Psychological safety as a mediator between role overload and depression under conditions of unit cohesion

According to the World Health Organization (2024), poor working environments that include excessive workloads may be detrimental to mental health. In 2019, an estimated 15% of working-age adults were living with a mental disorder. In addition, depression and anxiety account for the loss of approximately 12 billion working days globally, resulting in approximately US$1tn in lost productivity. These figures highlight the costs associated with workplace-related mental health challenges.

Given these outcomes, it is critical for organizations to better understand the conditions that influence employee well-being and functioning. In particular, the balance between job demands and job resources, as outlined in Job Demands–Resources (JD-R) theory (Bakker & Demerouti, 2007), provides a useful framework for examining how organizations can mitigate mental health risks and enhance organizational effectiveness and as such serves as the framework for the current study. Job demands are elements of the job that require ongoing effort and come with psychological and/or physiological costs. Resources are elements of the job that may include psychological, physical, social or organizational factors that enable employee goal achievement and the moderation of job demands. The authors note that this theory offers flexibility in how it is applied as demands and resources are dependent upon the specific organization or occupation that is studied.

Job demands may have a significant impact on work-related stress, social relationships and mental health. To determine how organizational and individual factors contribute to health outcomes, the current study examined role overload, unit cohesion, and psychological safety and their relationships to depression in service members, who by their profession are often subject to high job demands.

When employees work under conditions of high demand, dysfunctional behaviors may arise such as poor communication, conflicts and decreased performance (Bakker, Demerouti, & Sanz-Vergel, 2023). Thus, high job demands, such as role overload, may function as a situational pressure facilitating mental health problems even under conditions normally expected to ameliorate such tensions, such as perceived unit cohesion and perceived psychological safety. This aligns with the idea that health may be impaired through a depletion of resources over time and that demands and resources jointly impact well-being. In a review of JD-R theory, Bakker et al. (2023) indicated that burnout may have symptoms that overlap with depression. However, as Hakanen, Schaufeli, & Ahola (2008) note in their study of the JD-R model, while burnout is widely studied, depression is not. However, depression may be a long-term outcome of burnout and thus also signify a depletion of resources due to high job demands. Given the human and economic toll indicated by the World Health Organization (2024), studying depression, given that some symptoms overlap with burnout, may be a logical extension of the current research on job demands. Understanding whether or not job demands relate to mental health outcomes such as depression and under what conditions may provide greater insight on what resources may best help employees navigate workplace demands.

The literature examining the relationships among role overload, perceived unit cohesion, and perceived psychological safety and depression is limited. Role overload refers to a person’s perception that the occupational demands they encounter exceed their capacities such that their psychological health and work performance may be negatively affected (Tang & Vandenberghe, 2021). Psychological safety is defined as the perception of consequences associated with taking risks in the workplace (Edmondson & Lei, 2014). Cohesion reflects members of a team feeling connected and committed to one other (Passmore, Tee, & Gold, 2025). Finally, depression is a mood disorder characterized by sadness and a loss of interest and affects how a person thinks, feels and behaves (DSM-5, 2013).

Several studies have assessed the relationship between role overload and mental health across various occupations suggesting that role overload is associated with poor mental health outcomes (Choi et al., 2020; De Beer, Pienaar, & Rothmann Jr, 2016; Weigl et al., 2016). In a cross-sectional study of nurses, those who had the highest amount of work overload and least amount of supervisor support experienced increased depression (Weigl et al., 2016). Supervisor support has also played a role in other studies examining mental health outcomes. Results from a study that involved employees from accounting firms indicated that increased work overload was associated with negative impacts on mental health and burnout mediated the relationship of work overload and supervisor support on mental health (Su, Gao, Luo, & Luo, 2018). A third study found that supervisor support and perceived team climate moderated the effect of work overload on mental health, such that employees that perceived low support reported more negative health effects (Alfes, Shantz, & Ritz, 2018). Finally, a longitudinal study of employees from a financial services organization found that work overload at time 1 predicted burnout at time 2 and predicted psychological ill-health at time 3 (De Beer et al., 2016).

While the demands placed on employees due to work overload can be a risk factor for depression, it is important to recognize resources that may mitigate the impacts of role overload. A study examining 106 factors known to be associated with depression identified the ability to confide in others as the most important protective factor (Choi et al., 2020). Other research suggests that if employees feel safe vocalizing their concerns within their team, they are more likely to feel comfortable under vulnerable conditions and seek help from their teammates (Edmondson, 2011). Psychological safety has been identified as a mediator of organizationally imposed expectations (perfectionism) and depression, such that perfectionism leads to reduced psychological safety and a subsequent increase in depression symptoms (Kim & Lee, 2025). This research underscores that psychological safety (Kahn, 1990; Edmondson & Lei, 2014) may play an important role with respect to the prevalence of depression.

