Ideally, a stepped care approach would be implemented by the military healthcare system to address the full range of ASR-induced performance deficits, with the initial point of care available during combat by peers or medics and follow on care available by providers at battalion aid stations. Because ASR symptoms sufficient to degrade performance may emerge during the trauma or in the days thereafter, a stepped care approach must be designed to be implemented as needed. Solutions should be implementable under extreme conditions, including during ongoing traumatic exposure and potentially during combat. Ideally, multiple intervention options will be available, enabling rapid escalation in the event that performance is not adequately restored by the initial intervention. It is also possible that behavioral and/or pharmaceutical interventions will need to be administered repeatedly to restore performance to acceptable levels or if symptoms resurface. As currently conceptualized, fellow unit members or medics could administer behavioral interventions while medics and/or providers at a battalion aid station would play a primary role in detecting, assessing, administering medications, and monitoring for ASR symptom resolution or persistence.

Figure 2 describes the role of detection, assessment, and monitoring over the course of a stepped care model for ASR intervention. Initially, an ASR might be detected and assessed by peers or medics to determine the need for an intervention. Monitoring thereafter can be used to determine the next step of care.

The current state of ASR detection in operational settings relies on fellow service members to recognize the behavioral symptoms of an ASR through subjective observation. This approach largely relies on the degree to which a first responder or peer is able to accurately observe behavioral changes. While subjective observation is useful, an objective, standardized approach developed to be more sensitive and rapid would allow the management of ASR symptoms perhaps even before they have fully manifested. To address this gap, objective tools to detect ASRs in operational environments are being actively developed. One emerging method for objectively detecting and monitoring an ASR could leverage passively collected sensor-based data [7]. The advantage of this approach is that artificial intelligence can be applied early in the onset of symptoms to detect risk for an ASR. One promising effort involves the passive collection of various features of speech. Vocal biomarkers have been shown to discriminate cases and controls for a number of clinical disorders including depression, but the predictive utility of these measures for ASRs in otherwise healthy individuals is currently unknown [8]. Changes in vocal biomarkers that co-vary with ASR symptoms could serve as a meaningful non-invasive detection tool in operational environments. Overall, the use of biosensors that detect physiological changes associated with ASRs could prompt peers, leaders, and healthcare providers to intervene early and prior to more sustained or severe symptom manifestation.

Unfortunately, data on the assessment of acute stress experienced during a combat-relevant time window are limited. A review of the relevant studies assessing peri-traumatic distress symptoms, revealed that most relied on self-report measures such as the Impact of Events Scale (IES) and PTSD Checklist (PCL) that were administered within days of the traumatic event [9, 10]. These measures appear to be useful in assessing risk, but by definition, they rely on an individual’s ability to accurately recall and respond to questions. However, if an individual is in an acute dissociative or panic-like state, it may be extremely difficult to complete a valid assessment. The Clinician-Administered Dissociative States Scale is used in some military contexts, though narrow evaluations of dissociation alone do not capture the full scope of ASR symptoms. Therefore, it is critical to specify criteria that enable medics or other providers or team members to rapidly assess the severity of an ASR. In recognition of this, work has begun to develop modifications to medic training that would enhance their ability to detect and assess ASR, and thereby facilitate on-the-spot decision-making, as medics are often the first providers that would encounter an individual experiencing an ASR. New efforts are also underway to develop an assessment approach for medics to use, as current medic training is not comprehensive enough to tackle the challenges of formally evaluating ASRs. Although a behavioral intervention may be administered by individual teammates without a need for formal assessment, medication administration will likely require prior medic or other provider assessment.

In addition to detection and assessment, ongoing monitoring for the efficacy of the behavioral or medication intervention to resolve ASRs should be used. This is particularly important for medications that could have performance-impacting side effects. Monitoring for symptom improvement will help determine if there is a need for further intervention. For example, symptoms may re-emerge after initial dosing, or impairments may persist and require a higher level of care. As described in Fig. 2, monitoring can occur at multiple points in the stepped care model and be performed by medics and/or providers at battalion aid stations. While it is possible that the same detection or assessment tools could be used for monitoring, it is also possible that there is a need to develop specialized tools for monitoring.

There is broad agreement that mental health support is necessary in operational settings. However, providing mental health support during operations—arguably where and when it may be most effective—is challenging. Current practice relies on area support from providers assigned to combat brigades and/or Combat and Operational Stress Control units [11•, 12]. This model has been used with success to stabilize patients as close to operational settings as possible and return them to duty, or to medically evacuate them to higher levels of care depending on symptom severity and persistence. However, future combat is expected to be large-scale and fought across multiple domains including air, land, space, cyber, and electromagnetic domains [13]. In preparing for these types of multi-domain operations, it is anticipated that the USA will not have ready access to secure communication capabilities and air support for medical evacuations. Further, ready access to behavioral health providers, even via remote telehealth communications, is expected to be limited. In light of these anticipated challenges, the US Army has invested in the delivery of care as close to the frontlines as possible. This operating concept places fellow service members and medics at the center of care provision, and it is anticipated that they will be responsible for stabilizing and returning to duty to those who experience ASRs. Moreover, there will be a heightened need to ensure that individuals experiencing psychiatric symptoms resume functioning as quickly as possible in order to return to duty and ultimately, restore combat power. With this concept of future warfare in mind, behavioral interventions and medications tailored for use in operational settings are now under development. Depending on the level of care needed and the type of care available, these solutions are designed to be applied during operations at the front lines or at battalion aid stations. If a service member does not respond to initial interventions in a forward-deployed environment, they may require evacuation to a higher echelon of medical care with more robust treatment options and monitoring. Because patient movement may be delayed due to the operational environment, medics or providers at the battalion aid station require education on triage, monitoring, and treatment.

