* OR cluster OR control* OR determine* OR divide* OR division OR distribut* OR expose* OR fashion OR number* OR place* OR pragmatic OR quasi OR recruit* OR split OR subsitut* OR treat*))) PTSDpubs         2,342

S6        (((MAINSUBJECT.EXACT.EXPLODE("Military Personnel") OR MAINSUBJECT.EXACT.EXPLODE("Emergency Personnel") OR MAINSUBJECT.EXACT.EXPLODE("United Nations Personnel")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR armed personnel " or " national guard " or " civil defence " or civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR "armed personnel" OR "national guard" OR "civil defence" OR "civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(peacekeepers OR "peace keepers") OR noft((humanitarian OR peacekeep* OR "peace keep*" OR "united nations" OR NGO*) NEAR/3 (crew? OR personn* OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft((aid OR disasters OR "disaster recovery" OR relief) NEAR/1 (personnel OR team? OR volunteers OR workers OR workforce OR "work force")) OR noft((emergency OR "first respon*" OR frontline OR "front line" OR rescue) NEAR/2 (crew? OR personnel OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft("relief work*" OR "emergency responder?") OR noft(oxfam OR "red cross" OR "red crescent") OR noft("medicin sans frontier*" OR "medecin sans frontier*" OR "doctors without borders") OR noft("united nations" OR "humanitarian organi*"))) AND ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing")) OR ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing"))) OR (MAINSUBJECT.EXACT("Burnout") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT("Vicarious Traumatization") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("Anxiety Disorders") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("PTSD") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR ti(resilien* OR preparedness) OR noft(resilien* NEAR/3 (foster* OR improv* OR increas* OR build* OR educat* OR psychoeducat* OR intervention* OR management OR program* OR curriculum OR skill* OR train* OR therap*)) OR noft((psychotrauma* OR psycho‐trauma*) NEAR/3 (prevent* OR reduc* OR decreas* OR risk*)) OR noft((stress OR pretrauma* OR pre‐trauma*) NEAR/3 (psychotherap* OR therap* OR training)) OR noft("critical incident*" NEAR/3 (educat* OR psychoeducat* OR intervention* OR management OR program* OR skill* OR train*)) OR noft(coping NEAR/3 (educat* OR psychoeducat* OR intervention? OR program* OR skill? OR train*)) OR noft("stress inoculation" OR "stress vaccination") OR noft(exposure NEAR/1 (psychotherap* OR therap* OR training)) OR noft((predeployment OR pre‐deployment OR pre‐exposure OR pretrauma* OR pre‐trauma*) NEAR/3 (service OR duty OR duties OR deploy* OR frontline OR "front line" OR exposure OR war OR wars OR warfare OR disaster? OR crisis OR crises OR "critical incident?")))) AND (noft(trial*) OR noft(placebo)) PTSDpubs         243 

S5        noft(trial*) OR noft(placebo) PTSDpubs         3,928

S4        (((MAINSUBJECT.EXACT.EXPLODE("Military Personnel") OR MAINSUBJECT.EXACT.EXPLODE("Emergency Personnel") OR MAINSUBJECT.EXACT.EXPLODE("United Nations Personnel")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR armed personnel " or " national guard " or " civil defence " or civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR "armed personnel" OR "national guard" OR "civil defence" OR "civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(peacekeepers OR "peace keepers") OR noft((humanitarian OR peacekeep* OR "peace keep*" OR "united nations" OR NGO*) NEAR/3 (crew? OR personn* OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft((aid OR disasters OR "disaster recovery" OR relief) NEAR/1 (personnel OR team? OR volunteers OR workers OR workforce OR "work force")) OR noft((emergency OR "first respon*" OR frontline OR "front line" OR rescue) NEAR/2 (crew? OR personnel OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft("relief work*" OR "emergency responder?") OR noft(oxfam OR "red cross" OR "red crescent") OR noft("medicin sans frontier*" OR "medecin sans frontier*" OR "doctors without borders") OR noft("united nations" OR "humanitarian organi*"))) AND ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing")) OR ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing"))) OR (MAINSUBJECT.EXACT("Burnout") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT("Vicarious Traumatization") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("Anxiety Disorders") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("PTSD") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR ti(resilien* OR preparedness) OR noft(resilien* NEAR/3 (foster* OR improv* OR increas* OR build* OR educat* OR psychoeducat* OR intervention* OR management OR program* OR curriculum OR skill* OR train* OR therap*)) OR noft((psychotrauma* OR psycho‐trauma*) NEAR/3 (prevent* OR reduc* OR decreas* OR risk*)) OR noft((stress OR pretrauma* OR pre‐trauma*) NEAR/3 (psychotherap* OR therap* OR training)) OR noft("critical incident*" NEAR/3 (educat* OR psychoeducat* OR intervention* OR management OR program* OR skill* OR train*)) OR noft(coping NEAR/3 (educat* OR psychoeducat* OR intervention? OR program* OR skill? OR train*)) OR noft("stress inoculation" OR "stress vaccination") OR noft(exposure NEAR/1 (psychotherap* OR therap* OR training)) OR noft((predeployment OR pre‐deployment OR pre‐exposure OR pretrauma* OR pre‐trauma*) NEAR/3 (service OR duty OR duties OR deploy* OR frontline OR "front line" OR exposure OR war OR wars OR warfare OR disaster? OR crisis OR crises OR "critical incident?")))) AND MAINSUBJECT.EXACT.EXPLODE("Randomized Clinical Trial") PTSDpubs         105   

S3        MAINSUBJECT.EXACT.EXPLODE("Randomized Clinical Trial") PTSDpubs         1,343

S2        MAINSUBJECT.EXACT.EXPLODE("Randomized Clinical Trial") OR noft(trial*) OR noft(placebo) OR noft(RCT OR "at random" OR (random* NEAR/3 (administ* OR allocat* OR assign* OR class* OR cluster OR control* OR determine* OR divide* OR division OR distribut* OR expose* OR fashion OR number* OR place* OR pragmatic OR quasi OR recruit* OR split OR subsitut* OR treat*))) OR (noft((control* AND (trial OR study OR group*) AND (placebo OR waitlist* OR "wait* list*"))) OR noft((treatment OR care) NEAR/2 usual)) OR noft((single OR double OR triple OR treble) NEAR/2 (blind* OR mask* OR dummy)) PTSDpubs         4,571

S1        ((MAINSUBJECT.EXACT.EXPLODE("Military Personnel") OR MAINSUBJECT.EXACT.EXPLODE("Emergency Personnel") OR MAINSUBJECT.EXACT.EXPLODE("United Nations Personnel")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR armed personnel " or " national guard " or " civil defence " or civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(military OR soldier* OR army OR armies) OR noft("armed forces" OR "armed personnel" OR "national guard" OR "civil defence" OR "civil defense") OR noft(marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR noft(airforce? OR "air force?") OR noft((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR noft(airman OR airmen OR "air man" OR "air men")) OR (noft(peacekeepers OR "peace keepers") OR noft((humanitarian OR peacekeep* OR "peace keep*" OR "united nations" OR NGO*) NEAR/3 (crew? OR personn* OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft((aid OR disasters OR "disaster recovery" OR relief) NEAR/1 (personnel OR team? OR volunteers OR workers OR workforce OR "work force")) OR noft((emergency OR "first respon*" OR frontline OR "front line" OR rescue) NEAR/2 (crew? OR personnel OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft("relief work*" OR "emergency responder?") OR noft(oxfam OR "red cross" OR "red crescent") OR noft("medicin sans frontier*" OR "medecin sans frontier*" OR "doctors without borders") OR noft("united nations" OR "humanitarian organi*"))) AND ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing")) OR ((MAINSUBJECT.EXACT("Adaptability") OR MAINSUBJECT.EXACT.EXPLODE("Coping Behavior") OR MAINSUBJECT.EXACT("Resilience")) OR (MAINSUBJECT.EXACT("Stress Inoculation Treatment") OR MAINSUBJECT.EXACT("Critical Incident Stress Debriefing"))) OR (MAINSUBJECT.EXACT("Burnout") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT("Vicarious Traumatization") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("Anxiety Disorders") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR (MAINSUBJECT.EXACT.EXPLODE("PTSD") AND ti((prevent* OR reduc* OR decreas* OR risk?))) OR ti(resilien* OR preparedness) OR noft(resilien* NEAR/3 (foster* OR improv* OR increas* OR build* OR educat* OR psychoeducat* OR intervention* OR management OR program* OR curriculum OR skill* OR train* OR therap*)) OR noft((psychotrauma* OR psycho‐trauma*) NEAR/3 (prevent* OR reduc* OR decreas* OR risk*)) OR noft((stress OR pretrauma* OR pre‐trauma*) NEAR/3 (psychotherap* OR therap* OR training)) OR noft("critical incident*" NEAR/3 (educat* OR psychoeducat* OR intervention* OR management OR program* OR skill* OR train*)) OR noft(coping NEAR/3 (educat* OR psychoeducat* OR intervention? OR program* OR skill? OR train*)) OR noft("stress inoculation" OR "stress vaccination") OR noft(exposure NEAR/1 (psychotherap* OR therap* OR training)) OR noft((predeployment OR pre‐deployment OR pre‐exposure OR pretrauma* OR pre‐trauma*) NEAR/3 (service OR duty OR duties OR deploy* OR frontline OR "front line" OR exposure OR war OR wars OR warfare OR disaster? OR crisis OR crises OR "critical incident?"))) PTSDpubs         2,202 