Kahn (1990) notes that factors such as group dynamics, leader behaviors and organizational norms contribute to whether or not an individual experiences psychological safety. In spite of the numerous studies on psychological safety, the relationship between depression and psychological safety has not been widely studied. As Walton et al. (2024) indicate, mental health has not been given due consideration as part of, or a consequence of psychological safety. However, while burnout is different from depression, it is considered a mental health issue. In a study of medical students, an increased sense of psychological safety was associated with less burnout (Bitar, Boman, & Kristoffersson, 2025). In addition, psychological safety was a partial mediator between work environment and burnout in nurse practitioners, with a better environment being associated with increased psychological safety and less burnout (de Lisser et al., 2024).

Cohesion has also been examined as a predictor of positive mental health outcomes in both military and civilian sectors (Anderson et al., 2019; Breslau, Setodji, & Vaughan, 2016; Du Preez, Sundin, Wessely, & Fear, 2012). In a longitudinal study of Marines who deployed to either Iraq or Afghanistan, unit-level cohesion was not predictive of PTSD or depression; however, increases in individual-level cohesion were associated with better mental health outcomes (Breslau et al., 2016). Another longitudinal pre/post deployment study of cohesion and mental health outcomes with Army soldiers indicated that high levels of unit cohesion pre-deployment were associated with a reduced risk of mental health disorders including depression at three and nine months post-deployment (Anderson et al., 2019).

However, not all of the findings regarding cohesion are positive. For example, Griffith (2002) found that while individual levels of cohesion were associated with greater levels of well-being, cohesion at the group level was associated with lower levels of well-being. Thus, examining cohesion solely at the group level, rather than individual perceptions, may overlook other factors (e.g. sense of belonging, self-identity) that may affect performance and member well-being. Forsyth (2021) notes that group members’ perceptions of cohesiveness may be different than how they identify with a group. For example, Rovio, Eskola, Kozub, Duda, & Lintunen (2009) found that although junior league hockey players exhibited high group cohesion, increased pressure to conform led to performance deterioration. Thomas, Hummel, Schäfer, Wittchen, & Trautmann (2022) found that individual perceptions of group membership are influenced by interpersonal mistreatment and that these indicators reduced the protective properties of cohesion through weakened associations between cohesion and depression. Similarly, in Canadian police officers, themes of high group cohesion, high stress and operating under directive leadership were identified as barriers to mental health treatment-seeking (Ricciardelli et al., 2021).

Although the work on each of these concepts is fairly well represented in the literature, research on their interrelationships is more limited. However, findings that do exist suggest that team cohesion may not be beneficial when job demands and exhaustion are high (Bliese & Castro, 2000). Research indicates that while cohesiveness tends to be viewed as positive, the possibility of disclosing problems with team members may result in a negative contagion effect where the team feels higher job demands and greater exhaustion. In another study examining workload and cohesiveness, high cohesiveness did not affect how embedded someone felt with their job when they experienced a high level of work overload; however, cohesion did play a role when the perceived workload was low (Achmadi & Oktrivina, 2023).

Other research suggests that cohesion and psychological safety serve to mediate the relationship between perceived power distance, a potential job demand, (i.e. inequity between those with a higher and lower status) and team effectiveness. Specifically, one study of nursing and medical students demonstrated that as power distance decreased, psychological safety, team cohesion and perceived team effectiveness all increased (Appelbaum et al., 2020). Models developed by Razinskas & Hoegl (2020) also indicate that team-level stressors such as workload may be mediated by variables such as team cohesion at the team level and moderated by variables such as self-efficacy or feeling part of a team at the individual level.

