Efficacy of Cognitive Training When Translated From the Laboratory to the Real World

ABSTRACT

Introduction

Research shows that cognitive performance and emotional well-being can be significantly strengthened. A high-performance brain training protocol, Strategic Memory Advanced Reasoning Training (SMART), was developed by cognitive neuroscientists at The University of Texas at Dallas Center for BrainHealth based on 25-plus years of scientific study. Randomized controlled trials with various populations have shown that training and use of nine “SMART” strategies for processing information can improve cognitive performance and psychological health. However, the multi-week intensive training used in the laboratory is not practical for widespread use outside the laboratory. This article examines the efficacy of SMART when translated outside the laboratory to two populations (military/veterans and law enforcement) that received SMART in condensed time frames.

Materials and Methods

In two translation studies with healthy military personnel and veterans, 425 participants received between 6 and 10 hours of SMART over 2 days. In a third translation study, 74 healthy police officers received 9 hours of SMART over 3 days. Training was conducted by clinicians who taught the nine “SMART” strategies related to three core areas—strategic attention, integrated reasoning, and innovation—to groups of up to 25 participants. In all three translation studies, cognitive performance and psychological health data were collected before and immediately following the training. In one of the military/veteran studies, psychological health data were also collected 1 and 4 months following the training.

Results

In both translations to military personnel and veterans, there were improvements in the complex cognitive domains of integrated reasoning (P < .0001) and innovation (P < .0001) immediately after undergoing SMART. In the translation to police officers, there were improvements in the cognitive domains of innovation (P = .02) and strategic attention (P = .005). Participants in all three translations saw statistically significant improvements in self-reported symptoms of psychological health. The improvements continued among a subset of participants who responded to the later requests for information.

Conclusions

The results of translating to these two populations provide evidence supporting the efficacy of SMART delivered in an abbreviated time frame. The improvements in two major domains of cognitive function demonstrate that strategies can be taught and immediately applied by those receiving the training. The immediate psychological health improvements may be transient; however, the continued improvements in psychological health observed in a subset of the participants suggest that benefits may be sustainable even at later intervals.

INTRODUCTION

The military today is not only operating in the longest continuous period of armed conflict in our nation’s history, but they are doing so with the unprecedented levels of technological challenge and change, with increasing competition for superiority in every domain. For continued success, Warfighters must be more agile, adaptive, and innovative than our adversaries. They must be able to nimbly navigate constantly changing demands and unpredictable factors to make fast, complex, and accurate decisions in life-threatening situations. Police officers, while in a very different context, are nonetheless often having to respond to unpredictable threatening situations in rapid succession, calling upon a skill to quickly decipher the situation and respond with calm. In short, both populations must be equipped with a cognitive advantage to judge a context and respond to meet the quickly evolving demands to save lives.

SMART Description

Over the last decade, research implementing a high-perfo-rmance brain training has shown improvements in higher- order cognitive performance, psychological well-being, and neural health.^1–11 This training, Strategic Memory Advanced Reasoning Training (SMART), is based on 25-plus years of scientific study^12–21 funded by the NIH, DoD, and other sources.

SMART is an evidence-based cognitive training program that is strategy-driven, rather than content-specific. It entails a systematic use of three pivotal executive function cognitive processes of strategic attention, integrated reasoning, and innovation. Facility with these cognitive domains is linked to real-life performance and improved ability to interpret and respond to all types of input, including meetings, briefings, conversations, and contextual ongoings, to mention a few. These cognitive processes are required to execute tasks in everyday life; utilization generalizes to psychological well-being and social adeptness in understanding and responding appropriately to emotions of others. SMART engages the top-down cognitive control of complex data, where concentrated mental effort focuses selectively on important information, while blocking less important input so as to not drain mental resources. Thus, strategic attention strategies help to optimize the brain’s focus by narrowing the amount of data allowed in by giving less attention/effort to banalities, reserving mental resources to achieve the critical task at hand. The integrated reasoning strategies encourage inputs to be quickly encoded, synthesized, and reflected upon to improve performance moment to moment. The ability to hone skills to abstract big picture/ideas/interpretations/actions can guide real-life decisions and actions in a timely, yet calm manner based on the incoming data/input. Added to these, SMART trains individuals to make innovative thinking habitual, with strategies that guide individuals to continually generate multiple, diverse perspectives and seek multiple solutions or approaches to any tasks or problems. Innovation helps to prioritize multiple options to solve any situations. Participants are provided exercises to practice real-life tasks that incorporate strategic attention, integrated reasoning, and innovation strategies as often as possible within the context of their own daily responsibilities and relationships. The goal is to make this type of thinking habitual by processing information in a focused, calm, and deeper level way and to make innovative cognition intentional,¹ with a range of situations from daily responsibilities to hefty decision-making. For example, one exercise used in the training is to generate multiple options to improve a difficult team or personal relationship using the higher-order cognitive strategies to override a default reactive mode of response. Assignments are given to identify a situation/person that triggers an automatic negative emotional response. The trainees practice the strategies by consciously zooming out to take a broader perspective without the burden of emotional details and then utilizing innovation strategies to identify what is good and bad/threatening about the situation and listing numerous possible responses to improve the situation/interaction. What this exercise does is activate the integrated reasoning of the frontal networks to downregulate the automatic, flight-or-fight response of the amygdala.^1,10

