Measuring moral distress and moral injury: A systematic review and content analysis of existing scales.

BACKGROUND: Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use. METHOD: We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale. RESULTS: We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes. CONCLUSIONS: Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.

A meta-analysis of internet-based cognitive behavioral therapy for military and veteran populations.

BACKGROUND: Military and veteran populations are unique in their trauma exposures, rates of mental illness and comorbidities, and response to treatments. While reviews have suggested that internet-based Cognitive Behavioral Therapy (iCBT) can be useful for treating mental health conditions, the extent to which they may be appropriate for military and veteran populations remain unclear. The goals of the current meta-analysis are to: (1) substantiate the effects of iCBT for military and veteran populations, (2) evaluate its effectiveness compared to control conditions, and (3) examine potential factors that may influence their effectiveness. METHODS: This review was completed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting and Cochrane review guidelines. The literature search was conducted using PsycInfo, Medline, Embase, and Proquest Dissertation & Theses on June 4, 2021 with no date restriction. Inclusion criteria included studies that: (1) were restricted to adult military or veteran populations, (2) incorporated iCBT as the primary treatment, and (3) evaluated mental health outcomes. Exclusion criteria included: (1) literature reviews, (2) qualitative studies, (3) study protocols, (4) studies that did not include a clinical/analogue population, and (5) studies with no measure of change on outcome variables. Two independent screeners reviewed studies for eligibility. Data was pooled and analyzed using random-effects and mixed-effects models. Study data information were extracted as the main outcomes, including study condition, sample size, and pre- and post-treatment means, standard deviations for all assessed outcomes, and target outcome. Predictor information were also extracted, and included demographics information, the types of outcomes measured, concurrent treatment, dropout rate, format, length, and delivery of intervention. RESULTS: A total of 20 studies and 91 samples of data were included in the meta-analysis. The pooled effect size showed a small but meaningful effect for iCBT, g = 0.54, SE = 0.04, 95% CI (0.45, 0.62), Z = 12.32, p < .001. These effects were heterogenous across samples, (I2 = 87.96), Q(90) = 747.62, p < .001. Predictor analyses found length of intervention and concurrent treatment to influence study variance within sampled studies, p < .05. Evaluation of iCBT on primary outcomes indicated a small but meaningful effect for PTSD and depression, while effects of iCBT on secondary outcomes found similar results with depression, p < .001. CONCLUSIONS: Findings from the meta-analysis lend support for the use of iCBT with military and veteran populations. Conditions under which iCBT may be optimized are discussed.

The effects of child encounters during military deployments on the well-being of military personnel: a systematic review.

Background: Military members report higher instances of trauma exposure and subsequent posttraumatic stress disorder (PTSD) relative to civilians. Encounters with children in war and conflict settings may have particularly unsettling consequences. However, the nature of these consequences has yet to be systematically examined. Objective: This systematic review sought to identify and document deployment-related encounters with children and associated outcomes reported by military personnel, as well as identify any current training programs, policies, or procedures in place regarding encountering children during deployment. Method: A total of 17 studies with 86 independent samples were included. Analyses were based primarily on qualitative data. Results: Based on the review, 77 military personnel samples documented their experiences encountering children during deployment. Most commonly, child encounters included armed children, porters/human shields, suicide bombers, and ambiguous interactions. Outcomes from encountering children during deployment were diverse, occurring both during the encounter, and described by many as persisting years following the exposure. Consequences of encounters as described by military personnel included: hesitation to complete mission objectives, mental health concerns, moral struggles, social isolation, and sleep disturbances. Of the 86 included reports, only nine provided information regarding training at any stage (pre-, during, or post-deployment) in relation to encountering children. Much of the available information underscored the lack of training, with six reports highlighting the lack of pre-deployment training and five reports describing the lack of policies, including rules of engagement, as they relate to encountering children during deployment. Only two reports described post-deployment procedures made available to military personnel following exposure to children while on deployment. Conclusions: Results from this review will be used to identify available research, develop and support training initiatives, and increase awareness regarding implications of encountering children during deployment. We further provide recommendations regarding research needs, policy implementation, and current training gaps.

