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LEADERSHIP TOOLS TO FOSTER RESILIENCE AND READINESS IN SERVICE MEMBERS WORKING WITH HUMAN REMAINS DURING COVID-19 AND OTHER DISASTERS: TURNING EVIDENCE INTO ACTION WITH THE MA-STAR POCKET CARD Quinn M. Biggs, Ph.D., M.P.H.1,2, Joshua C. Morganstein, M.D.1, Britany Mullins-Hussain, B.A.1,2, Julia M. Petrini, Sc.B.1,2, James E. McCarroll, Ph.D., M.P.H.1,2, Carol S. Fullerton, Ph.D.1, Robert J. Ursano, M.D.1 U.S. military Service Members (SMs) are often called upon to support major disasters. These missions frequently involve the handling of human remains and the personal effects of the deceased, exposures that are associated with increased risk for psychological distress and psychiatric disorders,[1,2,3,4] which can diminish military readiness. Some SMs, such as Army Mortuary Affairs (MA) Soldiers, are specifically trained to work with human remains. Others, such as the majority of National Guard (NG) personnel, are untrained and inexperienced in work with human remains. Inexperienced, non-volunteer SMs who work with remains have a higher risk for psychological distress compared to experienced, volunteer SMs.[5] This study examined the experiences of MA Soldiers and NG personnel who deployed to New York City (NYC) and Washington, DC (DC) in 2020 to support human remains recovery and processing during COVID-19 fatality surges. Based on findings from interviews and our extensive experience working with MA Soldiers, we identified the need for resilience support material and developed an educational pocket card for inexperienced personnel who work with human remains in the COVID-19 pandemic and future disasters. The largely untrained, inexperienced NG personnel were valuable team members, however they had comparatively higher rates of psychological distress and required close supervision. Some became “uneasy, hesitant, and turn pale” following exposure to human remains and many requested a transfer to other duties. Importantly, the reactions of the NG personnel indicated, RITM0028213, U.S. military Service Members (SMs) are often called upon to support major disasters. These missions frequently involve the handling of human remains and the personal effects of the deceased, exposures that are associated with increased risk for psychological distress and psychiatric disorders,[1,2,3,4] which can diminish military readiness. Some SMs, such as Army Mortuary Affairs (MA) Soldiers, are specifically trained to work with human remains. Others, such as the majority of National Guard (NG) personnel, are untrained and inexperienced in work with human remains. Inexperienced, non-volunteer SMs who work with remains have a higher risk for psychological distress compared to experienced, volunteer SMs.[5] This study examined the experiences of MA Soldiers and NG personnel who deployed to New York City (NYC) and Washington, DC (DC) in 2020 to support human remains recovery and processing during COVID-19 fatality surges. Based on findings from interviews and our extensive experience working with MA Soldiers, we identified the need for resilience support material and developed an educational pocket card for inexperienced personnel who work with human remains in the COVID-19 pandemic and future disasters.

MORTUARY AFFAIRS SOLDIERS’ COVID-19 HUMANITARIAN RELIEF DEPLOYMENTS COMPARED TO WARZONE DEPLOYMENTS: A CASE STUDY Britany Mullins-Hussain, B.A.1,2, Julia M. Petrini, Sc.B.1,2, Quinn M. Biggs, Ph.D., M.P.H.1,2, Alexandra Blumhorst, B.S.1,2, Arrey Thomas, B.S. (candidate)1,2, Amy E. Steward, B.S.1, Carol S. Fullerton, Ph.D.1, Robert J. Ursano, M.D.1 • U.S. Army Mortuary Affairs (MA) Soldiers are trained to collect, identify, and process human remains. • MA Soldiers are routinely deployed to war zones where they work in established collection points processing the remains of military personnel. War zone deaths are often violent and remains may be burned or fragmented. Concerns about health and safety include being in a battlefield environment with enemy combatants. Work flow varies depending on the military operational tempo. • Importantly, MA Soldiers are also deployed to humanitarian relief efforts following major disasters. In spring 2020, MA Soldiers were deployed to New York City and Washington DC to support the Office of the Chief Medical Examiner (OCME) during COVID-19 fatality surges. • This study examines the experiences of MA Soldiers who deployed to the COVID humanitarian relief efforts and provides a comparison to experiences during warzone deployments. These findings increase our understanding of the unique nature of humanitarian relief missions for MA soldiers. • Soldiers indicated concerns regarding their personal safety as a result of working on COVID-related deaths in the midst of a global pandemic. • In contrast to a highly-secure warzone setting, soldiers worked in temporary, less secure sites located in familiar cities with largely intact civilian remains of all ages. • MA soldiers have additional responsibilities in humanitarian missions, such as supporting the Office of the Chief Medical Examiner. • These findings help us better understand humanitarian relief missions for MA Soldiers, particularly those involving infectious disease, and are import, RITM0023183, U.S. Army Mortuary Affairs (MA) Soldiers are trained to collect, identify, and process human remains. MA Soldiers are routinely deployed to war zones where they work in established collection points processing the remains of military personnel. War zone deaths are often violent and remains may be burned or fragmented. Concerns about health and safety include being in a battlefield environment with enemy combatants. Work flow varies depending on the military operational tempo. Importantly, MA Soldiers are also deployed to humanitarian relief efforts following major disasters. In spring 2020, MA Soldiers were deployed to New York City and Washington DC to support the Office of the Chief Medical Examiner (OCME) during COVID-19 fatality surges. This study examines the experiences of MA Soldiers who deployed to the COVID humanitarian relief efforts and provides a comparison to experiences during warzone deployments. These findings increase our understanding of the unique nature of humanitarian relief missions for MA soldiers.