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(NOFT((military OR soldier* OR army OR armies) OR ("armed forces" OR armed personnel " or " national guard " or " civil defence " or civil defense") OR (marines OR navy OR naval OR seamen? OR sailors OR submariners OR submariners OR "coast guard*" OR coastguard*) OR (airforce? OR "air force?") OR ((air* OR helicopter OR flight OR plane?) NEAR/3 (crew OR pilot*)) OR (airman OR airmen OR "air man" OR "air men")) OR (noft(peacekeepers OR "peace keepers") OR noft((humanitarian OR peacekeep* OR "peace keep*" OR "united nations" OR NGO*) NEAR/3 (crew? OR personn* OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft((aid OR disasters OR "disaster recovery" OR relief) NEAR/1 (personnel OR team? OR volunteers OR workers OR workforce OR "work force")) OR noft((emergency OR "first respon*" OR frontline OR "front line" OR rescue) NEAR/2 (crew? OR personnel OR staff OR nurs* OR team? OR technicians OR volunteers OR workers OR workforce OR "work force")) OR noft("relief work*" OR "emergency responder?") OR noft(oxfam OR "red cross" OR "red crescent") OR noft("medicin sans frontier*" OR "medecin sans frontier*" OR "doctors without borders") OR noft("united nations" OR "humanitarian organi*"))) AND (ti((resilien* OR preparedness)) OR noft((resilien* NEAR/3 (foster* OR improv* OR increas* OR build* OR educat* OR psychoeducat* OR intervention* OR management OR program* OR curriculum OR skill* OR train* OR therap*))) OR noft(((psychotrauma* OR psycho‐trauma*) NEAR/3 (prevent* OR reduc* OR decreas* OR risk*))) OR noft(((stress OR pretrauma* OR pre‐trauma*) NEAR/3 (psychotherap* OR therap* OR training))) OR noft(("critical incident*" NEAR/3 (educat* OR psychoeducat* OR intervention* OR management OR program* OR skill* OR train*))) OR noft((coping NEAR/3 (educat* OR psychoeducat* OR intervention? OR program* OR skill? OR train*))) OR noft(("stress inoculation" OR "stress vaccination")) OR noft((exposure NEAR/1 (psychotherap* OR therap* OR training))) OR noft((predeployment OR pre‐deployment OR pre‐exposure OR pretrauma* OR pre‐trauma*) NEAR/3 (service OR duty OR duties OR deploy* OR frontline OR "front line" OR exposure OR war OR wars OR warfare OR disaster? OR crisis OR crises OR "critical incident?")))

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Appendix 2. Author Correspondence

Cacioppo 2015: Author contacted for M/SDs for outcomes on the 28/2/2020. Currently awaiting response from the authors.

Christopher 2018: Author contacted for M/SDs for outcomes on the 28/1/2020. Currently awaiting response from the authors.

Crane 2019: Author contacted for M/SDs for outcomes on the 7/2/2020. The authors replied to this initial request on the 7/2/2020. Currently awaiting follow up from the authors.

Digliani 1994: Author contacted for PDF of their study on the 29/5/2019. Author responded and obliged this request on the 29/5/2019.

Hourani 2018: Author contacted for PDF of their study on the 15/7/2019. Author responded and obliged this request on the 15/7/2019.

Janka 2017: Author contacted for M/SDs for outcomes on the 28/1/2020. Currently awaiting response from the authors.

Joyce 2019: Author contacted for M/SDs for outcomes on the 20/10/2020. Currently awaiting response from the authors.

Keynan 2019: Author contacted for PDF of their study on the 11/3/2019. Authors responded and obliged this request on the 13/3/2019.

Author contacted for M/SDs for outcomes on the 5/7/2019. Author responded and obliged this request on the 9/7/2019.

Lewis 2015: Author contacted for M/SDs for outcomes on the 26/9/2019 and 12/12/2019. Currently awaiting response from the authors.

Taylor 2011: Author contacted for M/SDs for outcomes on the 10/12/2019. Currently awaiting response from the authors.

Trousselard 2015: Author contacted for intervention details and outcome M/SDs on the 3/12/19. Author responded to and obliged these requests on the 9/12/2019 and the 11/12/2019.

Wessemann 2016: Author contacted for M/SDs for outcomes on the 6/2/2020. Author responded to and obliged these requests on the 7/2/2020.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Adler 2015.

Study characteristics
Methods	Study design: cluster‐randomised controlled trial, randomised by platoon Hypothesis: individuals in the intervention condition would report better mental health, unit cohesion, better confidence in assisting others and rate the training higher compared to the control condition
Participants	Location: USA Sample size: n = 2019 (intervention n = 1019; control n = 1000) Age: 18‐24 years: 862 participants; 25+ years: 103 participants Sex: intervention 62% male, control 63% male Previous service: intervention 69%, control 49% Inclusion criteria: US military active duty soldiers who were undertaking basic combat training at a US army training base Exclusion criteria: not described
Interventions	Intervention This resilience training (RT) programme consisting of cognitive‐education‐positive psychology facets. Education re effects of stress and expected reactions including normalising symptomatology. Facets of positive psych included encouraging optimism. Cognitive aspects were based on Ellis 1991 model of adversity‐belief‐consequence. Comparator In the Military History (MH) control group, students attended a MH seminar in lieu of active treatment. The MH class covered military specific topics such as physical fitness, marksmanship etc.
Outcomes	Anxiety (GAD‐7) at 4 time points. Depressive symptoms (PHQ‐D) at 4 time points. Sleep problems were measured using an adapted scale from Morin 1993 developed by Bliese 2005. Unclear if this is a validated scale.
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Specific details not provided.
Allocation concealment (selection bias)	Unclear risk	Specific details not provided.
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Participants were not informed of the research hypothesis or how many training methods were under investigation.
Blinding of outcome assessment (detection bias) All outcomes	High risk	All measures were self reported.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Although there was some attrition, this was relatively balanced between the two conditions, given the large sample used in this trial, the risk is deemed to be low.
Selective reporting (reporting bias)	Unclear risk	No protocol available.
Other bias	Unclear risk	No declaration of interest was provided in the paper. The funding of research does not seem to be reported, staff are US army employee carrying out research on US solider.

Bouchard 2012.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: when facing an objective stressor, participants who received the ImPACT programme would experience less stress than those who only received usual training
Participants	Location: Canada Sample size: n = 41 (intervention n = 21; control n = 20) Age, mean: 24.9 (SD 5.55) years Sex: 100% male Previous service: mean 4.8 (SD 3.34) years, 62% had previous combat experience Inclusioncriteria: Canadian soldiers based at Valcartier military base, aged 18‐60 years of age who had received basic stress management programme and basic first aid training Exclusion criteria: suffering from vestibular problems, unfit physically/mentally for duty, recurrent migraines, epilepsy, postural balance problems, cardiac or ocular issues, frequent motion sickness
Interventions	Intervention The programme was titled 'Immersion and Practice of Arousla Control training' (ImPACT). This programme was a stress‐management training programme with biofeedback. Tactical breathing (TB) was taught as a skill that can be used to help soldiers in stressful situations. It involves a process of timed inhalations, holds and exhalations. The visual field of the participant in a video game was determined by performance in breathing technique skills, whereby better TB improved screen visibility. Comparator A training as usual condition was used as the control group.
Outcomes	Objective stress levels (cortisol levels): self‐administered free cortisol response collected via salivary swab, using Salivette collection devices. Heart rate: monitored using a wireless compact flash T9600 device (electrocardiograph device).
Notes	Actors were blinded to participant condition and were randomised during the simulation exercise.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Participants were randomly assigned, no specific details were provided.
Allocation concealment (selection bias)	Unclear risk	No details were given on allocation concealment strategy.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Assessor was blinded however, no details on participant blinding.
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Personnel assessing participants were blinded.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition is accounted for in the paper, relatively balanced between groups.
Selective reporting (reporting bias)	Unclear risk	There was no published protocol for this study.
Other bias	Low risk	No obvious other sources of bias. Full funding and competing interests declaration is evident.

Cacioppo 2015.

Study characteristics
Methods	Study design: cluster‐randomised controlled trial Hypothesis: H1) Social Resilience Training (SIT) would improve specific aspects of social resilience i.e. improve empathy, hardiness etc but have no impact on perception of warmth of Afghans H2) Afghan training would increase perception of warmth of Afghans etc. no impact on social resilience
Participants	Location: USA Sample size: n = 48 platoons (1138 soldiers) (intervention n = 29 platoons (688 soldiers); control n = 19 platoons (450 soldiers)) Age, mean: 24 (range 18‐42) years Sex: 100% male Previous service: mean 4.5 years (range 1‐24). 76% had a previous deployment. 78% were junior ranks, 19% NCOs and 3% were officers Inclusion criteria: soldiers drawn from active duty units, specifically operational brigades subject to constant pre‐deployment training Exclusion criteria: not from national guard or reserve, or training brigades
Interventions	Intervention The intervention, social resilience training (SRT), had a theoretical underpinning in CBT practices. It was designed to address feelings of isolation and maladaptive social cognition with an emphasis on modifying maladaptive social cognition. The programme motivated soldiers to practice new skills learned in the course. It was delivered in largely a psycho‐educational format with some skills based rehearsal. Comparator Participants assigned to the control group, took part in the 'Afghanistan Cultural Awareness training' programme which aimed to reduce social prejudice to local Afghani nationals, focusing on individual learning rather than group activities.
Outcomes	Empathy (IRI using 4 items from the Empathic concern sub scale) Generalized trust (Rosenberg’s Faith in People Scale) Loneliness (revised UCLA scale) Hardiness Alcohol misuse (TICS) Anxiety (IAS) Catastrophising (ASQ) Depression (PHQ‐9) Life satisfaction Perceived stress (PSS) Sleep quality (SQI)
Notes	Trainers were nine former Army NCOs, received a three week‐ train the trainer instructional programme and remained blind to the study hypothesis throughout.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Participants were randomly assigned, no specific details provided.
Allocation concealment (selection bias)	Unclear risk	No details give on allocation concealment strategy.
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Assessors were blinded to participant condition.
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Measures reported both self report and objective measures. However, the experimenters utilised blinded assessors in this research, no details on participant blinding.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition was adequately described in the paper.
Selective reporting (reporting bias)	Unclear risk	No protocol available.
Other bias	Low risk	No obvious sources of bias.