Taken altogether, role overload appears to contribute to mental health outcomes such as depression, with psychological safety potentially acting as mediator. However, the presence of high unit cohesion in contexts of role overload may have a more nuanced effect, serving as a boundary condition for psychological safety. In environments with high job demands, role overload may escalate to exhaustion or burnout, and psychological safety may be diminished for highly cohesive groups due to increased pressure to conform to group norms and not let the team down. This is especially relevant for those individuals who perceive their professional roles to be a core part of their social identity (Tajfel & Turner, 1979). Similar dynamics have been observed in studies of collegiate athletes, where overconformity to role expectations leads some athletes to persist through pain and injury to avoid letting the team down and to not be perceived as weak (Coker-Cranney, Watson, Bernstein, Voelker, & Coakley, 2018; Hughes & Coakley, 1991). Similarly, Marmarosh et al. (2005) found that group cohesion and a member’s identity were highly correlated and protective against depression; however, in a study of task-focused groups, group identification and psychological safety decreased under conditions of elevated task and process conflict (Johnson & Avolio, 2019).

High cohesion may intensify pressure to meet group expectations and discourage individuals from acknowledging personal struggles, which may exacerbate depressive symptoms. Indeed, Magal (2017) discusses how strong bonds in highly cohesive military units and fear of ostracism are associated with self-censorship in reporting misconduct. Ganz, Yamaguchi, Koritzky, & Berger (2021) found moderate endorsement of the military culture to be associated with higher levels of depression, and Jones, Campion, Keeling, & Greenberg (2018) found that 25% of persons reporting high unit cohesion reported more than three items of stigma to mental health care. Although cohesion can promote well-being in some contexts, in others it may undermine psychological safety and worsen mental health outcomes.

Within the JD-R framework, several studies have examined the relationship between job demands and burnout, with many studies indicating that burnout is due to prolonged demands and a lack of resources (e.g. Demerouti & Bakker, 2025; Lesener, Gusy, & Wolter, 2018). Although Demerouti & Bakker (2025) take the position that burnout is conceptually distinct from depression, both represent psychological strain that are evidenced after the effects of job demands are already in motion. Furthermore, burnout reflects an internal state shaped by job demands that are often beyond an individual’s direct control and may also be associated with depression. Thus, the current model focuses on depression as a health issue given its association with burnout and the paucity of research in this area (Hakanen et al., 2008).

In contrast, cohesion and psychological safety may be conceptualized as social resources within the JD–R framework (Demerouti & Bakker, 2023; Nwanzu & Babalola, 2024; Wolter et al., 2019). Unlike many job demands, these resources can be more directly and proactively developed at the individual, team and organizational levels. As such, they may serve a protective function, mitigating the negative psychological consequences associated with high job demands. Thus, among these constructs, psychological safety was chosen to serve as the mediator in the proposed model as opposed to burnout, as it provides a social resource mechanism through which cohesion may be linked to depression. Specifically, this study examines how the social environment associated with psychological safety may affect responses to job demands before negative health outcomes such as burnout and depression may emerge.

In the present study, psychological safety is conceptualized as a climate resource that facilitates interpersonal risk taking, including the expression of voice (Edmondson & Lei, 2014). Voice and other behaviors that arise from psychological safety are not the resources, rather psychological safety is the resource that enables the expression of these behaviors. When psychological safety is high, individuals may be more willing to voice concerns, seek assistance and disclose difficulties, thereby allowing cohesion to function as a protective resource under conditions of role overload. However, when psychological safety is low, employees may be less willing to engage in these behaviors, limiting the protective value of cohesion and potentially exacerbating the psychological consequences of high job demands. Strengthening cohesion and psychological safety may help shape the work environment before adverse outcomes such as depression emerge. However, Demerouti (2025) notes that JD-R theory does not adequately address the resource level that is ideal, as it is possible that a resource may not always be helpful, thus it is possible that under certain circumstances resources may become a demand. Accordingly, the purpose of this paper is to focus on resources that may mitigate or potentially exacerbate the harmful effects of job demands.

Based upon JD-R theory, the model in Figure 1 proposes that role overload reflects the health impairment process of the theory in which job demands, represented by role overload, deplete physical, cognitive and emotional resources that may lead to health issues, specifically depression. In addition, cohesion and psychological safety are resources that reflect the motivational process of the theory whereby work goals may be achieved, learning and development may occur, and work demands may be mitigated (Demerouti, 2025). More specifically, the model depicted in Figure 1 proposes that perceived psychological safety mediates the link between role overload and symptoms of depression, but that perceived unit cohesion moderates the link between role overload and psychological safety.