Person-mean of SI With PTSD Without PTSD Participants • Current and former military Service members (N = 156) were recruited from a military medical center as part of a larger study of PTSD symptoms • Demographic characteristics: age: M = 41.7 (SD = 13.7); male: 60.3%; Caucasian: 64.1%; Bachelor’s degree or higher: 55.8%. There were no differences between those with and without PTSD in categorical demographic characteristics. Individuals with PTSD were younger than those without PTSD, t = 2.35, p = .020 Measures • Probable PTSD: assessed with the 20-item PCL-5.6 Endorsement of PTSD required at least one qualifying traumatic event, meeting DSM-5 criteria B-E,7 and a symptom severity score ³ 38. Upon enrollment, n = 78 had PTSD and n = 78 did not have PTSD • SI: assessed with one item from the PHQ-9: Thoughts that you would be better off dead or hurting yourself in some way.8,9 Response choices were modified to a 0 (Not At All) to 10 (Extremely) range. SI was assessed four times daily (fixed interval, 4 hours apart) for 15 consecutive days Analyses • Each participant’s daily SI scores were averaged to produce a daily mean and all SI scores were averaged across the 15-day period to produce a person-mean Disclaimers: The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. The views expressed in this abstract are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. Methods Introduction Results DAIL, RITM0023224, Suicidal ideation (SI) is a known risk factor for suicide. SI is significantly and positively correlated with post-traumatic stress disorder (PTSD) in civilian2 and military populations. For decades, most suicide research focused on long-term risk factors that did not accurately predict suicide risk. Ecological momentary assessment (EMA)5 is a method of experience sampling that is well suited to assessing daily symptom change. Recent EMA studies of SI suggest that SI fluctuates substantially in short periods of time. Little is known about whether daily variation in SI differs between those with and without PTSD. This study used an EMA methodology to examine daily variation in SI among military Service members with and without PTSD.

Potentially-Traumatic Exposures in Middle East Deployed and Non-Deployed U.S. Army Mortuary Affairs Specialist Soldiers • U.S. Army Mortuary Affairs (MA) Specialist Soldiers recover, identify, and evacuate the remains of the dead from the battlefield • Their unique mission exposes them to violent death, personal effects (information and belongings) of the deceased, work in a combat environment, and other deployment-related stressors • These exposures can be stressful1 and have been associated with increased risk for psychological distress and psychiatric disorders,2,3 which can diminish military readiness • This study examines the potentially-traumatic exposures commonly reported by Middle East deployed and non-deployed MA Soldiers • MA Soldiers who deploy to the Middle East report significantly more potentially-traumatic exposures than MA Soldiers not deployed • Most MA Soldiers report being exposed to human remains after one deployment • In contrast, combat exposures are reported less frequently but the risk of exposure tends to increase with each additional deployment • These findings are relevant to developing training, behavioral health assessment, and intervention programs for high-risk groups including military populations, first responders, disaster workers, and others exposed to human remains We would like to thank the Mortuary Affairs Soldiers for their participation Introduction Results Acknowledgement, References, & Disclaimers Quinn M. Biggs, Ph.D., M.P.H.1,2, Britany Mullins-Hussain, B.A.1,2, Julia M. Petrini, Sc.B.1,2, Arrey Thomas, B.S. (Candidate)1,2, Amy E. Steward, B.S.1, Leming Wang, M.S.1, Carol S. Fullerton, Ph.D.1, Robert J. Ursano, M.D.1 1Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 2Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD Methods Conclusions 1. Flynn, B. W., McCarroll, J. E., & Biggs, Q. M. (2015). Stress, RITM0022356, U.S. Army Mortuary Affairs (MA) Specialist Soldiers recover, identify, and evacuate the remains of the dead from the battlefield. Their unique mission exposes them to violent death, personal effects (information and belongings) of the deceased, work in a combat environment, and other deployment-related stressors. hese exposures can be stressful and have been associated with increased risk for psychological distress and psychiatric disorders which can diminish military readiness. This study examines the potentially-traumatic exposures commonly reported by Middle East deployed and non-deployed MA Soldiers.