Chitra 2018.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: the resilience intervention would develop or strengthen factors that can serve as potential latent reserves within participants
Participants	Location: Chennai City, India Sample size: randomised n = 63 (intervention n = 32 randomised but due to attrition, final sample analysed n = 26; control n = 30 initially analysed but due to attrition final sample analysed n = 25) Age, mean: 27 (range 23‐41) years Sex: 100% female Previous experience, mean: 5 years 7 months (range 3‐14) Inclusion criteria: female Indian Police Constables, minimum of 3 years professional experience  Exclusion criteria: physical illness, pregnancy, on "long leave"
Interventions	Intervention The intervention was based upon the "protective model of resilience" and drew upon the transactional model of stress and coping and positive psychology. The programme also incorporated evidence based frame works such as cognitive behavioural approaches, mindfulness and relaxation techniques.The intervention consisted of 20 group sessions, each lasting between 60‐90 minutes, taking place three times weekly for a total of 2 months. Comparator No‐treatment control group
Outcomes	Occupational stress (OSI) Resilience (CD‐RISC) Psychological well‐being (PGWBI) Job satisfaction Overall job satisfaction scale
Notes	Programme was delivered in Tamil. No funding declaration is made.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Random table technique used in this study.
Allocation concealment (selection bias)	Low risk	Reseacher and statistician were blinded to condition assignment.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Unlcear to what extent participants and training personnel were blinded to condition. Some evidence of blinding evident.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures utilised, no blinding took place.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition is balanced between groups and is adequately explained.
Selective reporting (reporting bias)	Unclear risk	No protocol available.
Other bias	Low risk	No obvious other source of bias.

Chongruska 2015.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: army rangers deploying in southern conflict areas, after participating in integrated group counselling, would have significantly higher scores in resilience and mental health, as well as have score reductions in anxiety, depression, social dysfunction and physical symptoms when compared with the control group.
Participants	Location: Thailand Population: participants were drawn from 7500 Thai army rangers deployed in three southernmost provinces of Thailand Sample size: randomised n = 60 (intervention n = 30; control n = 30) Age, mean: 30.34 (SD 5.23) years Sex: 100% male They were based in 6 army units 20 were selected through simple random sampling across the 6 units. Sixty participants were chosen based on their lowest scores on TMHI‐54 and highest scores on Thai GHQ‐28. The 60 were randomised equally between IGC and Control. Inclusion criteria: these were not outlined in the paper Exclusion criteria: these were not outlined in the paper
Interventions	Intervention The programme used was an 'Interactive model of existential therapy' incorporating, art therapy by drawing mandalas, CBT and psycho‐educational practices. These constituted the theoretical underpinning of this intervention known as Integrated Group Counselling (IGC). IGC consisted of three phases each lasting 2 days each. Sessions lasted from 50 minutes to 90 minutes.The total programme consisted of 20 sessions. Comparator The control group received 20 sessions of didactic information on mental health and resilience.
Outcomes	Resilience (THMI: adapted from CD‐RISC) Mental well‐being (THMI‐54) Somatic symptoms (anxiety, social dysfunction, depression) (GHQ‐28 (Thai))
Notes	The intervention group participated in three marathon IGC sessions each lasting 2 days over a three‐month period. Details on control group as regards to session lengths and timings are unclear.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	No specific details provided on sequence generation.
Allocation concealment (selection bias)	Unclear risk	No information provided on allocation concealment.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details on blinding of participants or personnel provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures utilised, no blinding took place.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Equal levels of attrition from both experimental and control conditions, reasons documented in text.
Selective reporting (reporting bias)	Unclear risk	No protocol available.
Other bias	Low risk	No other known source bias.

Christopher 2018.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: The Mindfulness‐Based Resilience Training (MBRT) would be feasible and acceptable to LEOs (Law Enforcement Officer). The MBRT programme would, relative to control group (at post training & three months follow up) show improved psych health and risk outcomes, reduced aggression/anger and improved stress regulation.
Participants	Location: USA Sample size: n = 61 (intervention n = 31; control n = 30) Age, mean: intervention 44.73 (SD 6.63) years, control 17.97 (SD 6.69) years Sex (male): intervention n = 28, control n = 26 Previous experience, mean: intervention 18.50 (SD 6.98) years, control Inclusion criteria: full‐time sworn Law Enforcement Officers (LEOs) were included in this study Exclusion criteria: participants were excluded if they had been exposed to MBRT or a similar mindfulness course previously
Interventions	Intervention Titled, 'Mindfulness‐Based Resilience Training (MBRT)', this intervention was based on mindfulness practices to build resilience in LEOs based on the work by Kabat‐Zinn 1990. The primary focus of the curriculum was learning strategies to manage stressors such as critical incidents. MBRT was delivered in 8 weekly 2‐hour sessions with an extended session in week 6 of the intervention. The sessions contained experiential and didactic exercises including body‐scan, sitting and walking, meditations etc. To supplement in class learning, LEOs were given an Ipod touch which had guided practices and monitoring software. Comparator The control condition or (NIC) group received no training whatsoever.
Outcomes	Psychological health/risk (sleep disturbance, alcohol use, anxiety, depression) (PROMIS v1.0 short version) Suicidal ideation (CHRT) Operational and Organisational stress (PSQ) Burnout (OLBI) Mindfulness (FFMQ‐SF) Resilience (CD‐RISC) Psychological flexibility (AAQ‐11) Self‐compassion (SCS‐SF) Aggression and anger (BPAQ‐SF) Cortisol awakening response (passive drool method = 2‐3ml of saliva, collected at 0, 30 & 45 minutes post awakening)
Notes	The programme was overseen by a developer of MBRT who is a police Lieutenant and a certified mindfulness trainer.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Permuted block randomisation utilised.
Allocation concealment (selection bias)	Unclear risk	No details on concealment procedure.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details on blinding of participants/personnel provided.
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	No details on blinding of outcome assessment provided, mix of objective and self report measures.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Authors conducted an ITT analysis and imputed data. Attrition and reasons for such are documented and explained.
Selective reporting (reporting bias)	Low risk	Study protocol provided.
Other bias	Low risk	No obvious sources of bias.

Crane 2019.

Study characteristics
Methods	Study design: cluster‐randomised controlled trial Hypothesis: the intervention would produce a greater decline in perceived stressor frequency, anxiety and depression symptoms between initial follow up‐ long term follow up compared to CST control group
Participants	Location: Australia Sample size: n = 215 (intervention n = 96 (3 platoons); control n = 130 (4 platoons)) Age, mean: 22 (SD 3.86) years Sex: 16.9% female Previous service, mean: 2.4 years (SD 1.74) ranging from 6 months to 11 years Inclusion criteria: Australian army cadets Exclusion criteria: not described
Interventions	Intervention  Self‐reflection training. Approach involved the use of a single meta cognitive skill: coping and emotion regulatory self‐reflection as vehicles for increased resilience. This was operationalised by means of guided coping and emotion regulatory self‐reflection. The training consisted of several stages beginning with a 30‐minute briefing which outlined the programme and included Psycho‐educational content. Comparator A training as usual comparator control group was used, titled 'Coping skills training' (CST). The CST programme is based on Cohn 2008 and uses CBT techniques to build resilience. After an initial Psychoeducational PowerPoint, no other training was received by this group.
Outcomes	Stressor frequency (23 item list created by the researchers to capture perceived stressor frequency) Depression symptoms (PHQ‐8) Anxiety (GAD‐7)
Notes	The training was delivered by 2 army clinical psychologists, both with a minimum of 2 years’ experience (both CST and SRT), who both received 30‐minute training sessions for both programmes however the SRT clinical psychologist received an additional 1‐day training programme from the lead investigator.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Cluster randomisation details unclear as to precise method of random sequence generation.
Allocation concealment (selection bias)	Unclear risk	No details provided.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Some level of personnel blinding, however no details on participant blinding.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures utilised.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	No specific details provided for attrition.
Selective reporting (reporting bias)	Unclear risk	No protocol published.
Other bias	Low risk	No obvious sources of bias.

Digliani 1994.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: SIT group (intervention) would provide significant differences in stress, trait anxiety and trait anger levels, immediately after and approximately 4 weeks post intervention, compared to controls
Participants	Location: Colorado, USA Sample size: n = 51 (intervention n = 23; control n = 28) Age, mean: 37.6 (range 27‐58) years Sex: 34 males, 17 females Previous experience, mean: 11.3 (range 1‐30) years Inclusion criteria: volunteer police officers from Fort Collins Colorado Police Services, Loveland PD and Larimer county Sheriff’s department Exclusion criteria: not described
Interventions	Intervention The programme was titled'Stress inoculation training protocol' (SIT) as developed by Meichenbaum 1985. The intervention consisted of three major components delivered over the space of seven weeks: Conceptualization, which involved rapport building, and instruction on transactional stress, stress reaction etc. Skill acquisition, this consisted of education in stress and coping, along with rehearsal of relaxation techniques and stimulus control/response disruption. Application and follow through, focused on continued development of differential appraisal, relaxation skills, stimulus control/response disruption. Comparator This study used a delayed treatment control condition. Participants received no training, but training would be offered to them upon completion of the study, if they expressed interest.
Outcomes	Trait anxiety (EMAS‐T: 4 sub scales) Trait anger (STAS‐T) Personal stress (PSS) Self‐efficacy (SES) Stress level (LSR)
Notes	There were 4 separate agencies from which police were drawn, not a cluster randomised trial, so unit differences may impact results.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Random numbers table method utilised.
Allocation concealment (selection bias)	Low risk	Random numbers table method utilised.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No specific details provided on participant/personnel blinding.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report scales.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition accounted for in detail.
Selective reporting (reporting bias)	Unclear risk	No protocol available.
Other bias	Low risk	No obvious sources of bias.

Fikretoglu 2019.