To better understand how a high-demand environment may relate to mental health, moderated-mediation was used to model the interrelated dynamics between the study variables (see Figure 1). Consistent with the literature, role overload is predicted to be associated with an increase in depression symptoms (Weigl et al., 2016) and perceived psychological safety is predicted to mediate the role overload and depression relationship (H1; Kim & Lee, 2025; Razinskas & Hoegl, 2020). It is also predicted that perceived unit cohesion will moderate the relationship between role overload and perceived psychological safety with a pattern of results that indicate higher perceived unit cohesion as deleterious (H2; Achmadi & Oktrivina, 2023; Bliese & Castro, 2000) to perceived psychological safety, thus substantiating the broader challenges identified in team dynamics under stress (Coker-Cranney et al., 2018; Jones et al., 2018). Building on H1 and H2, a moderated-mediation effect (the indirect effect of role overload on depression through perceived psychological safety) is predicted to be stronger when perceived unit cohesion is high, compared to when it is low (H3; Appelbaum et al., 2020; Magal, 2017; Jones et al., 2018). Thus, this study contributes to the organizational management literature by studying social resources that may work jointly in a manner such that one social resource may constrain another under high job demands. Sustained demands may result in long-term health outcomes such as depression that may affect job performance. Understanding the nuances of these relationships allows for organizations and leaders to design work environments and cultivate resources for optimal outcomes.

Participants consisted of active-duty soldiers from one brigade level expeditionary unit providing combat sustainment operations, force protection and area security. Participation was voluntary and involved the completion of a paper and pencil survey in a garrison (military post), non-deployed environment in 2016. The command allocated a time and place for each soldier to meet with the study team. Soldiers were briefed on the purpose and procedure of the study and handed surveys by the study staff to be returned in envelopes. Unit leadership were not present during the data collection. A total of 92% of the soldiers provided their written informed consent (311 of 339), with 8% (28 of 339) returning blank surveys in their envelopes. Consenters included 241 junior enlisted soldiers, 64 non-commissioned officers (NCOs), and 5 officers; 282 were male, while 197 had no previous deployments to a combat environment, 63 had one deployment, 23 had two deployments, and 27 had three or more deployments. The high response rates and demographics characteristics are similar to large sample studies of military populations collected in garrison facilities (Thomas et al., 2010). The survey was anonymous and took approximately 30 min to complete. The Institutional Review Board approved the research protocol, procedure, consent question and survey.

Depression. Depression was assessed with the 9-item Patient Health Questionnaire (PHQ-9; Spitzer, Kroenke, & Williams, 1999). Items were rated on a four-point scale (0 = not at all to 3 = nearly every day) in terms of the last 4 weeks. Screening positive was based on cutoff scores for severe depression. The Cronbach’s alpha for depression was 0.92.

Role overload. Role overload was assessed using three items from the Michigan Organizational Assessment Questionnaire – Role Overload Subscale (MOAQ-ROS; Cammann, Fichman, Jenkins, & Klesh, 1983). Items were rated on a five-point scale (1 = strongly disagree to 5 = strongly agree). Cronbach’s alpha for the scale was 0.91.

Perceived unit cohesion. Unit cohesion was assessed with three questions adapted from Podsakoff & MacKenzie (1994). Questions (“The members of my unit are cooperative with each other;” “The members of my unit know they can depend on each other;” and “The members of my unit stand up for each other”) were rated on a five-point scale (1 = strongly disagree to 5 = strongly agree). Cronbach’s alpha for the scale was 0.88.

Perceived psychological safety. Psychological safety was assessed using seven items developed by Edmondson (1999). Sample items include, “If you make a mistake in this team, it is often held against you” [reverse coded], and “It is safe to take a risk on this team.” Items were measured on a five-point scale (1 = strongly disagree to 5 = strongly agree). Cronbach’s alpha for the scale was 0.68.

Analysis of missing data (Enders, 2010) revealed 28 patterns of missingness with no single variable exceeding 11% missing. Little’s MCAR test: χ² (563, 311) = 606.11, p = 0.101, indicates data were missing completely at random. Multicollinearity was examined with all variables showing low variance inflation factor values less than 1.5. Descriptive indices (i.e. means and standard deviations) along with correlation results of measured variables are presented in Table 1. To explore moderation and moderated-mediation PROCESS macro in R with robust bootstrap statistics consisting of 10,000 bootstrap observations with two-sided statistical tests was used. Statistical significance was determined if zero was not part of the confidence interval. Mean centering was used for continuous variables under conditions of moderation analysis. All continuous variables fit within acceptable levels of skewness (between −2 and +2) and kurtosis (between −7 and +7; Hair, Black, Babin, & Anderson, 2010). Common method variance bias was assessed using Harman’s (1967) single factor test and identified that bias was less than 50% of the total variance which is within the acceptable threshold.

