Professionals' perspectives on relevant approaches to psychological care in moral injury: A qualitative study.

OBJECTIVES: Despite the increasing consensus that moral injury (MI) is a unique type of psychological stressor, there is an ongoing debate about best practices for psychological care. This qualitative study explored the perceptions of UK and US professionals in the field of MI investigating advances and challenges in treatment or support delivery and issues relating to treatment/support feasibility and acceptability. METHODS: 15 professionals were recruited. Semi-structured, telephone/online interviews were carried out, and transcripts were analyzed using thematic analysis. RESULTS: Two interconnected themes emerged: perceived barriers to appropriate care for MI cases and recommendations for providing effective care to MI patients. Professionals highlighted the challenges that occur due to the lack of empirical experience with MI, the negligence of patients' unique individual needs and the inflexibility in existing manualised treatments. CONCLUSIONS: These findings illustrate the need to evaluate the effectiveness of current approaches and explore alternative pathways, which will effectively support MI patients in the long-term. Key recommendations include the use of therapeutic techniques which lead to a personalised and flexible support plan to meet patients' needs, increase self-compassion and encourage patients to reconnect with their social networks. Interdisciplinary collaborations (e.g., religious/spiritual figures), could be a valuable addition following patients' agreement.

Adherence to protective measures among healthcare workers in the UK: a cross-sectional study.

BACKGROUND: Healthcare workers (HCWs) are frontline responders to emergency infectious disease outbreaks such as COVID-19. To avoid the rapid spread of disease, adherence to protective measures is paramount. We investigated rates of correct use of personal protective equipment (PPE), hand hygiene and physical distancing in UK HCWs who had been to their workplace at the start of the COVID-19 pandemic and factors associated with adherence. METHODS: We used an online cross-sectional survey of 1035 UK healthcare professionals (data collected 12-16 June 2020). We excluded those who had not been to their workplace in the previous 6 weeks, leaving us with a sample size of 831. Respondents were asked about their use of PPE, hand hygiene and physical distancing in the workplace. Frequency of uptake was reported descriptively; adjusted logistic regressions were used to separately investigate factors associated with adherence to use of PPE, maintaining good hand hygiene and physical distancing from colleagues. RESULTS: Adherence to personal protective measures was suboptimal (PPE use: 80.0%, 95% CI 77.3 to 82.8; hand hygiene: 67.8%, 95% CI 64.6 to 71.0; coming into close contact with colleagues: 74.7%, 95% CI 71.7 to 77.7). Adherence to PPE use was associated with having received training about health and safety in the workplace for COVID-19, greater perceived social pressure to adopt the behaviour and availability of PPE. Non-adherence was associated with fatalism about COVID-19 and greater perceived difficulty of adopting protective measures. Workplace design using markings to facilitate distancing was associated with adherence to physical distancing. CONCLUSIONS: Uptake of personal protective behaviours among UK HCWs at the start of the pandemic was variable. Factors associated with adherence provide insight into ways to support HCWs to adopt personal protective behaviours, such as ensuring that adequate PPE is available and designing workplaces to facilitate physical distancing.

Psychosocial impact of the COVID-19 pandemic on 4378 UK healthcare workers and ancillary staff: initial baseline data from a cohort study collected during the first wave of the pandemic.