Study characteristics
Methods	Study design: "group"/cluster‐randomised controlled trial Hypothesis: the intervention was hypothesised have a beneficial impact on individual i) psychological functioning ii) resilience iii) attitudes towards mental health support services iv) military performance
Participants	Location: Canada, Canadian Military facility Sample size: n = 2806 (intervention T1 n = 1452 (33 platoons), T3 n = 862 (28 platoons); control T1 n = 1379 (32 platoons), T3 n = 786 (25 platoons)) Age, mean: intervention 23.47 (SD 5.51) years, control 23.38 (SD 5.13) years Sex: 2400 male, 406 female Ethnicity: 84.74% white Education: 6.93% had a college level degree Inclusion criteria: Canadian military recruit attending 13‐week BMQ training Exclusion criteria: none specified
Interventions	Intervention "Road to Mental Readiness" (R2MR) training consists of didactic modules (stress management skills training and psycho‐educational instruction on recognising when they may need to use mental health supports) and small group based vignette exercise to reinforce skills learned. Comparator "delayed intervention group". The intervention and control group used the same slides however in the delayed control group, delivery scripts focused on using skills learned over the entirety of ones military career: the intervention group scripts encouraged the use of learned skills during basic training.
Outcomes	Psychological distress (K‐10) Subjective levels of distress (SUDS) Resilience (CD‐RISC) Anxiety (GADS‐7) Depression (PHQ) Mental health service use (CAF‐MHSUQ)
Notes	Full funding declaration is made.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	A blocked randomisation scheme was developed by an independent contractor.
Allocation concealment (selection bias)	Low risk	Random allocation software was utilised.
Blinding of participants and personnel (performance bias) All outcomes	Low risk	"Triple blinded study" the investigator, participants and civilians in charge of data collection were blinded to platoon conditions.
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Civilians in charge of data collection were blinded to platoon conditions.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition adequately described.
Selective reporting (reporting bias)	Low risk	Published protocol available, outcomes reported as per protocol.
Other bias	Unclear risk	Funding is from a Canadian Armed forces grant and no competing interests are declared by the authors.

Hourani 2016.

Study characteristics
Methods	Study design: cluster‐randomised controlled trial Hypothesis: 1) Would PRESIT participants have decreased physiological arousal as measured by increased cardiac vagal tone compared to controls 2) Would PRESIT group be less likely to meet criteria for PTSD post deployment compared to controls 3) Would PRESIT group be more likely to use positive coping and report less perceived stress than controls post deployment
Participants	Location: Camp LeJeune Marine base USA Sample size: n = 351 (PRESIT group n = 251 (48 squads): PRESIT + HRV BF n = 76, PRESIT + sound/visual pacing n = 175; control n = 97 (22 squads): control + HRV n = 17, control + sound/visual n = 80) Age (mean): 21.7 years Sex: 100% male Previous deployment: mean 1.44 Education: 72% high school education or less, some college/third level exposure 28% Inclusion criteria: active duty male marines at camp Lejeune scheduled for imminent deployment for combat operation Exclusion criteria: not described
Interventions	Intervention The programme used in this study was titled 'Pre‐Deployment Stress Inoculation Training' (PRESIT). SIT training is designed to enhance skills to minimise the impact of traumatic events. There are three stages to SIT training. Skill introduction, HRV Biofeedback training and application of skills in a multimedia stressor environment. HRV Biofeedback training was the methodological approach used in this programme. Minimisation of hyper arousal as achieved by HRV control implicated in reduction in PTSD symptoms. Comparator The control group, "Current best practice", received a 20‐minute current best practice (CBP) on Combat and operational stress controls materials.
Outcomes	Heart period (HP) Respiratory sinus arrhythmia (RSA) Both cardiac measures were captured by a photoplethysmograph sensor attached to the ear lobe, which measured pulse signals from the heart PTSD (PCL‐C) Perceived Stress (coping; PSS)
Notes	Arm 1 = PRESIT + HRV + SV Arm 2 = Control + HRV + SV Arm 3 = PRESIT + SV pacing only Arm 4 = Control + SV pacing only
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Cluster randomisation used but method for randomisation not outlined.
Allocation concealment (selection bias)	Unclear risk	No information provided.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No information provided.
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	No information provided.
Incomplete outcome data (attrition bias) All outcomes	Low risk	detailed description of attrition provided in the paper, data imputed.
Selective reporting (reporting bias)	Unclear risk	No protocol available.
Other bias	Unclear risk	No obvious source of bias however funding provided by Department of Defence Office of Naval Research (USA).

Hourani 2018.

Study characteristics
Methods	Study design: cluster‐randomised controlled trial Hypothesis: SIT group would have fewer PTSD symptoms and stress related symptoms at follow up than the participants in the SM (control) group
Participants	Location: Large East Coast US army base Sample size: n = 891 (intervention n = 469; control n = 422) Age (mean): 23.82 years Sex: 851 male Mental health problems: n = 564 Previous deployment: 41.9%. Previous trauma: 59.9% Education: 7.8% college graduates Other: 63.3% mental health issues, medication, seeing a counsellor, sleep problems Inclusion criteria: US Army Soldiers Exclusion criteria: not described
Interventions	Intervention The PRESIT (Predeployment Stress Inoculation Training Programme) consisted of three core components; education, skills acquisition and practice in a simulated environment specifically targeting HRV as mechanism of action. This study builds upon the work of Hourani et al.2016. The training began with a 90‐minute session which included an orientation, 25 minute questionnaire on their personal mental health state. Participants received a stress management leaflet which acted as the psycho‐educational component of the SIT programme. SIT was administered over the course of two twenty minute presentations, each dealing with a separate breathing technique 1) abdominal breathing and 2) attentional retraining with eyes open.The SIT group took part in Pre/post training MSE simulations, a virtual simulation of relevant combat stimuli gave participants a chance to practice and apply the skills learned previously. They also received MP3 players which contained SIT material. They were also to encourage to use the MP3 recording to practice the SIT techniques. Comparator The control group received a taped Stress management narrative slide show and participated in MSE pre and post where they were asked to think about SM skills from slide show.
Outcomes	Perceived stress (PSS)  PTSD symptoms (PCL‐M)
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Cluster randomisation however method of randomisation not described.
Allocation concealment (selection bias)	Unclear risk	No details provided.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures used.
Incomplete outcome data (attrition bias) All outcomes	High risk	High levels of attrition reported, no specific details provided. More attrition from Control than Experimental condition.
Selective reporting (reporting bias)	Unclear risk	No protocol available.
Other bias	Unclear risk	No other obvious source of bias funded by the department of the army (US).

Janka 2017.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: participants in the Biofeedback training group would show improved self‐control of the autonomic nervous system compared to controls
Participants	Location: Germany, Austria, Luxembourg Sample size: n = 36 (intervention n = 18; control n =18) Age, mean: intervention 38 (SD 11.92) years; control 31.1 (SD 8.38) years Sex: 31 male Education, mean: intervention 14.86 (SD 2.59) years; control 15.44 (SD 4.05) years Duration of crisis management, mean: intervention 9.67 (SD 8) years; control 10.06 (SD 6.68) years Number of ops, mean: intervention 47.61 (SD 100.35); control 33.56 (SD 66.38) 16 were in rescue service, 10 fire brigades, 6 other organisations, 4 Police Inclusion criteria: participants were Gold or Silver commanders in groups involved in crisis management of major incidents (they were required to have staff and decision‐making responsibilities and have experience of management of real life crises) Exclusion criteria: any kind of serious physical disease or psychiatric disorder i.e. PTSD, medication use which affected the CNS or ANS
Interventions	Intervention Titled'Biofeedback training': The intervention was carried out in accordance with the guidelines of the association of the applied psycho‐physiology and Biofeedback (2003). The programme, using biofeedback techniques, consists of exercises designed to promote deliberate control over electro dermal activity (EDA) under resting conditions and during exposure to various experimental conditions. EDA is a well‐established indicator of stress related changes in sympathetic nervous system activity. Comparator The crisis managers in the control condition received no intervention. They were assigned to a waiting list and were given the option to receive the intervention post trial.
Outcomes	Perceived stress (PSS)  Changes in sympathetic tone: EDA Signal Maximal Relative decrease Proportion of time during which the EDA signal decreased during the respective 9‐min period Maximal relative decrease during the ‐ minute exercise period relative to a 60s baseline was computed SOFTmed Physio system, a finger sensor was used to measure EDA
Notes	Participants could choose two different display settings (on Biofeedback software): 1) EDA was presented as a line which moved in relation to levels of physical/mental relaxation 2) EDA was displayed as a lotus flower that opened with decreased EDA and closed with increased EDA Trainers received a 4‐day train the trainer programme prior to commencement.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	No specific details provided on randomisation process.
Allocation concealment (selection bias)	Unclear risk	No details provided.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	no details provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Details not provided.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	No details on attrition, unclear if any took place.
Selective reporting (reporting bias)	Unclear risk	No protocol available.
Other bias	Low risk	No obvious sources of bias.

Jones 2019.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: participants in the SPEAR intervention group would have better mental health, less alcohol use and lower stigmatisation compared to control condition
Participants	Location: UK  Sample size: n = 707 (intervention baseline n = 358 (post recruit training n = 333; 3‐month follow up n = 261); control baseline n = 349, (post recruit training n = 321; 3‐month follow up n = 220)) Age: all participants were 18 years or older. No means or SDs provided Sex: 119 were female Inclusion criteria: RAF recruits, 18 years or older Exclusion criteria: none applied
Interventions	Intervention "SPEAR" is a programme which emphases i) social networks ii) capitalising on personal strengths & weaknesses iii) managing emotions iv) enhancing awareness of psychological symptoms and learning methods to promote resilience The SPEAR intervention involved training recruit trainers in SPEAR concepts, allowing them to "frame" their interactions with recruits, and were trained in several models of support and tools to assist interaction with recruits Comparator The control condition was recruit training as normal
Outcomes	Symptoms of common mental disorder General Health Questionnaire (GHQ) Symptoms of PTSD (Caseness; PC‐PTSD‐5) Alcohol use (AUDIT‐C)
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Alternate number sequence was used to allocated trainers to condition.
Allocation concealment (selection bias)	High risk	Alternate number sequence was used to allocated trainers to condition.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Participants in the control condition received additional training but details on blinding not provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures used and no detail on blinding provided.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition is adequately explained.
Selective reporting (reporting bias)	Unclear risk	No protocol available.
Other bias	Unclear risk	No obvious other source of bias however funding was provided by the UK Ministry of Defence.