An ANOVA showed that those reporting two deployments reported higher depression (M = 8.25, SD = 8.08) than those who reported zero deployments (M = 4.27, SD = 5.89), F(3, 274) = 4.04; p = 0.01; no significant differences by rank or number of deployments were found for role overload or unit cohesion.

Figure 2 illustrates a negative relationship between role overload and perceived psychological safety. Those reporting high unit cohesion show a reduced association with perceived psychological safety in comparison to those reporting low perceived unit cohesion. Spotlight analysis revealed that under conditions of increasing role overload high perceived unit cohesion accounted for a decrease in perceived psychological safety (t = −4.93; p = 0.001) while low perceived unit cohesion did not (t = −1.46; p = 0.141).

To test H1 (see Table 2) the mediation of the effect of perceived psychological safety on the relationship between role overload and depression using the PROCESS Model 4 was examined (Hayes, 2022). Table 2 illustrates a significant overall indirect effect of role overload on depression through perceived psychological safety; thereby corroborating H1. PROCESS Model 7 (Hayes, 2022) creates two models that were used to examine the moderating role of perceived unit cohesion on the link between role overload and perceived psychological safety (H2), and the indirect effect on depression (H3). In both models of PROCESS 7, rank and multiple deployments were used as control variables for analytical purposes as has been the practice with prior research. In addition, other studies have included these variables as they have been associated with depression (Chou et al., 2016; Shen, Arkes, & Williams, 2012). Results from the first step of the model demonstrated a significant interaction effect between role overload and perceived unit cohesion predicting perceived psychological safety, corroborating H2. This first step supported the prediction that perceived unit cohesion moderates the a path between role overload and perceived psychological safety.

Examining the interaction in more detail, under conditions of high unit cohesion (set at the 84th percentile), there was a significant association between role overload and perceived psychological safety, whereas under conditions of low unit cohesion (set at the 16^th percentile) there was no such relationship (see Table 3). The conditional indirect effects, as measured by the index of moderated-mediation, were significant and positive (0.2637, CI = 0.0466, 0.5044), indicating that the negative relationship of role overload and perceived psychological safety is strengthened under conditions of high unit cohesion.

PROCESS Model 7 was then used to compute the indirect bootstrapped effect of role overload and depression symptoms at varying levels of perceived unit cohesion. The indirect influence of role overload on depression through psychological safety is significant (Table 3) when perceived unit cohesion is high. Thus, H3 is also supported. These findings suggest that the indirect influence of role overload on depression occurs through psychological safety and depends upon high rather than low unit cohesion ^[1].

The findings indicate that all three hypotheses are supported. Role overload relates to depression through the mediating effects of perceived psychological safety (H1) and moderating effects of unit cohesion (H2) that links role overload to perceived psychological safety. A significant portion of variance between role overload and depression is answered through perceived psychological safety. However, the “a” path, (link from role overload to psychological safety) is moderated by perceived unit cohesion. More specifically, high unit cohesion predicts the negative relationship between role overload and perceived psychological safety. This indirect path from role overload through high perceived unit cohesion to perceived psychological safety predicts an increase in depression symptoms (H3).

The current findings are especially noteworthy as they suggest that cohesion may be a boundary condition for psychological safety when operating in a high demand environment. Moreover, by measuring individuals’ perceptions of psychological safety and cohesion, this study was able to explain variance that may better align with health outcomes than the group level construct.

The JD-R theory highlights that job demands may be offset by sufficient organizational resources such as psychological safety and team cohesion to mitigate negative outcomes. However, under conditions of consistent high strain, maladaptive behaviors may surface. Our findings align with these predictions and indicate that demands such as role overload, may impact cohesion leading to group dynamics that result in a decrease in psychological safety (Johnson & Avolio, 2019) and susceptibility to depression (Forsyth, 2021). These data indicate that simple measures of group cohesion, a perceived unified alliance, may fail to account for the intricacies inherent within group dynamics (Forsyth, 2021), which become increasingly apparent under conditions of an increase in job-demands.

These findings extend JD-R theory by suggesting the existence of important boundary conditions associated with psychological safety. Eldor, Hodor, and Cappelli (2023) note that high levels of psychological safety may not always yield positive outcomes, depending on the social context associated with cohesion. This perspective aligns with evidence indicating that high levels of cohesion may also have unintended negative consequences. While several mechanisms may explain the observed pattern of high cohesion, low psychological safety, and increased depression, it is proposed that the primary mechanism lies in the role of conformity pressures within highly cohesive teams. The literature suggests that strong cohesion may foster implicit expectations for agreement and uniformity, which can suppress dissenting viewpoints. Under such conditions, individuals may feel less comfortable voicing concerns thereby undermining psychological safety (Rovio et al., 2009). This dynamic may ultimately contribute to adverse psychological outcomes, including depression that can negatively affect workplace functioning.