OBJECTIVES: This study reports preliminary findings on the prevalence of, and factors associated with, mental health and well-being outcomes of healthcare workers during the early months (April-June) of the COVID-19 pandemic in the UK. METHODS: Preliminary cross-sectional data were analysed from a cohort study (n=4378). Clinical and non-clinical staff of three London-based NHS Trusts, including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire. Secondary outcomes are probable anxiety (seven-item Generalised Anxiety Disorder), depression (nine-item Patient Health Questionnaire), post-traumatic stress disorder (PTSD) (six-item Post-Traumatic Stress Disorder checklist), suicidal ideation (Clinical Interview Schedule) and alcohol use (Alcohol Use Disorder Identification Test). Moral injury is measured using the Moray Injury Event Scale. RESULTS: Analyses showed substantial levels of probable CMDs (58.9%, 95% CI 58.1 to 60.8) and of PTSD (30.2%, 95% CI 28.1 to 32.5) with lower levels of depression (27.3%, 95% CI 25.3 to 29.4), anxiety (23.2%, 95% CI 21.3 to 25.3) and alcohol misuse (10.5%, 95% CI 9.2 to 11.9). Women, younger staff and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one's moral code) was strongly associated with increased levels of probable CMDs, anxiety, depression, PTSD symptoms and alcohol misuse. CONCLUSIONS: Our findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic.

Restore and Rebuild (R&R) - a feasibility pilot study of a co-designed intervention for moral injury-related mental health difficulties.

BACKGROUND: Moral injury can significantly negatively impact mental health, but currently no validated treatment for moral injury-related mental health difficulties exists in a UK context. This study aimed to examine whether the Restore and Rebuild (R&R) treatment was feasible to deliver, acceptable and well tolerated by UK military veterans with moral injury related mental health difficulties. METHOD: The R&R treatment was delivered to 20 patients who reported distress related to exposure to a morally injurious event(s) during military service. R&R is a 20-session psychotherapy with key themes of processing the event, self compassion, connecting with others and core values. Treatment was delivered online, weekly, one-to-one by a single therapist. Qualitative interviews with patients and the therapist who delivered R&R were conducted to explore acceptability and analysed using thematic analysis. RESULTS: Following treatment, patients experienced a significant reduction in symptoms of post-traumatic stress disorder, depression, alcohol misuse and moral injury related distress. R&R was found to be well tolerated by patients and improved their perceived wellbeing. CONCLUSIONS: These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment.

Evidence before this study: Moral injury can negatively impact the mental health of military veterans. Currently no validated treatment for moral injury related mental health difficulties exists for UK military personnel/veterans.Added value of this study: Restore and Rebuild (R&R) is a co-designed psychotherapy for moral injury-related mental health difficulties. This study provides the first evidence that R&R treatment is associated with a significant improvement in patient symptoms of PTSD, depression, alcohol misuse and moral injury related distress. R&R was feasible to deliver, acceptable to patients and well tolerated.Implications of all the available evidence: These results provide preliminary evidence that veterans struggling with moral injury related mental ill health can benefit from R&R treatment. With further evaluation, R&R may be beneficial to other occupational groups affected by moral injury.

Extreme sport as an intervention for physically injured military veterans: the example of competitive motorsport.

PURPOSE: Physically or psychologically injured military veterans are motivated and benefited by physical activity or sport that may involve high levels of achievement. The aim of this study was to provide an in-depth insight into the impact of Competitive Motorsport (CM) on physically injured/disabled veterans' subjective well-being and in turn determine if it improves the quality of their lives. METHODS: This is a qualitative study. Two sets of semi-structured interviews were conducted with 14 male British military veterans including a 6-month follow-up. All participants were subjected to a permanent, moderate or severe, physical injury/disability. Data were analysed in accordance with the principles of Thematic Analysis. RESULTS/CONCLUSIONS: Five key elements (familiar environment, team spirit, adrenaline rush, competition and equality) made CM a unique experience for physically injured/disabled veterans. Various psychological and physical benefits were found, including an increased sense of accomplishment, opportunity to socialise in a non-clinical environment, embracement of body image and adoption of a healthier lifestyle. Since physical activity and sport are among growing research on alternative interventions for military veterans, they deserve serious consideration as part of the treatment regimens and rehabilitation programmes to improve physically inured/disabled veterans' physical and mental health.Implications for RehabilitationCompetitive Motorsport is an effective means of improving physical health and subjective well-being of physically injured/disabled military veterans.Multiple perceived psychological and physical benefits were identified over time, including motivation for living, embracement of body image and adoption of a healthier lifestyle.Competitive Motorsport deserves consideration as part of the treatment regimens and rehabilitation programmes to improve physically injured/disabled veterans' physical and mental health while facilitating transition to civilian life.