Antecedentes: Los miembros de las fuerzas militares reportan mayor exposición al trauma y posterior trastorno de estrés postraumático (TEPT), comparados con civiles. Los encuentros con niños en escenarios de guerra y conflictos pueden tener consecuencias particularmente inquietantes, sin embargo, la naturaleza de estas consecuencias aún no se ha examinado sistemáticamente.Objetivo: Esta revisión sistemática buscó identificar y documentar los encuentros con niños relacionados con el despliegue militar, y los resultados asociados reportados por el personal militar, así como identificar cualquier programa de capacitación, política o procedimiento vigente en relación con el encuentro con niños durante el despliegue militar.Método: Se incluyeron un total de 17 estudios con 86 muestras independientes. Los análisis se basaron principalmente en datos cualitativos.Resultados: Según la revisión, 77 muestras de personal militar documentaron experiencias al encontrarse con niños durante el despliegue. Más comúnmente, los encuentros con niños incluyeron niños armados, porteadores/escudos humanos, terroristas suicidas e interacciones ambiguas. Los resultados del encuentro con niños durante el despliegue fueron diversos, ocurriendo durante el encuentro, y siendo descritos por muchos como persistentes años después de la exposición. Las consecuencias de los encuentros descritas por el personal militar incluyeron: vacilación para completar los objetivos de la misión, problemas de salud mental, luchas morales, aislamiento social y trastornos del sueño. De los 86 informes incluidos, solo nueve proporcionaron información sobre la capacitación en cualquier etapa (antes, durante o después del despliegue militar) en relación con el encuentro con los niños. Gran parte de la información disponible subrayó la falta de capacitación, con seis informes que destacaron la falta de capacitación previa al despliegue y cinco informes que describieron la falta de políticas, incluidas las reglas de participación, en relación con el encuentro con niños durante el despliegue. Solo dos informes describieron los procedimientos posteriores al despliegue puestos a disposición del personal militar después de la exposición a los niños durante el despliegue.Conclusiones: Los resultados de esta revisión se utilizarán para identificar la investigación disponible, desarrollar y apoyar iniciativas de capacitación y aumentar la conciencia sobre las implicaciones de encontrarse con niños durante el despliegue militar. Además, brindamos recomendaciones sobre las necesidades de investigación, la implementación de políticas y las brechas de capacitación actuales.

Retracted: The Effect of Bilingualism on Older Adults' Inhibitory Control: A Meta-Analysis.

BACKGROUND AND OBJECTIVES: The effect bilingualism has on older adults' inhibitory control has been extensively investigated, yet there is continued controversy regarding whether older adult bilinguals show superior inhibitory control compared with monolinguals. The objective of the current meta-analysis was to examine the reliability and magnitude of the bilingualism effect on older adults' inhibitory control as measured by the Simon and Stroop tasks. In addition, we examined whether individual characteristics moderate the bilingual advantage in inhibition, including age (young-old vs old-old), age of second language acquisition, immigrant status, language proficiency, and frequency of language use. RESEARCH DESIGN AND METHODS: A total of 22 samples for the Simon task and 14 samples for the Stroop task were derived from 28 published and unpublished articles (32 independent samples, with 4 of these samples using more than 1 task) and were analyzed in 2 separate meta-analyses. RESULTS: Analyses revealed a reliable effect of bilingualism on older adults' performance on the Simon (g = 0.60) and Stroop (g = 0.27) tasks. Interestingly, individual characteristics did not moderate the association between bilingualism and older adults' inhibitory control. DISCUSSION AND IMPLICATIONS: The results suggest there is a bilingual advantage in inhibitory control for older bilinguals compared with older monolinguals, regardless of the individual characteristics previously thought to moderate this effect. Based on these findings, bilingualism may protect inhibitory control from normal cognitive decline with age.

Comprehensive meta-analysis of resilience interventions.