Joyce 2019.

Study characteristics
Methods	Study design: cluster‐randomised controlled trial Hypothesis: first responders receiving the RAW mindfulness programme would have increased resilience post training compared to controls
Participants	Location: New South Wales, Australia Sample size: n = 143 (intervention n = 60 (6‐week n = 41; 6‐month follow up n = 31); control n = 83 (6 weeks n = 38; 6‐month follow up n = 36) Age (mean): 42.5 years Sex: 6 participants were female Inclusion criteria: full time firefighters Exclusion criteria: receiving regular therapy from a psychologist/psychiatrist
Interventions	Intervention Resilience@work (RAW) was comprised of 6 online training sessions, each taking 20‐25 minutes to complete. The programme consisted of mindfulness training, psycho‐educational and a range of skills and strategies drawn from therapies such as ACT, mindfulness‐based cognitive therapy and compassion focused therapy. Comparator Control Participants received an attentional control programme titled "Healthy living Programme". This was also an online programme which consisted of 6 modules. These modules provided information on topics such as healthy skin, healthy home environment etc.
Outcomes	Resilience (CD‐RISC) Brief resilience scale (BRS) Mindfulness (FMI‐14) Cognitive fusion (CFQ) Experiental avoidance and psychological inflexibility (AAQ‐II) Self‐compassion (SCS‐SF) Optimism (LOT‐R) Coping (Brief‐COPE) Sense of Purpose (LET)
Notes	Entirely online delivery. Participants could sign up for text or email reminders.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Randomisation was conducted using third party computer software.
Allocation concealment (selection bias)	Low risk	Online random sequence generator was used by a 3rd party researcher.
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Participants were blinded to their condition status (intervention or control).
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures were used.
Incomplete outcome data (attrition bias) All outcomes	Low risk	considerable more attrition in control group vs intervention group however this equalised at 6 month follow up.
Selective reporting (reporting bias)	Low risk	Study protocol is available.
Other bias	Low risk	No obvious other source of bias.

Keynan 2019.

Study characteristics
Methods	Study design: double‐blind randomised controlled trial Hypothesis: relative to control NF, and NoNF, intervention would have larger improvements in Emotional regulation as measured by Stroop test., and a greater reported reduction in anxiety
Participants	Location: Israel Sample size: n = 180 (intervention n = 90; control n = 45; no control n = 45) Age: 18‐24 years, no more details provided Sex: 100% male Inclusion criteria: healthy IDF combat soldiers, during basic training prior to deployment were eligible for inclusion Exclusion criteria: an existing diagnosis of a mental disorder or use of psychoactive drugs were grounds for exclusion in this study
Interventions	Intervention Titled 'Repeated Amyg‐EFP‐Neutofeedback training'. Cognitive Neurofeedback was the theoretical underpinning used here. Downregulation of the amygdala activity is considered a key mechanism in emotional control and the programme aimed to achieve this through NF. NF training took the form of guided animated scenarios interfaces as designed by Cohen 2006. The programme consisted of 6 sessions, each of which had 5 training cycles, broken down into three components 1) attend 2) regulate 3) washout. Duration: six sessions (1‐2 session a week) for a period of 4 weeks. Comparator There was a comparator and a control condition in this study. The comparator group received the exact same training as the experimental condition however this group were trained in down regulating the Alpha/Theta ratio, titled "different region approach". Rationale of this comparator condition was "(this method will) account for global processes that are induced by NF (reward, control, learning) without targeting the mechanism of interest". The control group received no neuro‐feedback training whatsoever.
Outcomes	Emotional regulation: measured using RT on the eStroop task Anxiety (STAI, Hebrew version) Alexithymia (TAS‐20, Hebrew version)
Notes	Participants in the NF condition used their own mental strategies to achieve down regulation, there was no set strategy taught by the researchers. Training took place at an Israeli Military base, post training fMRI scans were taken at; Sagol Brain Institute, Wohl institute for Advanced Imaging, Tel Aviv Sourasky Medical Centre (Israel).
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Program created to specifically randomise population.
Allocation concealment (selection bias)	Low risk	Double‐blind allocation, software further allowed for blinding between Amyg‐EFP‐NF and Control‐NF by providing on‐line feedback without revealing the source signal.
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Blinding of both participants and personnel.
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	No details provided.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition adequately explained in text.
Selective reporting (reporting bias)	Low risk	Study protocol published.
Other bias	Unclear risk	No obvious other source of bias however one author is employed by the Mental health department, medical corps IDF. Two of the authors are the inventors of related patent applications entitled "method and system for use in monitoring neural activity in subject's brains".

Lewis 2015.

Study characteristics
Methods	Study design: cluster‐randomised controlled trial Hypothesis: following PRESTINT training, HRV in the low and high ranges will be elevated following the intervention and a subsequent stressor
Participants	Location: Army base Fort Bragg NC, USA Sample size: n = 891 (intervention n = 469; control n = 422) Age, mean: intervention 23.66 (SD 4.48) years, control 23.99 (SD 4.30) years Sex: 95.5% male Inclusion criteria: paratroopers from the 82nd Airborne division Exclusion criteria: not described
Interventions	Intervention Pre‐deployment stress inoculation therapy (PRESTINT) uses Heart Rate Variability (HRV) biofeedback practice as its resilience building methodology.This programme consisted of an initial educational phase and the PRESTINT training. The training aimed to increase HRV in presence of stress as increased HRV is associated with increased protection against PTSD symptomatology. HRV‐biofeedback training to The PRESTINT training itself began with 'Battle Breathing' techniques, followed by biofeedback training, ending with a Multimedia Stress Environment exercise (MSE). The MSE was employed to test reactivity and as a chance to practice breathing skills whilst under stress. Comparator Participants in the control group received a presentation providing information on common stress reactions, recommended self‐help behaviours and details for professional help if required.
Outcomes	PTSD (PCL‐C) Heart rate and RSA collected using an RTI‐developed field data collection system
Notes	Because the sample was tested in groups of 20 over several days, participants were taking part in different military activities (morning PT, lunch, training jump etc.) which impacted HRV data, however this was statistically accounted for.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	Randomization was based on an assigned date and time of the training session and determined prior to the training.
Allocation concealment (selection bias)	Unclear risk	No details provided.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self‐report measures used.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	no details on attrition provided.
Selective reporting (reporting bias)	Unclear risk	No published protocol.
Other bias	Unclear risk	No declaration regarding conflict of interest present. Supported by a grant from US Army medical acquisitions materials command.

McCraty 2012.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: no specific hypothesis stated, aim of study: provided training in practical resilience building and assess the impact of this training on physiological activation and re‐calibration following simulated stress inducing scenarios.
Participants	Location: California, USA Sample size: n = 65 (intervention n = 29; control n = 36) Age mean: 39 (range 24‐55) years Sex: 55 male, 10 female Employment: 43 patrol officers, 12 detectives, 9 administration officers Previous experience: mean 14.4 years, 16 participants had 1‐5 years experience, 28 had 16‐30 years experience Inclusion criteria: US law enforcement officers from Santa Clara County California Exclusion criteria: not described
Interventions	Intervention Coherence Advantage Stress Resilience and Performance Enhancement Program (CASRPEP), entails educational components about what resilience is and a series of research based self‐regulation techniques developed by the institute of HeartMath (IMH). The programme is classroom delivery based, skills learned are then tested in real life scenario simulations. Comparator The control condition took the form of a waiting list control group, but received the intervention at the end of the program.
Outcomes	Heart rate variability, 24hr ambulatory ECG (Holter) recordings Blood pressure
Notes	A subset of the control group and the CASRPEP group took part in the simulation part of the study. Each participant in the one of the simulation study arms, took part in three different job realistic simulations (building search, high speed pursuit, domestic violence)
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	No information provided on sequence generation.
Allocation concealment (selection bias)	Unclear risk	No information provided on concealment.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	There appears to have been no blinding with regards to the clinical interviews post programme or for the actual performance appraisal.
Incomplete outcome data (attrition bias) All outcomes	High risk	Vague reasoning provided for attrition, more attrition from control group than experimental.
Selective reporting (reporting bias)	Unclear risk	No study protocol published.
Other bias	Unclear risk	Author is employed by charity who developed materials used in this study.

Pyne 2018.

Study characteristics
Methods	Study design: cluster randomised controlled trial Hypothesis: the interventions tested would improve physiological resilience and cognitive resilience to the stress of deployment and result in lower levels of post deployment PTSD symptoms compared with controls.
Participants	Location: USA Sample size: n = 600 (intervention 1 n = 98; intervention 2 n = 102; control n = 142) Age, mean: 28.7 (SD 8.4) years Sex: male 314 (91.8%) Previous combat exposure: 44.6% Deployment related traumatic head injury: 9.4% Inclusion criteria: US National Guard soldiers from an aviation battalion and an infantry Battalion preparing to deploy to Iraq. Participants must have been scheduled to deploy within 12 months, 18‐60 years old and willing to provide at least one person to assist in locating the soldier for follow‐up. Exclusion criteria: using benzodiazepines or beta blockers was ground for exclusion in this study.
Interventions	Intervention Intervention 1) Heart rate variability biofeedback (HRVB). The HRVB interventions method of action was a blend of HRV and cognitive bias feedback to prevent PTSD. This practically involved identifying the breathing frequency that maximised a participants HRV, this frequency was used as the target for the BreathPacer app. Intervention 2) Cognitive Bias modification for interpretation (CBM‐I) CBM‐I intervention shifted a soldier’s interpretive style by presenting an increased proportion of neutral or non‐negative interpretations of an ambiguous deployment‐related scenario. Both interventions included self‐paced HRVB or CBM‐I training sessions on laptop computers, followed by brief individual training sessions using the relevant app on an iPod. Comparator Soldiers randomised to the control arm did not receive any additional resilience training. They did receive an Ipod but without any of the resilience apps installed.
Outcomes	PTSD (PCL‐M) Heart rate variability 12 Channel J&J engineering I‐330‐C2 instrument with 3M Red Dot ECG electrodes
Notes	This study was part of the "Warriors Achieving Resilience" (WAR) study. The project was part funded by a department of defence research grant (USA).
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Specific details on random sequence generation not described.
Allocation concealment (selection bias)	Unclear risk	Specific details on allocation concealment not described.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures used in this study.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition, and reasons for said attrition, is explained in detail in supplementary data.
Selective reporting (reporting bias)	Unclear risk	A protocol is referenced in text, however it is unclear if this protocol relates to this study or the larger Warriors Achieveing Resilience study from which the sample is drawn.
Other bias	Unclear risk	Salary funding was receive from Virtual Realtiy Medical Centres and the Institute of Heartmath (who's equipment was used in this programme).