Prior Research

The efficacy of SMART for improving higher-order cognitive functions has been demonstrated in nine randomized controlled trials,^{3,10,15–18,20–22} the two most comprehensive of which were the Healthy Adults study and the Traumatic Brain Injury (TBI) study. The Healthy Adults study was conducted following review and approval by the Institutional Review Boards at The University of Texas at Dallas, the University of Texas Southwestern Medical Center, and Cooper Institute (registered at ClinicalTrials.gov, NCT# 00977418).^1–5 Cognitively normal adults over 56 years of age were randomized into a cognitive training cohort (n = 19), a physical exercise group (n = 19), or a non-intervention, wait-list control group (n = 20). The cognitive training group participated in 12 hours of SMART, plus 24 hours of at-home exercises (total = 36 hours) over a 12-week period; the physical exercise group participated in 36 hours of physical training over a 12-week period. The cognitive training cohort showed statistically significant improvements in integrated reasoning (P = .01), working memory (P = 0006), and innovation (P = .014) across three time points from baseline to mid-training to 12 weeks from start. Further, there were improvements in functional connectivity of the Central Executive and Default Mode Networks, which corresponded with gains in integrated reasoning and innovation.^1,2 Psychological health was not assessed in this study.

The TBI study was conducted following review and approval by the Institutional Review Boards at The University of Texas at Dallas and the University of Texas Southwestern Medical Center (registered at ClinicalTrials.gov, NCT# 01552473).^6–11 After providing written informed consent, adults with mild symptoms of chronic-phase traumatic brain injury were randomized into a cognitive training cohort (n = 31) and an active control (n = 29). The cognitive training group participated in 18 hours of SMART over a 12-week period, while the active control group participated in 18 hours of the BrainHealth Workshop, an education-based workshop providing information about the brain and approaches to keeping it healthy. The cognitive training cohort showed statistically significant gains in cognitive performance over the active control group on integrated reasoning (P = .02), working memory (P = .002), and task switching (P < .001). With regard to psychological health, the SMART group showed significant reductions in depressive (P = .003, d = 0.97) and stress-related (P = .004, d = 0.94) symptoms.⁶ The SMART-trained group showed gains in self-reported real-life function as well.

Although the results of the clinical trials were encouraging, to be able to scale SMART to the military and police officers, efficacy in a phase I trial must be demonstrated outside the laboratory environment. These groups, in particular, have unpredictable and uncontrollable demands on their time, which restrict availability for both training and data collection.

Hypothesis

This article reports on the translation of the SMART brain training protocol out of the laboratory and applied to two populations: military veterans and police officers. In both translations, the number of hours of cognitive training and the period of time over which the training occurred were dramatically reduced, as compared to the prior randomized controlled trials. We hypothesized that (1) post-training outcome measures would show statistically significant improvements in cognitive functions of strategic attention, integrated reasoning, and innovation and (2) post-training outcome measures would demonstrate improvements in self-reported symptoms of psychological health.

METHODS

There were two translational studies for military populations, both of which included veterans, reservists, National Guard, and active duty soldiers. Both studies were approved by the Institutional Review Board at The University of Texas at Dallas. Participants in both studies were recruited through the Center for BrainHealth website, Veteran Service Organizations, and fliers distributed at public events held at the Center for BrainHealth.

