Wayne Chappelle, Psy.D ., ABPP Kent McDonald, Col, USAF, MC, FS Neuropsychiatry Branch

1. Every Airman a Force Multiplier Occupational Health Stress Screening for Remotely Piloted Aircraft & Intelligence (Distributed Common Ground System) Operators Wayne Chappelle, Psy.D., ABPP Kent McDonald, Col, USAF, MC, FS Neuropsychiatry Branch USAF School of Aerospace Medicine Wright-Patterson Air Force Base, OH

2. BACKGROUND • Questions & concerns from Air Force (AF) leadership on the impact on psychological health of operators • Unit commanders (CCs) & flight docs • operational tempo (manning, hours, shift work) • systemic stressors (involuntary assignments, hold on personnel moves, career progression concerns). • geographical location (commute, limited access to services) • human-machine interface & developments in technology • nature of the work (deployed in garrison w/domestic life) • High interest from Headquarters/Chief of Staff of the AF, AF Medical Operations Agency (post-traumatic stress disorder, PTSD), major command chiefs of aerospace medicine (MAJCOM/ SGPs) (Air Combat Command/AF Special Operations Command), Intelligence, Surveillance, & Reconnaissance Agency chief of aerospace medicine

3. BACKGROUND • Research needed to fully understand nature of remotely piloted aircraft (RPA) & intelligence (Intel) operations and impact on operator health • Supports aeromedical consultations for RPA operators to: • USAF/SG: RPA aeromedical policy/standards • MAJCOM/SGPs: Aeromedical Consultation Service (ACS) RPA operator medical consultations in neurology, psychiatry/ psychology, internal medicine • Enhance aeromedical screening/selection of nonpilot (e.g., beta test) RPA pilot applicants

4. BACKGROUND • Main concerns are impact of operations on mental health (MH) of RPA precision strike operators (Predator/Reaper) within the media and supporting units (Intel & Cyber ops) • Subjective stress • Occupational fatigue • Clinical distress • PTSD • How do Predator/Reaper crew compare with: • Noncombatant control groups (enlisted/officer) at same geographic locations • Distributed Common Ground System (DCGS) Intel operators & non-Intel control groups

5. REQUIREMENTS • Line CC study implementation requirements: • Minimal interference on line operations • Quick, flexible administration • Immediate feedback & recommendations on solutions • Installation & squadron specific solutions • Air Force Specialty Code specific solutions • Collaborative meeting w/line CCs, MAJCOM representatives, medical leadership/providers

6. SCREENING • 10-15 minutes to complete • Multiple choice, write-in responses • Demographics (personal & occupational) • Sources of stress (write-in & rate) • Standardized measures/instruments • Occupational fatigue • Clinical distress • PTSD • Nonstandardized items (Likert rating scales) • Subjective stress • Medical & mental health service utilization • Alcohol usage, relationship changes, job satisfaction

7. STRESS SURVEY • 2010 • Brief, yet comprehensive • Qualitative items assessing sources of stress • Evaluation of healthcare utilization & changes in physical and psychological health • Standardized instruments: burn-out, clinical distress, PTSD • Includes: active duty (AD), Air National Guard (ANG), Reserves- Predator/Reaper/Global Hawk • 2011 (modifications) • Web-based version to increase access/ease of administration • Increased focus items on medical care utilizations and prescription medications • Includes: AD, ANG, Reserves & Intel, Cyber operators

8. RESULTS (SUBJECTIVE) % verbally reporting high operational stress Global Hawk sensor operators (48%) DCGS Intel operators (44%) Global Hawk pilots (44%) Noncombatant RPA control group (36%) Percent Reporting High Operational Stress Non-Intel control group (20%) Mission Intel Coordinators (MICs) Operator

9. RESULTS (Sources of Stress) Active Duty RPA and Intel (Preliminary) • Shift work, schedule changes • “Shift changes every month.” • “Strange hours, working weekends, • shift changes, all impact quality of life.” • RPA operators • “Rotating every 30 days” (RPA AD). • Long hours & low manning • “Too much to do, not enough people!” • “Can’t make plans due to low manning.” • “Never ending surge & restricted leave.” • Nature of job • “Sustaining vigilance is mind numbing.” • “Too much monotony/Ground Hog Day!” • Maintaining relationships w/family • “Not being around to do stuff at home.” • “Family care is complicated due to shift • work.” • Relational conflict w/ Leadership & co-workers • “Not enough time for team building; communication gap w/ leadership” • Deployed In-Garrison (nature of job) • “Still expected to do admin minutia • despite deployed status.” • “6 days on w/1 day devoted to • admin.” Those surveyed did not list exposure or participation in combat as a top occupational stressor.