This study and future studies may help in better understanding which variables have the greatest impact on depression and how those variables have an impact, whether direct, via moderating effects, or via mediating effects.

Awareness by organizations, leaders and subordinates of factors that may affect mental health as well as the context under which mental health could be impacted, may lead to developing strategies that mitigate negative health outcomes that can impair effective organizational functioning (e.g. turnover, productivity, performance). Some factors that may foster psychological safety and/or build cohesion may include: supportive leaders and peers (Adrian et al., 2018; O’donovan & Mcauliffe, 2020), taking collective responsibility for a task (Newman, Donohue, & Eva, 2017), and autonomy and role clarity (Frazier, Fainshmidt, Klinger, Pezeshkan, & Vracheva, 2017).

Leaders may be able to foster psychological safety and cohesiveness while also enabling members of a team to voice different opinions. Bradley, Postlethwaite, Klotz, Hamdani, & Brown (2012) indicate that psychological safety allows for disagreements but to be effective team members should not take the disagreements personally. The authors indicate that team training and team-building exercises that focus on handling interpersonal risk taking is one strategy that can help teams to avoid groupthink (Janis, 1982).

Tsai & Bendersky (2016) also indicate that psychological safety can encourage dissenting opinions. This may be particularly true when the receiver of the message views the sender of the message as amenable to dissenting opinions and the message is framed as a debate rather than a disagreement.

In addition to fostering psychological safety and cohesion, leaders may also assist by providing other resources as well as by assisting with job demands. A recent review by Tummers & Bakker (2021) on leadership and JD-R theory indicate three ways in which leaders may affect employee behaviors. The first suggests that leaders influence both job demands as well as job and personal resources. For example, servant leaders may increase job resources such as autonomy and social support while transformational leaders can reduce cognitive, emotional, as well as physical job demands. Second, leadership may serve as a moderator between job/personal resources and motivation. For example, a servant leader may provide employees with autonomy that may help when dealing with a high workload. Third, empowering leadership may directly impact employee job crafting. This may take the form of employees reducing their own workload through revising work methods or schedules.

While the findings provide meaningful insight, several limitations exist. First, the study was conducted within a structured context that reflects relatively stable operations. However, these conditions likely differ from environments characterized by greater uncertainty and potentially higher consequences such as a crisis or unexpected conditions (Weick, Sutcliffe, & Obstfeld, 1999). Thus, the findings observed in the present study may not fully reflect what occurs in various work contexts.

The methodology and measurement also yielded some concerns. This is a cross-sectional study thereby limiting any declaration of true mediation, which requires temporal ordering; perhaps the effects of cohesion over time may show different depression outcomes. In addition, the n-size required for moderated-mediation may be under powered (Fritz & MacKinnon, 2007). To provide more clarity regarding the impact of individual perceptions of cohesion and psychological safety, future research should include group level data. Also, the internal reliability of our mediator, psychological safety, was 0.68 indicating a need for sensitivity checks when administering to military populations. These limitations are subject to potential endogeneity and common method bias effects, thus limiting the ability to state definitively the direction of the effects. Future research that addresses these limitations may help organizations and leaders improve mental health outcomes.

The authors gratefully acknowledge the support of numerous personnel at the Walter Reed Army Institute of Research.

Lolita Burrell- ORCID iD 0000-0003-3472-523X-Introduction, Discussion and overall collating. Mike Wood- ORCID iD0000-0001-9455-7480-Methods and Analyses. Elizabeth Wetzler ORCID iD 000-0001-5266-4747- Introduction and Discussion. James Cornwell- ORCID iD-0000-0002-0865-424X-Methods and Analyses. Nickalous Korbut-ORCID iD 0009-0009-3496-6763-Introduction.

Material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of War. The investigators have adhered to the policies for protection of human subjects as prescribed in AR 70–25. Correspondence concerning this article should be addressed to Lolita M. Burrell.

The Institutional Review Board of the Walter Reed Army Institute of Research approved the research protocol, procedure, consent question and survey.

Not applicable.

Written informed consent was obtained from participants.

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