In the first study, 246 military personnel and veterans participated in SMART, and in the second study, 179 additional military personnel and veterans participated in SMART. The training schedule varied from 6 to 10 hours to accommodate external schedule constraints, with all participants consistently receiving the first 6 hours of training within 1 week, and some returning for an additional 3- to 4-hour session 4 weeks thereafter. During the first 6 hours of training, the core SMART strategies for strategic attention, integrated reasoning, and innovation, each strategy composed of three components, were taught and practiced. About 60% returned for a 3- to 4-hour session 4 weeks later, where they were given a refresher briefing of the core strategies, additional practice exercises, and opportunities to ask questions based upon their experiences in applying the strategies during the previous 4 weeks. The attrition rate of approximately 40% at this 1-month session was due to conflicts with participants’ unpredictable schedules. All training sessions were conducted in an interactive workshop with up to 25 participants and two trainers, at least one of which was a speech-language pathologist (Appendix). The second trainer was either another speech-language pathologist, or “subject-matter expert,” i.e., an individual with history serving in the military.

The police officer translation was conducted following review and approval by the Institutional Review Board at The University of Texas at Dallas. The leadership command from a police department requested SMART as a professional development activity; the research team had no involvement in recruitment.

In this translation, 74 police officers, aged 28-60 years, ranging in rank from Senior Corporals to Chief of Police underwent 9 hours of SMART, with the first 6 hours of training in 3-hour blocks over 2 consecutive days, and the last 3-hour block delivered 4 weeks later. As with the military translations, all core SMART strategies were taught and practiced in the first 6 hours of training; the subsequent 3 hours were used to refresh the learning on the SMART strategies, provide additional practice exercises, and answer questions. All training sessions were conducted with two trainers. The primary trainer was a speech-language pathologist. The secondary trainer was, again, an individual with history serving in the military, since an experienced SMART trainer with subject-matter expertise in law enforcement was not available.

For all three translations, participants were required to be healthy adults over the age of 18 years and native speakers of English, as the language for which assessments were developed and normed. No exclusions were made based on race or gender. Table I lists basic demographics data from all three translation studies.

TABLE I.

Demographics of Translational Studies

Demographics
	First military/veteran translation	Second military/veteran translation	Police officer Translation
Number of participants	246	179	74
Age	18-85 (M = 39.5, SD = 13.5)	20-85 (M = 44.8; SD = 14.7)	28-60 (M = 45.2; SD = 8.3)
Gender	154 male 55 female 38 NA	118 male 42 female 19 NA	32 male 42 female
Service status	16 active duty 69 reservists 114 veteran 1 ROTC 36 retired 1 active duty/retired 1 active duty/reserve 2 reserve/veteran 7 NA	25 active duty 15 reservists 104 veterans 30 retired 5 NA	Senior Corporals to Chief
Years of service	1-45 (M = 10; SD = 8.5)	1-30 (M = 10.1, SD = 8.1)	NA
Years of post-high school education	None—14 1 to 4-112 5 to 7-45 >8-30 NA—46	None—6 1 to 4-72 5 to 7-42 >8-25 NA—34	1 to 4-51 5 to 7-21 >8-1 NA—1

Abbreviation: ROTC, Reserve Officers’ Training Corps.

For all three translation studies, pretraining and post-training data were collected. For the first military training, psychological health data were solicited from all participants at the 1- and 4-month time points following training. Table II lists the assessment tools used in all three translation studies. All of the test instruments were standard except for the Test of Strategic Learning (TOSL), which was developed at The University of Texas at Dallas’ Center for BrainHealth.²² The TOSL was developed to assess real-world complex cognitive functions in healthy individuals who require synchronization of multiple cognitive processes simultaneously. The multidimensional aspect of TOSL helps to address the hurdle of current neurocognitive measures that were developed primarily to detect impairments of specific cognitive domains, not to assess the upward potential of human performance optimization on tasks requiring cognitive systems working together. The cognitive domains assessed by TOSL include strategic attention to quickly sort relevant information, integrated reasoning to adeptly boil complex ideas into the essence, and adaptive generative capacity of innovative possibilities. The TOSL does not suffer from ceiling effects observed in traditional neuropsychological tests, and it has been found, in combination with a brief test of proverb interpretation, to have both superior specificity and sensitivity to the Wechsler’s similarities test of executive functioning.^22,23

TABLE II.