10. RESULTS (BURNOUT) % reporting high emotional exhaustion (one or more times a week) from work Global Hawk sensor operators (34%) DCGS Intel operators (29%) Percent Reporting Emotional Fatigue/Burnout from Work Noncombatant RPA control group (16%) Global Hawk pilots (11%) WebHA results for AD RPA operators (9%) Non-Intel control group (7%) Operator

11. RESULTS (CLINICAL DISTRESS) Stress levels crossing the threshold into a high emotional distress Operation Iraqi Freedom (OIF) soldiers (28%) Global Hawk sensor operators (25%) DCGS Intel Operators (17%) Percent Reporting Clinical Distress Noncombatant RPA control group (15%) General civilian population (13%) Non-Intel operator control group (6%) WebHA results for AD RPA operators (4%) Operator Approximately 65%-70% of those with clinically significant distress report they do not use MH support services (i.e., chaplain, counselor, one-source).

12. RESULTS Hours worked and % of operators reporting burnout & clinical distress Overall results for RPA and Intel operators Lack of perceived control over work environment, duties/schedule is likely a contributing factor to the onset of burnout/distress Percent Reporting Burnout and Clinical Distress 14% of Participants 53% of Participants 27% of Participants 6% of Participants Hours Worked Per Week Operators working over 50 h/wk are at higher risk

13. RESULTS (PTSD) % reporting to be at high risk of PTSD OIF/OEF returning soldiers (12% to 17%) Global Hawk sensor operators (10%) Percent Reporting PTSD Symptoms General civilian population(5%) DCGS Intel operators (3%) Non-Intel control group (2%) Operator Noncombatant RPA control group (1%) WebHA results for AD RPA operators (.5%) Global Hawk pilots (0%)

14. RESULTS (PTSD) • Typical Combat PTSD • Clear/present danger & threat to life/safety (fear/horror/helplessness) • Symptoms of hypervigilance, avoidance (emotional numbing), re-experiencing (nightmares, flashbacks) • Focus on internal & external threat • RPA operator… post clinical distress… existential “conflict” • “Aerial Sniper” status/discomfort (guilt/remorse/role conflict) • Psychological identification/attachment to combatant • Collateral damage/post-battle damage assessment • Focus on internal conflicts PTSD Symptoms Existential Conflict

15. DISCUSSION • At-Risk Operators • “Stressed to extremely stressed” (17x more likely) • Shift work with frequent changes (5x more likely) • Chronic/long work hours (50+ h/wk) • Rank & age (18-35; enlisted 4x more likely) • High level of emotional exhaustion/fatigue • Career & future prospect concerns • High level of cynicism about duties • Single or married/children & family troubles • Supervisor w/conflict with others at work Finding: Greater the level of distress…, the more concern there is for seeking MH services

16. RECOMMENDATIONS • First Tier – Line recommendations: • Optimize work/rest cycles (4 on 3 off/less than 50 h) • Optimal shift rotation schedules • Unless first two are addressed, all other recommendations are considered simple “band-aids” • Stress inoculation briefings during training • Base/Sq/Partner-relational/family retreats, events, and off-site workshops • CC awareness “last 3 months, stressed-extremely stressed”

17. RECOMMENDATIONS • Second Tier – Medical treatment facility recommendations: • Access, continuity of care, and identification of at-risk airmen • Single/dedicated medical/MH provider (Flight Surgeon (FS) model of care) assigned to specific Sq/units with Top Secret clearance • Implementation of OQ45 screener in medical clinic appropriately briefed to increase self-disclosure & identify at-risk airmen • Experienced MH provider (FS model) briefing units on operational stress and co-located in medical clinic.

18. RECOMMENDATIONS • Third Tier – Aeromedical recommendations: • Retain high selection/screening standards • RPA operators to meet aeromedical criteria (cognitive & noncognitive aptitudes) and effectively screened upon career field entry • Aeromedical Adaptability Rating with initial physicals or recommendations for cross training • Weapons deployment • Occupational awareness • Air Crew Standards Working Group • Medical standards • Medical fatigue management tools • Crew rest requirements • Review of Selective Serotonin Reuptake Inhibitors (anti-depressants) policy

19. QUESTIONS