For the past several decades, pre-deployment training designed to promote resilience and mental health have been provided to deploying units, though these trainings have not specifically addressed the management of ASRs. Psychological first aid is currently the first-line treatment for acute traumatic stress effects. This treatment is limited because it was developed to address civilian traumatic stress and does not address the return to performance that would be needed in operational settings [14]. Therefore, this gap has resulted in service members managing ASR symptoms by responding instinctually or making the best guess about what might work [15•]. Across two independent samples, the most common strategies service members reported included calmly speaking to or yelling at the individual experiencing the ASR, as well as directing them to perform a simple task [6•]. Though less frequently reported, some reported shaking, hitting, or pushing the individual in an attempt to resolve the ASR, and others expressed that they did not know how to respond. These responses indicate the need for both structured training and interventions to enable all unit members to address ASR symptoms effectively at the moment, even in the midst of combat.

A recently developed intervention was specifically designed to meet this need, with the goal of restoring performance as quickly as possible. This intervention is based on one originally created by the Israel Defense Forces and consists of a series of steps service members can use with team members experiencing an ASR at the frontlines [16]. The US version of this training, iCOVER, also includes steps designed to refocus the affected individual through connecting, offering commitment, engaging the brain’s automatic processes through simple questions, grounding the individual by providing a brief sequencing of events, and requesting purposeful action. Notably, iCOVER can be used by anyone following a single session of training and is designed to address both active and passive ASR symptoms. Initial studies of iCOVER training have demonstrated its feasibility, acceptance, and positive impact on attitudes, as well as an increase in the ability of individuals to enact these steps in realistic training scenarios [15•]. More recently, over 90% of National Guardsmen undergoing iCOVER training in preparation for deployment found the training important, relevant, and useful [5•]. Importantly, iCOVER training increased service members’ own confidence to help a fellow unit member manage an ASR and also increased confidence in their fellow unit members to help them if they experienced an ASR. Currently, iCOVER is being disseminated in the US Army as part of Deployment Cycle Resilience Training and has been adapted by militaries in other nations as well. Overall, though additional efficacy testing is needed, iCOVER is a major advance in the management of ASRs in an operational setting.

In the event that ASR symptoms persist after behavioral intervention and symptoms continue to be severe enough to impact performance or put the service member or team members in danger, medications could be used to alleviate symptoms and restore performance. These medications may be self-administered or administered by a medic on the frontlines or a provider at a battalion aid station, depending on the capability of the service member requiring treatment and proximity to the battalion aid station. As no medications designed for this context are currently available, the need for rapid development is critical.

Although the neuropathophysiology between ASRs and ASD/PTSD may differ, it would be reasonable to postulate that medications used for ASD and PTSD may be useful for managing ASRs. Currently, there are two FDA-indicated medications for PTSD, sertraline and paroxetine. Both medications are selective serotonin reuptake inhibitors (SSRIs) and are also used to treat ASD off-label. However, neither is particularly promising for the treatment of ASRs because symptom relief is not immediate upon initiating SSRI treatment, with symptom relief often taking weeks to sometimes months [17]. Another reason is that even once this period has elapsed, many patients find limited therapeutic benefit of SSRIs for trauma-related symptoms [18]. Off-label prescribing of medications to treat long-lasting post-trauma symptoms is common, but SSRIs are not an ideal treatment for ASD because they take weeks to reach therapeutic effect and may be stopped prematurely due to lack of benefit. Other SSRIs, monoamine oxidase inhibitors (MOA-Is), serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, and atypical antipsychotics are most commonly tried [19]. Although off-label use of these medications for the management of ASD/ PTSD may be supported somewhat by research and clinical practice, none of these medications have been evaluated for the management of ASRs. In addition, the side effect profiles of these medications may potentially be problematic in operational settings, particularly for MAOIs and antipsychotics.

Rather than searching among existing treatments for long-term trauma-associated symptoms, we propose that new medication identification efforts be initiated that focus on treatment efficacy for specific ASR symptoms. Because ASR symptoms can present at both ends of the active versus passive spectrum, it is likely that two or more medications may be needed to adequately restore performance, depending on symptom presentation. For example, medications addressing active symptoms may reduce sympathetic activity or amygdalar drive, while medications addressing passive symptoms may activate these mechanisms. In addition to demonstrating efficacy in restoring performance and basic safety and tolerability requirements, several other conditions must be met for medications to be suitable for operational use. For example, medication development efforts must account for the specific needs of service members operating in austere, often hostile, environments with extreme weather conditions and limited storage options. As such, potential solutions must be carefully vetted for shelf stability, ease of administration, risk of abuse/dependence, and side effects that may interfere with operational performance and other undesired effects (e.g., interactions with common medications or foods, diuretic or dehydrating effects). Where and by whom medications will be administered must also be considered (e.g., during operations at frontlines versus at a battalion aid station, and self-administered versus assisted administration, respectively). Additionally, as medics may need to administer medications for ASRs, it is important to consider which medications should be included in a space-limited medic bag or at a battalion aid station.