Outcome Measures of Translation Studies

	First military/veteran	Second military/veteran	Police officers
Outcome measures
Integrated reasoning	Proverb interpretation26,27	Proverb interpretation	Proverb interpretation
Selective attention	Visual selective learning (VSL)28	VSL	VSL
Innovation	Test of Strategic Learning (TOSL),22 Part II	TOSL, Part II	TOSL, Part II
Depression	Depression, Anxiety, Stress Scale-21 (DASS21-D)29,30	Beck Depression Index31	DASS21-D
Anxiety	DASS21-A	Beck Anxiety Index32	DASS21-A
Stress			DASS21-S
Overall well-being	Satisfaction with Life survey33	Quality of Life survey34
Resilience	Connor-Davidson Resilience Scale35

Statistical Analysis

Each of the outcome measures (dependent variables) listed in Table II was modeled using standard linear mixed effects models to assess the efficacy of cognitive training over time. The models included pretraining, immediate post-training and, in the case of the first translational veteran sample, 1-month and 4-month post-training sessions. Two variance components, one due to variability within subjects and one due to variability across subjects, were included and estimated by restricted maximum likelihood. Primary interest was in measuring mean change from the pretraining session (baseline), and we hypothesized that cognitive training would improve mean assessment measures in post-training sessions relative to baseline. Inference was based on t-statistics for all change-from-baseline contrasts. The models were implemented in the R statistical computing language (http://r-project.org), and significance levels were set at .05.

RESULTS

Military and Veteran Translation Studies

Both groups in the military translation studies showed improvement in higher-order cognitive functions and psychological health. In the first translation to the military, 200 of the 246 participants participated in both pre- and post-training assessments. Post-training testing indicated significant improvements in integrated reasoning (P < .0001, d = 0.43) and innovation (P < .0001, d = 0.48), with no significant improvements in strategic attention (P = .15, d = 0.1). There was also a significant decrease in self-reported symptoms of stress (P < 0.0001, d = 0.62), depression (P < .0001, d = 0.5), and anxiety (P < .0001, d = 0.36). Self-reported satisfaction with life was improved post-training (P < .0001, d = 0.41), as was resiliency (P < .0001, d = 0.29). None of the participants reported symptoms in the range to be diagnosed with significant mental health issues, but nonetheless, improvement in a positive direction to reduce symptom complaints was noted. Results are summarized in Table III.

TABLE III.

Summary of Results

	Pretraining		Post-training
Outcome measure	Mean	SE	Mean	SE	P-values
First military/veteran translation study
Integrated reasoning	2.86	0.09	3.64	0.11	<.0001
Selective attention	52.91	1.26	55.32	1.49	.15
Innovation	5.29	0.16	6.94	0.22	<.0001
Depressionaa	4.46	0.26	3.05	0.20	<.0001
Anxietya	4.08	0.25	3.06	0.21	<.0001
Stressa	7.22	0.27	5.22	0.24	<.0001
Overall well-beinga	22.31	0.46	24.35	0.43	<.0001
Resiliencea	74.07	0.93	76.86	0.96	<.0001
Second military/veteran translation study
Integrated reasoning	2.90	0.09	3.55	0.12	<.0001
Selective attention	51.55	1.38	50.77	1.62	.63
Innovation	5.27	0.19	6.56	0.21	<.0001
Depression	14.39	0.98	11.83	0.88	<.0001
Anxiety	11.17	0.84	8.73	0.86	<.0001
Stress	Not assessed
Overall well-being	78.51	1.34	83.48	1.44	<.0001
Resilience	Not assessed
Police officer translation study
Integrated reasoning	4.43	0.25	4.34	0.28	.67
Selective attention	46.83	3.14	56.04	3.20	.005
Innovation	6.09	0.36	7.21	0.40	.02
Depression	2.34	0.24	1.61	0.25	.004
Anxiety	1.87	0.24	1.51	0.26	.12
Stress	5.60	0.38	4.56	0.37	.007
Overall well-being	Not assessed
Resilience	Not assessed

a

See Fig. 1 for 1- and 4-month follow-up data.

DASS21, Depression, Anxiety, Stress Scale-21; SMART, Strategic Memory Advanced Reasoning Training.

As shown in Fig. 1, the psychological assessments were repeated 1 month post-training (69 participants responded) and four4 months post-training (77 participants responded). Across all measures, scores continued to improve, with the statistically significant improvements still occurring between 1 and 4 months following training in all psychological measures except for anxiety.

FIGURE 1.

Psychological health and well-being results in the first translation to military personnel and veterans show statistically significant improvements that are sustained or continuing to improve up to 4 months following learning the Strategic Memory Advanced Reasoning Training strategies (t-test: ***P < .0001; *P < .05; ns indicates that results were not significant).