Ranta 2008.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: the multidimensional intervention would be more effective than only relaxation training in reducing job related stress and the burnout potential of police personnel.
Participants	location: Himachal Pradesh, Indian Sample size: n = 80 (intervention n = 40; control n = 40) Age: no specific details provided Inclusion criteria: lower ranked Indian police officers (constable, head constables, assistant sub inspectors, inspectors) Exclusion criteria: not described
Interventions	Intervention The intervention, 'Multidimensional intervention', consisted of three distinct phases, duration is described below, phase 1‐ consisted of a stress management session including a relaxation training plan. Phase 2 ‐ involved instruction on self‐management techniques and mood management skills.  Phase 3‐ rehearsal of learned skills, involving a practice in an imaginary scenario situation. For a total duration of 3, 1‐hour sessions. Comparator The control group received "Relaxation training". This was the first phase of the intervention programme. It was given to participants so they wouldn't feel "left out". The total duration of the control programme was one, 1‐hour session.
Outcomes	Occupational stress (Police stress questionnaire) Burnout (emotional exhaustion, depersonalization & personal accomplishment) Maslach Burnout inventory
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Specific details on random sequence generation not described.
Allocation concealment (selection bias)	Unclear risk	Specific details on allocation concealment not described.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details on blinding provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures used in this study.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	No details on attrition provided however it appears that there was no attrition in this study.
Selective reporting (reporting bias)	Unclear risk	No published protocol available.
Other bias	Unclear risk	No other obvious source of bias, however no declaration of funding was made/conflict of interest.

Rosmith 2013.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: participants in the SIT programme would experience lower levels of organisational stress, operational stress, perceived life stress and lower total mood disturbance than controls (delayed training).
Participants	Location: South West USA Sample size: intervention 1 n = 8; intervention 2 n = 8; control n = 8 Age, mean: 38.92 (SD 6.72) years Sex: 79% male Ethnicity: 83% Caucasian  Education: 8 held a bachelor’s degree education Previous military experience: n = 19 Inclusion criteria: US Law enforcement officers Exclusion criteria: not described
Interventions	Intervention The intervention used in this study was titled 'Stress inoculation training' (SIT). Stress inoculation training was the methodological/theoretical underpinning of this programme. SIT was adapted from the works of Meichenbaum 1988 and Sheehy 2004. Aspects of CBT and motivational interviewing were also incorporated in the programme used in this study. The programme was group based, incorporating psychoeducational/skills based sessions and role play skills practice elements. There was also a SIT + booster subset used in the research. Some participants had been randomly selected to take part in SIT booster sessions. The booster session was a 20‐30 minute phone call from a member of the research team designed to motivate the participant and help fine tune skills learned during the SIT programme. Comparator A delayed training control was used in this study. The programme would be repeated for these participants if they expressed an interest post study completion.
Outcomes	Organisational stress (PSQ‐Org) Operational stress (PSQ‐Op) Perceived life stress (PSS‐10) Mood disturbance (POMS‐SF) Depression (POMS‐SF, su scales for depression) Anger (POMS‐SF, sub scales for anger)
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Participants were randomised to group using a table of random numbers.
Allocation concealment (selection bias)	Low risk	Participants were randomised to group using a table of random numbers.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Not described.
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not described.
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Some attrition reported but not described in detail.
Selective reporting (reporting bias)	Unclear risk	No published protocol, part of PhD thesis.
Other bias	Low risk	No obvious sources of bias.

Shipley 2002.

Study characteristics
Methods	Design: randomised controlled trial Hypothesis: participation in VMBR would improve performance by reducing acute stress associated with a dynamic critical event scenario compared to controls.
Participants	Location: Ontario, Canada Sample size: n = 54 (intervention n = 26; control n = 28) Age, mean: 27 years Sex: 40/54 recruits were male Inclusion criteria: police recruits in their final phase of training Exclusion criteria: not described
Interventions	Intervention Visuo‐motor behaviour rehearsal (VMBR) combines progressive relaxation, mental practice, performance‐related imagery, with the aim of reducing acute stress associated with a dynamic, critical event scenario. Also, components of emotion based training as proposed by Keinan 2006. The procedure was based on the work of Richardson 1972. Skills learned during VMBR were applied during a police scenario live simulation exercise. Comparator The control group were ordered to report a half hour after the experimental group to the simulation centre. They received no treatment.
Outcomes	Anxiety Cognitive state anxiety Somatic state anxiety Self‐confidence (CSAI‐2)
Notes	If officers failed the first scenario (VMBR condition) they were allowed a repeat attempt however this repeat was not included in this study analysis.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Method of randomisation not described.
Allocation concealment (selection bias)	Unclear risk	No details provided on allocation concealment.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Participants were naive with respect to the nature and aims of the experiment as stated in text but specific details on blinding not provided.
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	A mix of self report and objective measure used however no details provided.
Incomplete outcome data (attrition bias) All outcomes	Low risk	No attrition from recruitment to analysis.
Selective reporting (reporting bias)	Unclear risk	No published protocol.
Other bias	Unclear risk	No conflict of interest declaration provided.

Skeffington 2016.

Study characteristics
Methods	Study design: cluster‐randomised controlled trial Hypothesis: compared to TAU controls, intervention group would show a significant increase in trauma knowledge and show significant improvements in perceived social support, and coping from pre‐test to 6 & 12‐month follow ups. TAU group would show significant increases in pathology compared to Intervention group at 6/12 month follow‐ups.
Participants	Location: Washington State USA Sample size: n = 77 (intervention n = 30 (one cluster/school); control n = 45 (2 school, of 24/21 TFFs, respectively)) Age, mean: 28.85 (SD 4.73) years Sex: 97.3% male Inclusion criteria: US firefighter Trainees from June 2013‐December 2014 Exclusion criteria: none
Interventions	Intervention The intervention used in this study was titled 'Mental Agility and Psychological Strength training programme' (MAPS). MAPS focuses on a blend of CBT practices and psychoeducational components e.g. cognitive restructuring, support seeking and knowledge building. The programme was group delivered, at the rate of 4, one‐hour sessions, over a period of 4 weeks. Each session constituted a single MAPS module. Comparator There was a training as usual (TAU) control used in this study. TAU group treated identically to intervention group, except they did not complete the intervention programme.
Outcomes	PTSD symptoms (PCL‐C) Other Mental Health Symptoms (DASS) Coping strategies, adaptive coping, maladaptive coping (Brief COPE) Perceived social support (SSQ)
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Randomisation of clusters achieved by use of sealed envelopes.
Allocation concealment (selection bias)	Low risk	Concealment was achieved through use of sealed envelopes.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures used in this study.
Incomplete outcome data (attrition bias) All outcomes	Low risk	There are low levels of attrition in this study. Reasons for attrition are described in adequate detail.
Selective reporting (reporting bias)	Unclear risk	No protocol published.
Other bias	Low risk	No obvious sources of bias.

Taylor 2011.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: survival training would precipitate substantial stress responses, which in turn would be modulated by PST.
Participants	Location: USA Sample size: n = 64 (analysed n = 18: intervention n = 10; control n = 8) Age, mean: 25 (SD 0.05) years Sex: 100% male Years of military service, mean: 3.9 (SD 0.4) years Previous deployment, mean: 0.8 (SD 0.2)  Combat experience: 87.7% Inclusion criteria: active duty US navy personnel, students of Survival Evasion Resistance Escape (SERE) training Exclusion criteria: not described
Interventions	Intervention The intervention used in this study was titled 'Psychological skills training (PST). Psychological skills training as applied in this study followed the guidelines as described by Weinberg 2007. The programme consisted of two 40‐minute presentations covering: goal setting, arousal control, positive self talk and mental imagery, delivered in a group setting. Comparator The control group received no extra training during their period at military survival school.
Outcomes	Dissociation (CADSS) PTSD symptomatology (IESR)
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	No details provided.
Allocation concealment (selection bias)	Unclear risk	No details provided.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures used in this study.
Incomplete outcome data (attrition bias) All outcomes	High risk	High levels of attrition observed from recruitment to analysis, attrition not adequately justified.
Selective reporting (reporting bias)	Unclear risk	No study protocol available.
Other bias	Unclear risk	No other obvious source of bias however two authors employed by Naval health research centre. This study was carried out as part of their work.

Trousselard 2015.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: stress management programmes would be effective for reducing stress in French military firefighter trainees.
Participants	Location: France Sample size: n = 180 randomised (n = 84 completed the whole study) (TOP n = 41; CBF n = 45 CBF; control n = 35) Age (range): 18‐25 years (no mean (SD) provided) Gender: 100% male Education: 50% university degrees Inclusion criteria: volunteer firefighters from the French Army’s firefighter service Exclusion criteria: endocrine issues, extra‐professional stressful life events, current illness, no medication use (for inflammatory disease), no chronotropic medication over the previous 6 months.
Interventions	Intervention 1  Tactics to optimise the potential (sic) (TOP). TOP Involves controlling breathing through the use of relaxation and visualisation to improve cognitive based problem‐solving. TOP focuses on cognitive training to regulate emotions, using techniques that optimise potential (TOP). TOP consists of learning easy techniques of mental skill to improve cognitively based problem‐solving through control of respiration, by relaxation and using visualisation. Intervention 2  Cardio Biofeedback training: this approach increases cardiac coherence by training users to stabilise negative emotions while stressed. The CBF program uses feedback from a simple pulse sensor to reflect changes in emotional/psychological state, and to learn how to reduce stress and stabilise emotions. Comparator Placebo + TAU. A training as usual control, with placebo starch pill treatment. One pill per day during the last 2 months of training. The placebo was administered to all groups.
Outcomes	Perceived stress, uncontrolled stress and distress (PSS) Mood (POMS)
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Randmomisation was carried out by randomisation software.
Allocation concealment (selection bias)	Low risk	Randomisation and allocation was carried out by randomisation software.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details provided.
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	No details provided, self report measures utilised and objective measures.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition was similar across treatment groups.
Selective reporting (reporting bias)	Unclear risk	No published protocol.
Other bias	Unclear risk	No other obvious source of bias however several authors are active duty members of the French Army.