Effectiveness of treatments for symptoms of post-trauma related guilt, shame and anger in military and civilian populations: a systematic review.

INTRODUCTION: Individuals who have been exposed to a traumatic event can develop profound feelings of guilt, shame and anger. Yet, studies of treatments for post-traumatic stress disorder (PTSD) have largely investigated changes in PTSD symptoms relating to a sense of ongoing fear or threat and the effectiveness of such treatments for post-trauma related guilt, shame or anger symptom reduction is comparatively not well understood. METHODS: This review systematically examined the effectiveness of existing treatment approaches for three symptoms associated with exposure to traumatic events: guilt, shame and anger. Studies included had to be published after 2010 with a sample size of n=50 or greater to ensure stable treatment outcome estimates. RESULTS: 15 studies were included, consisting of both civilian and (ex-) military population samples exposed to a wide range of traumatic events (eg, combat-related, sexual abuse). Findings indicated a moderate strength of evidence that both cognitive-based and exposure-based treatments are similarly effective in reducing symptoms. Cognitive-based treatments were found to effectively reduce post-trauma related guilt and anger, while exposure-based treatments appeared effective for post-trauma related guilt, shame and anger. CONCLUSIONS: The findings suggest the importance of confronting and discussing the traumatic event during therapy, rather than using less directive treatments (eg, supportive counselling).Nonetheless, while these results are promising, firm conclusions regarding the comparative effectiveness and long-term impact of these treatments could not be drawn due to insufficient evidence. Further empirical research is needed to examine populations exposed to traumatic events and investigate which treatment approaches (or combination thereof) are more effective in the long-term.

UK veterans' mental health and well-being before and during the COVID-19 pandemic: a longitudinal cohort study.

OBJECTIVE: To investigate the impact of the COVID-19 pandemic on the health and well-being of UK ex-service personnel (veterans) before and during the pandemic, and to assess associations of COVID-19 experiences and stressors with mental health, alcohol use and loneliness. DESIGN: An additional wave of data was collected from a longitudinal cohort study of the UK Armed Forces. SETTING: Online survey June-September 2020. PARTICIPANTS: Cohort members were included if they had completed a questionnaire at phase 3 of the King's Centre for Military Health Research health and well-being study (2014-2016), had left the Armed Forces after regular service, were living in the UK, had consented to follow-up and provided a valid email address. Invitation emails were sent to N=3547 with a 44% response rate (n=1562). PRIMARY OUTCOME MEASURES: Common mental health disorders (CMDs) (measured using the General Health Questionnaire, 12 items-cut-off ≥4), hazardous alcohol use (measured using the Alcohol Use Disorder Identification Test, 10 items-cut off ≥8) and loneliness (University of California, Los Angeles, Loneliness Scale- 3 items-cut-off ≥6). RESULTS: Veterans reported a statistically significant decrease in hazardous drinking of 48.5% to 27.6%, while CMD remained stable (non-statistically significant increase of 24.5% to 26.1%). 27.4% of veterans reported feelings of loneliness. The COVID-19 stressors of reporting difficulties with family/social relationships, boredom and difficulties with health were statistically significantly associated with CMD, hazardous drinking and loneliness, even after adjustment for previous mental health/hazardous alcohol use. CONCLUSIONS: Our study suggests a COVID-19 impact on veterans' mental health, alcohol use and loneliness, particularly for those experiencing difficulties with family relationships. Veterans experienced the pandemic in similar ways to the general population and in some cases may have responded in resilient ways. While stable levels of CMD and reduction in alcohol use are positive, there remains a group of veterans who may need mental health and alcohol treatment services.