The results of the second translation to 179 military personnel and veterans were in the same domains as the first, with post-training measures indicating statistically significant improvements in integrated reasoning (P < .0001, d = 0.44) and innovative cognition (P < .0001, d = 0.45), and no significant improvement in strategic attention (P = .63, d = 0.03). Stress was not evaluated in this second translation, but participants reported a decrease in symptoms of depression (P < .0001, d = 0.40) and anxiety (P < .0001, d = 0.34). They also reported an improved assessment of quality of life (P < .0001, d = 0.36). Results are summarized in Table III.

Police Officer Translation Study

Similar to the military translation studies, the police officers also showed improvements in higher-order cognitive functions and psychological well-being. The 74 police officers showed improvements in innovative cognition (P = .013, d = 0.47) and strategic attention (P = .005, d = 0.54). This translation did not, however, yield an improvement in integrated reasoning (P = .79, d = 0.05). In the law enforcement population, symptoms of anxiety did not improve significantly following the training (P = .12, d = 0.29), but they did report reduced symptoms of depression (P = .004, d = 0.55) and stress (P = .007, d = 0.52). Results are summarized in Table III.

DISCUSSION

Translating SMART outside the laboratory required moving from SMART delivered over extended hours and time course (i.e., 18-36 hours over a 12-week period), to an abbreviated time frame of 6 to 10 hours over a 4-week period. We sought to determine whether participants could learn the core cognitive strategies in a reduced time that would improve their complex cognition and generalize to psychological well-being, despite limited opportunities for practicing the strategies during training. Both military translation studies support the hypothesis that participants of these SMART workshops would show gains to cognition function, as their performance on measures of integrated reasoning and innovation showed significant improvement. Concerning the police officers, they demonstrated gains in innovation, the same domain as the military groups, but unlike the military group showed significant gains in strategic attention. The police officers failed to show improvements in the domain of integrated reasoning, a domain in which gains were manifested by both military groups.

Improvements in cognitive performance immediately following training indicate that participants understood and immediately applied the SMART strategies to improve cognitive function (i.e., integrated reasoning and innovation and, to a lesser degree, strategic attention). Without follow-up data, we do not know whether the SMART strategies endured beyond the training effects. We recognize that what is important in training is to habituate utilization of the strategies to achieve sustained improvements in cognitive performance and yield concomitant neural changes as observed in our clinical trials.^{1–3,5–9,11}

All three translation studies supported the hypothesis that post-training self-report measures would indicate improvements in psychological well-being. Although all the participants of three translation studies indicated, on average, good psychological health, these improvements were, in fact, similar to other studies involving group-based cognitive behavioral therapy directly targeting depressive symptoms.^24,25 These results suggest a potential for some trainings, such as SMART, to intercept early psychological symptoms with strategies to mitigate the complaints from increasing in symptom severity. Such a possibility would need to be validated in longitudinal studies but certainly offer hope that preclinical depression and stress should be assessed and not delayed until full diagnosis is made. The improvements observed immediately following the training may reflect solely the benefits of social interactions during the training and have nothing to do with utilizing cognitive strategies to overcome hurdles.²⁵ One point suggesting it may be adoption of strategies and not just the time with social interaction is implicated by the evidence that the first translation military/veteran participants’ responses to the neuropsychological well-being assessments at 1- and 4-months following training showed that improvements continued long after the social activity of the training. We cautiously interpret our results regarding continued improvement in psychological well-being given only a small percentage of the original cohort (31%) responded to the 4-month post-training questionnaires. It may be that those who did respond were those who enjoyed and/or benefited from the training. Nonetheless, this preliminary data suggest that long-term improvements in psychological well-being may be due to strategy application and not merely socialization, as supported by our TBI randomized controlled trial.⁶ In this randomized controlled trial, the SMART cohort and the active control group had equivalent levels of socialization, but improvements in psychological health were specific to the SMART cohort.¹⁰

Limitations

The present work represents a necessary first step of phase I pilot studies to explore whether a condensed shorter-term (reduced hours and days) training delivered to the military and police officers in their own training context would show benefits. We acknowledge that translational research inevitably has significant limitations, making it difficult to address the possible factors that may have contributed to the gains reported. The motivation for these pilot trials was strong evidence from prior laboratory randomized trials that showed significant gains in cognition, neural health, psychological well-being, and real-life function.

One limitation is sorting out whether the gains were due to SMART participants paying more attention to how they process information or to actual application of the SMART strategies. We are cautiously optimistic that the results may be valid, since similar findings emerged across the three pilot translations, and previous randomized trials showed similar gains among participants in SMART, but not in active control groups. Nonetheless, a good next step from the present pilot studies would be a randomized field trial against another training approach, such as mindfulness training or a brain health workshop that delivers information about general ways to keep your brain healthy.