Wald 2016.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: using AMBT to induce vigilance towards minor threats before combat deployment reduces risk of PTSD following combat ACT would also be effective in reducing PTSD levels post combat.
Participants	Location: Israel Sample size: n = 719 (AMBT HD n = 179; AMBT LD n = 184; ACT n = 180; control n = 176) Age, mean: AMBT HD 19.2 years; AMBT LD 19.4 years; ACT 19.3 years; control 19.3 years Education, mean (range): AMBT HD 12 (11.9‐12.0); AMBT LD 12.0 (12.0‐12.1); ACT 12.0 (12.0‐12.1) years; control 12 (12.0) years Inclusion criteria: first tier infantry unit Israeli soldiers Exclusion criteria: participants were excluded if they had any reading difficulties or dyslexia.
Interventions	Intervention Attention Bias Modification Training (ABMT)/Attentional Control Training (ACT), high dose. MBT is a computer‐based protocol developed by Linetzky 2015 and MacLeod 2015. Its proposed mechanism of anxiety reduction is its targeting of disruptions in a threat monitoring system responsible for focusing on potential threats in the environment. High dose AMBT towards threat for a total of 8 sessions (computer‐based delivery). AMBT (low dose) As above, for a total of 4 sessions. Attentional control training (ACT). The same protocol as the AMBT sessions however response target is balanced between threat stimuli and neutral attention stimuli. Comparator No training control. Participants attended 8 check‐ins, matched time to other groups actual training. They entered a room, checked in and were told they would not be training today.
Outcomes	PTSD prevalence at 4 months post combat ‐ CAPS‐PTSD diagnosis (blinded clinician administered) Self reported PTSD (PCL‐M) Depression symptoms (PHQ‐9)
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Online randomised tool used to generate random sequence.
Allocation concealment (selection bias)	Low risk	Online generator provided allocation concealment.
Blinding of participants and personnel (performance bias) All outcomes	Low risk	Study was described as double blind.
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Phone call interviews and assessments were carried out over the phone by supervised clinical psychologists who were not aware of participant allocations.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Detailed reporting of attrition provided in the paper, relatively uniform attrition rates between studies.
Selective reporting (reporting bias)	High risk	Published protocol available however in the study protocol, attention bias was listed as a secondary outcome however it is not included in the final study, replaced with combat experience scale.
Other bias	Unclear risk	No obvious other source of bias however one author involved in the Israeli military and another in a US military run college WRAIR. Funded by a US military grant.

Wessemann 2016.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: intervention (CHARLY) would be superior to former deployment training approaches in reducing post‐traumatic and general psychological stress. CHARLY also superior to previous training for immediate post deployment mental state.
Participants	Location: Germany Sample size: Randomised n = 67 (intervention = 36; control n = 31)  Analysed: intervention n = 29; control n = 31 Final group post loss to follow‐up n = 24 Age, mean: intervention 29 (SD 5.50) years; control 27.9 (SD 5.36) years Sex: intervention 67% male; control 74% male Time served, mean: intervention 9.36 (SD 4.80) years; control 9.00 (SD 5.29) years Deployments, mean: intervention 1.58 (SD 2.64); control 0.97 (SD 1.56) Inclusion criteria: members of a German medical military unit which was to be deployed to Afghanistan Exclusion criteria: personnel with a diagnosis of an acute medical disorder were excluded
Interventions	Intervention Titled 'Chaos Driven Situations Management Retrieval System' (CHARLY), the CHARLY programme is a technology‐based approach to blend the following preventative approaches: Blended learning (bringing together different approaches for the same goal) Internal differentiation, strategy that focuses on strength, weaknesses and speeds of individual group members Technology‐based simulation techniques Computer‐assisted methods and biofeedback during pre‐deployment training In essence cognitive biofeedback training to reduce stress response. Comparator The control group was trained in parallel with the experimental group by a military psychologist. Psychoeducational components were exactly the same for both groups. Also included an introduction and exercise of relaxation and distancing techniques. There was no biofeedback component.
Outcomes	Current mental state (BSI) PTSD symptoms (PDS, German version)
Notes	Control condition training was a half day longer than intervention. Material was all matched for content minus biofeedback component.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Randomisation was conducted by drawing lots.
Allocation concealment (selection bias)	Unclear risk	Not enough detail provided on allocation concealment for assessment.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No details provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	No details provided, self report measures used.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition relatively balanced between groups, attrition explained in flow diagram.
Selective reporting (reporting bias)	Unclear risk	No published protocol available.
Other bias	Unclear risk	No obvious other source of bias however authors have links to the German military. Funding received from Bundeswehr.

Wild 2016.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: the authors hypothesised that the group‐based resilience intervention would lead to greater improvements in resilience, well being, social capital, self‐efficacy, problem solving ability, and confidence in managing mental health than the online control intervention. We hypothesised that the group‐based resilience intervention would lead to reductions in maladaptive coping behaviours, depressive attributions and rumination.
Participants	Location: United Kingdom Sample size: 430 participants took part in the study Age, mean: 41.41 (SD 9.78) years Service branch: Police n = 225; Ambulance n = 120; Fire n = 68; Search and Rescue n = 17 Sex: male n = 180; female n = 250 Inclusion criteria: being employed or volunteering as frontline or office based staff in the Police, FIre & Rescue, Ambulance or Search and Rescue services. Exclusion criteria: participants who scored in the clinical range for a diagnosis of PTSD or depression. Those who expressed suicidal Ideation were interviewed by staff and included if they evidenced risk, symptoms were not interfering with daily function and they did not wish to access treatment.
Interventions	Intervention The "resilience intervention" consisted of six sessions, each 2.5 hrs in length, delivered once a week over six weeks. The course aimed to improve participants well being by building social capital, encouraging positive activities and teaching psychological coping skills drawn from CBT and mindfulness. Comparator Involved participants accessing mental health information online, covering topics such as sleep, stress, depression and PTSD. It was delivered over six weeks. Participants were sent a weekly email containing the link for the week's topic of focus.
Outcomes	Wellbeing (Warick Edinburgh Mental Wellbeing Scale) Resilience (CD‐RISC25) Self‐efficacy (Schwarzer‐ Jerusalem General Self‐Efficacy Scale) Social support (adapted version of Sarason 1987 questionnaire) Coping (Coping style confidence in managing mental health & resilience (unpublished scale)) & (Coping behaviour Questionnaire (Short version)) Post traumatic stress disorder (PCL) Depression Patient Health Questionnaire (PHQ‐9)
Notes	ISRCTN69644721
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Specific details on randomisation sequence generation are not provided.
Allocation concealment (selection bias)	Unclear risk	No specific details provided.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No specific details provided.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures used.
Incomplete outcome data (attrition bias) All outcomes	High risk	Insufficent detail provided on attrition.
Selective reporting (reporting bias)	Low risk	Protocol was pre‐published. Evidence that all prespecified outcomes have been reported in actual trial.
Other bias	Low risk	No obvious other source of bias evident.

Wild 2017.

Study characteristics
Methods	Study design: randomised controlled trial Hypothesis: authors hypothesised that the newly developed resilience intervention would lead to greater improvements in resilience, well being, social capital, psychological distress, rumination and confidence to manage mental health compared to the placebo and wait list conditions.
Participants	Location: United Kingdom Sample size: n = 180 Age, mean: 42.54 (SD = 6.68) years Service branch: Police n = 143; Ambulance n = 15; Fire n = 22 Sex: male n = 76; female n = 103; other n = 1 Inclusion criteria: employed or volunteering as front‐line or office‐based staff in one of the following emergency services: police, fire and rescue, ambulance and search and rescue. Exclusion criteria: participants who scored in the clinical range on measures of post‐traumatic stress or depression, or those who expressed suicidal ideation, had a one‐to‐one discussion with the study’s psychologist. They were included in the study if they did not evidence risk, their symptoms were not interfering with their daily functioning and they did not wish to access treatment.
Interventions	Intervention  The resilience intervention consisted of 4 online modules and 4 linked group sessions (two hours in length) delivered once a week over a 4‐week period. The course aimed to improve resilience to stress by targeting key predictors of long‐term stress reactions in emergency service workers. Comparator  The placebo online intervention consisted of accessing already available information on mental health developed by Mind and, where possible, tailored for emergency service workers. The online intervention was delivered over 4 weeks.
Outcomes	Wellbeing (The Warwick‐Edinburgh Mental Wellbeing Scale (WEMWBS)) & (ONS Wellbeing) Resilience (Resilience Scale) Self‐efficacy (Schwarzer‐ Jerusalem General Self‐Efficacy Scale) Psychological Coping style (Attributions Questionnaire) Mental Health Awareness & Confidence in Managing Mental Health (unpublished scale) Mindful Attention (Mindfulness Attention Awareness Scale (MAAS)) Post‐traumatic Stress Disorder Checklist (PCL) Depression (PHQ‐9) General Anxiety Disorder (GADS) General Health Questionnaire (GHQ‐12)
Notes
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	No specific detail reported.
Allocation concealment (selection bias)	Unclear risk	No specific detail reported.
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	No specific detail reported.
Blinding of outcome assessment (detection bias) All outcomes	High risk	Self report measures used.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Attrition is low and appears equal between groups.
Selective reporting (reporting bias)	Unclear risk	Congruency in outcome measures specified at trial registration stage and those that appear in the study. However PTSD as measured by PCL, or depression, specific outcome data is not reported.
Other bias	Low risk	No other obvious source of bias.