A second limitation in these studies was attrition. In the military translation studies, we had two time periods to consider attrition. The first was immediate and had an attrition rate of roughly 20% between the pre- and post-training data collections. This rate is fairly modest and, in fact, common in longitudinal studies. Further attrition occurred in our samples which obtained data 1 and 4 months following the training, with attrition rates of 40% and 69%, respectively. Some contributing factors could be that participants were not incentivized (e.g., payments), and e-mailed requests for information are easily disregarded or, perhaps, concerning to individuals from a privacy standpoint.

A third limitation is the lack of detailed histories from study participants. In both the military and police officers populations, there is a reluctance to provide demographic information or medical histories, so a robust comparison of the participants to those in randomized controlled trials was not possible. This type of comparison would be particularly interesting in both of the translation populations, where traumatic events are common and can result in post-traumatic stress and both transient and chronic physical and psychological health issues. The reluctance to reveal personal information in real-life contexts is understandable, given the persistence of stigma that is pervasive about cognitive performance being assessed. Until we update the outdated notion of a fixed mindset and labels that identify problems rather than the upward potential of the human brain to improve, this will be a constant concern.

Future Directions

The translations of SMART from the laboratory to the “real world” in the form of 6- to 10-hour in-person “workshops” offer a promising first step toward scalability. However, even the workshops are labor-intensive and can only be attended by participants who have the ability to set aside time to participate. Moreover, neuroplastic changes require habituation of the SMART strategies, something that is difficult to accomplish with just a one-time workshop. To address these limitations, BrainHealth researchers have developed an online version of SMART, which replaces the in-person delivery with a series of short (1-2 minutes) videos and quick questions/exercises. Individuals receiving the training online will also receive access to additional content, both related to the strategies and related to lifestyle factors influencing brain health. The additional content will be “packaged” with questions and exercises that transform the content from being something that is passively viewed to something in which the participant actively engages as a brain training exercise. The “micro-learning” format for SMART improves the accessibility to SMART and supports habituation of SMART strategies, but it does so at the cost of the social activity of in-person training. A pilot of online SMART is ongoing, which will provide data to quantify its efficacy.

CONCLUSION

Military and law enforcement personnel work under increasing pressure to make faster and more accurate complex decisions in unpredictably risky environments. Hence, equipping them as effectively as possible, not only with the appropriate gear and technology but maybe even more importantly with the tactical cognitive tools, is a vital line of research. This article offers preliminary evidence that a research-based, high-performance brain training that had previously been restricted to the laboratory (with other populations) could yield consistent results of improved cognition and self-reported symptoms of psychological health when delivered in an abbreviated format with military veterans and active duty law enforcement personnel. As these individuals significantly improved from baseline, the present results also provide valuable exploratory evidence that cognitive training is not limited to remediating deficits but can be an effective performance-enhancing tool. More work is needed to understand the generalizability of gains from a short-term workshop to the varied demands out in the field.

ACKNOWLEDGMENTS

The University of Texas at Dallas’ Center for BrainHealth would like to recognize the law enforcement and military personnel who participated in this research and give so much to keep our nation safe.

SUPPLEMENTARY MATERIAL

Supplementary material is available at Military Medicine online.

FUNDING

Five studies are included in this article. Funding sources were as follows: (1) Healthy Aging Study—Funded by the National Institute of Health, grant RC1-AG-035954; (2) Traumatic Brain Injury Study—Funded by the US Army Medical Research Acquisition Activity (grant no. W81XWH-11-2-0194); (3) The first translation study to military personnel and veterans was funded by the State of Texas Health and Human Services Commission’s Texas Veterans and Family Alliance Grant Program (grant no. 529-16-0088-00003); (4) The second translation study to military personnel and veterans was funded by the State of Texas Health and Human Services Commission’s Texas Veterans and Family Alliance Grant Program (grant no. 519-17-0058-00008); (5) The translation to law enforcement personnel was funded through philanthropic donations from the community of Dallas, Texas.

Author notes

Presented as an abstract at the 2019 Military Health System Research Symposium, Orlando, FL; MHSRS-19-01666.

The opinions or assertions contained herein are those of the author/speaker and are not to be construed as official or reflecting the views of the Department of Defense, the Uniformed Services University of the Health Sciences, or any other agency of the U.S. government.