AAQ: Acceptance and Action Questionnaire; ACT: Attentional Control Training; AMBT: Attention Bias Modification Training; ASQ: Attachment Style Questionnaire;AUDIT‐C: Alcohol Use Disorders Identification Test;BPAQ‐SF: Buss‐Perry Aggression Questionnaire‐Short Form; Brief‐COPE: Brief Coping Orientation to Problems Experienced;BSI: Brief Symptom Inventory; CADSS: Clinician‐ Administered Dissociative States Scale; CAF‐MHSUQ: Canadian Armed Forces Mental Health Service Use Questionnaire;CAPS: Clinician‐Administered PTSD Scale; CBT: cognitive behavioural therapy; CDRS: Connor Davidson Resilience Scale; CFQ: Cognitive fusion Questionnaire; CHRT: Concise Health Risk Tracking Scale;CSAI‐2: Competitive State Anxiety Inventory‐2;ECG: electrocardiogram; EMAS‐T: Endler Multidimensional Anxiety Scale‐Trait; FFMQ‐SF: Five Facet Mindfulness Questionnaire‐short form; FMI: Freiburg Mindfulness Inventory; GAD‐7: Generalised Anxiety Disorder; GHQ: General Health Questionnaire;HRV: heart rate variability;IAS: Clinician‐Administered PTSD Scale;ICS: Intelligibility in Context Scale;IESR: Impact of Event Scale‐ Revised;IGC: Integrated Group Counselling; IRI: Interpersonal Reactivity Index; ITT: intention‐to‐treat;K‐10: Kessler Psychological Distress scale;LET: Life Engagement Test; LOT‐R: Life Orientation Test‐Revised;LSR: Level of Stress Rating;M: mean; MAAS: Mindfulness Attention Awareness Scale; ml: millilitres;n: number;NCO: non‐commissioned officer; OLBI: Oldenburg Burnout Inventory; OSI: Occupational Stress Inventory;PCL‐C: PTSD Checklist‐ Civilian Version; PCL‐L: Posttraumatic Stress Disorder Checklist;PCL‐M: PTSD checklist – Military version; PDS: Post traumatic Stress Diagnosis Scale; PGWBI: Psychological General Well‐being Index; PHQ: Patient Health Questionnaire; POMS‐SF: Profile of Mood States – Short Form; PROMIS: Patient‐Reported Outcomes Measurement Information System; PSS: Perceived Stress Scale;PSS: Personal Stress Situation;PSQ: Police Stress Questionnaire; PSQ‐Op: Operational Police Stress Questionnaire; PST: Psychological skills training ; PTSD: post‐traumatic stress disorder; RT: resilience training; SCS‐SF: Self Compassion Scale‐Short Form; SD: standard deviation; SES: Self‐Efficacy Scale; SQI: Sleep Quality Index;SSQ: Social Support Questionnaire; STAI: State‐Trait Anxiety Inventory; STAS‐T: State‐trait Anger Scale;SUDS: Subjective Units of Distress Scale; TAS‐20: Toronto Alexithymia Scale;TAU: treatment as usual; TICS: two‐item conjoint screen; TMHI: Thai Mental Health Indicator; UCLA: University of California, Los Angeles; WEMWBS: Warwick‐Edinburgh Mental Wellbeing Scale

Characteristics of excluded studies [ordered by study ID]

Study	Reason for exclusion
Cigrang 2000	Post trauma intervention
Cohn 2008	Induction training specific intervention focusing on retention of soldiers during training, not trauma/pre‐deployment focused
Guo 2019	Intervention was not pre‐emptive
Lee‐Wesely 1994	Post deployment intervention
MacNab 2003	Post trauma intervention
McCaslin 2018	Post deployment intervention
McClernon 2011	Wrong sample (non‐military/front line emergency services)
NCT2170194	Post deployment intervention

Characteristics of ongoing studies [ordered by study ID]

Christopher 2020.

Study name	Mindfulness‐based resilience training for aggression, stress and health in law enforcement officers: study protocol for a multi site, randomised, single‐blind clinical feasibility trial
Methods	Full‐scale, multi‐site trial assessing effects of mindfulness‐based resilience training versus an attention control (stress management education) and a no‐intervention control on physiological, behavioral, and psychological outcomes
Participants	Law enforcement officers (LEOs)
Interventions	Mindfulness training
Outcomes	Physiological, behavioural, and psychological outcomes
Starting date	December 2017
Contact information	Michael Christopher, PhD, Pacific University
Notes

LaMontagne 2016.

Study name	An integrated workplace mental health intervention in a policing context
Methods	A mixed‐methods pilot study, and combines multi‐session leadership coaching for the senior officers within stations
Participants	Police officers
Interventions	Tailored mental health literacy training for lower and upper ranks
Outcomes	Psychosocial working conditions (e.g. supervisory support, job control, job demands), mental health literacy (e.g. knowledge, confidence in assisting someone who may have a mental health problem), and mental health will be assessed using validated measures. Organisational outcomes will include organisational depression disclosure norms, organisational cynicism, and station‐level sickness absence rates.
Starting date	July 2014
Contact information	Centre for Population Health Research, School of Health & Social Development, Deakin University, Geelong, VIC, 3220, Australia. tony.lamontagne@deakin.edu.au
Notes

NCT01599624.

Study name	Stress Resilience Training System (SRTS)
Methods	Randomised controlled trial
Participants	US naval personnel
Interventions	Stress Resilience Training System (SRTS) Progressive Muscle Relaxation (PMR)
Outcomes	Perceived stress, sleep quality, anxiety
Starting date	2012
Contact information	Office of Naval Research
Notes	Results not yet published

NCT03401684.

Study name	The Resilient Minds Program in Fire Departments
Methods	Interventional (Clinical Trial)
Participants	Firefighters (volunteer or career)
Interventions	Resilient Minds‐Building the Psychological Health of Fire Fighters." The Resilient Minds training will educate firefighters about the effects of trauma, how to recognise signs of mental health illness and how to access support after critical events. It also trains firefighters to recognise mental health and addictions in co‐workers and how to facilitate their help‐seeking
Outcomes	The impact of the program will be assessed by pre‐ and post‐program surveys and a 3‐month follow‐up survey
Starting date	January 2018
Contact information
Notes	Recruitment ongoing

NCT03488875.

Study name	Impact of mindfulness training on stress‐related health outcomes in law enforcement
Methods	Randomised controlled trial of an 8‐week mindfulness‐based training program for police officers
Participants	120 officers from Dane County law enforcement agencies
Interventions	Madison Mindfulness‐Based Resilience Training (mMBRT)
Outcomes	Subjective responses to stress, stress‐related psychological and physical health outcomes, and biological and behavioral correlates of perceived stress
Starting date	January 2020
Contact information	Daniel W Grupe, PhD
Notes

Trombka 2018.

Study name	The POLICE study
Methods	This multicentre randomised controlled trial has three assessment points: baseline, post‐intervention, and six‐month follow‐up. Active police officers (n= 160) will be randomised to Mindfulness‐Based Health Promotion (MBHP) or wait list control group at two Brazilian major cities: Porto Alegre and São Paulo
Participants	Police officers
Interventions	Mindfulness training
Outcomes	Primary outcomes: burnout symptoms and quality of life. Consistent with the MBHP conceptual model, assessed secondary outcomes include perceived stress, anxiety and depression symptoms, and the potential mechanisms of resilience, mindfulness, decentering, self‐compassion, spirituality, and religiosity
Starting date	March 2017
Contact information	Marcelo Demarzo. Mente Aberta ‐ Brazilian Center for Mindfulness and Health Promotion ‐ Universidade Federal de São Paulo, 545, Padre José Maria Avenue, São Paulo, Brazil
Notes

Wild 2018.

Study name	Preventing PTSD, depression and associated health problems in student paramedics: protocol for PREVENT‐PTSD, a randomised controlled trial of supported online cognitive training for resilience versus alternative online training and standard practice
Methods	570 student paramedics will be recruited from participating universities. They will be randomly allocated to iCT‐R or to supported online training of an alternative, widely available intervention or to training‐as‐usual.
Participants	Student paramedics
Interventions	Internet‐delivered cognitive training for resilience (iCT‐R), a supported online intervention
Outcomes	Primary outcomes include rates of PTSD and MD and subsyndromal PTSD and MD, measured by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fifth edition, the Patient‐Health Questionnaire‐9 and the Post‐traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Secondary outcomes include measures of resilience, rumination, anxiety, psychological distress, well‐being, salivary cortisol, plasma levels of C‐reactive protein, smoking and alcohol use, weight gain, sleep problems, health‐related quality of life, health resource utilisation and productivity
Starting date	2018
Contact information	jennifer.wild@psy.ox.ac.uk
Notes	Funder is MQ: Transforming Mental Health

Differences between protocol and review

We have removed the a‐priori outcome "PTSD". The review now includes two new outcomes to replace "PTSD. These are "symptoms of post traumatic stress" and PTSD caseness (clinical diagnosis). We have also included stress as an outcome of interest in the review. We have included these outcomes as they contribute to the overall completeness and applicability of evidence as it currently exists.

Contributions of authors

CD wrote the protocol and the review.

LR contributed to the methodology of the protocol and the writing of the review.

KC contributed to the writing of the review.

JB and JE contributed to the clinical and forensic conceptualisation.

KS contributed to writing the review and is the principal investigator.

Sources of support

Internal sources

• National University of Ireland Galway, Ireland

  Supported author time on this project.

External sources

• Irish Research Council, Ireland

  Funded this project.

• National Institute for Health Research (NIHR), UK

  Funded LR  input on this review.

Declarations of interest

CD: no conflicts of interest.
LR: is a member of the editorial team of the Cochrane Common Mental Disorders Review Group. LR was not involved in the editorial approval process for this review.
KC: no conflicts of interest.
JB: no conflicts of interest.
JE: no conflicts of interest.
KS: no conflicts of interest.

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