BACKGROUND/RATIONALE: There is no current consensus on operational definitions of resilience. Instead, researchers often debate the optimal approach to understanding resilience, while continuing to explore ways to enhance and/or promote its qualities in various populations. The goal of the current meta-analysis is to substantiate existing evidence examining the promotion of resilience through various interventions. Particular emphasis was placed upon the factors that contribute to variability across interventions, such as age, gender, duration of intervention, intervention approaches and risk exposure of targeted population. METHOD: The literature search was conducted on May 28, 2019. Search terms included "resilience intervention" OR "promoting resilience" OR "promoting resiliency" OR "resilience-based intervention". A total of 268 studies, with 1584 independent samples, were included in the meta-analysis. In addition to overall efficacy, outcome-based analyses were conducted for intervention outcomes based on action, biophysical, coping, emotion, resilience, symptoms, and well-being. Finally, moderators of age, gender, length of intervention, intervention approach, intervention target, and the level of risk exposure of the sampled population were examined as moderators. RESULTS: The multi-level meta-analysis indicated that resilience-promoting interventions yielded a small, but statistically significant overall effect, Hedges's g = 0.48 (SE = 0.04, 95% CI = [0.40, 0.56]. The variability in study effect sizes within and between studies was significant, p < .001, with many falling short of the threshold for practical significance. DISCUSSION: Findings lend some support for the overall efficacy of resilience interventions. However, empirical results should be cautiously interpreted in tandem with their theoretical relevance and potential advancements to the construct of resilience. Variabilities across findings reflect the current ambiguities surrounding the conceptualization and operationalization of resilience. Directions for future research on resilience as well as practical considerations are discussed.

The efficacy of stress reappraisal interventions on stress responsivity: A meta-analysis and systematic review of existing evidence.

BACKGROUND: The beliefs we hold about stress play an important role in coping with stressors. Various theoretical frameworks of stress point to the efficacy of reframing stress-related information through brief reappraisal interventions in order to promote adaptive coping. PURPOSE: The goal of the current meta-analysis and systematic review is to substantiate the efficacy of reappraisal interventions on stress responsivity compared to control conditions. Differences in experimental methodologies (e.g., type of stressor used, timing of reappraisal intervention, and content of intervention instructions) will be examined to further delineate their effects on intervention outcomes. METHODS: The literature searches were conducted on May 16, 2018 using PsycINFO, ProQuest Dissertations and Theses, and PILOTS databases with no date restriction. The search terms included stress, reframing, reappraisal, mindset and reconceptualising. A total of 14 articles with 36 independent samples were included in the meta-analysis, while 22 articles with 46 independent samples were included in the systematic review. Random-effects model was used to test the null hypothesis using two-tailed significance testing. Fisher's Z value was reported for each corresponding test. Heterogeneity tests are reported via Cochran's Q-statistics. RESULTS: Findings from both the meta-analysis and systematic review revealed that overall, reappraisal interventions are effective in attenuating subjective responsivity to stress. Standard differences in means across groups are 0.429 (SE = 0.185, 95% CI = 0.067 to 0.791; z = 2.320, p = .020). However, reappraisal intervention groups did not outperform control groups on measures of physiological stress, with standard differences of -0.084 (SE = 0.135, 95% CI = -0.349 to 0.180; z = -0.627, p = .531). Moderator analysis revealed heterogeneous effects suggesting large variability in findings. CONCLUSIONS: On one hand, findings may suggest a promising avenue for the effective management of self-reported stress and optimization of stress responses. However, more research is needed to better elucidate the effects, if any, of reappraisal interventions on stress physiology. Implications for the use of reappraisal interventions on stress optimization are discussed in the context of theoretical frameworks and considerations for future studies.

Subjective and physiological responses to the 35% carbon dioxide challenge in healthy and non-clinical control populations: a meta-analysis and systematic review.

BACKGROUND/RATIONALE: The carbon dioxide (CO2) challenge has been reliably used in laboratory settings as a panicogen in clinical populations. However, the magnitude of these effects on healthy and non-clinical control populations are not clear. The aim of this meta-analysis and systematic review is to provide quantitative estimates of those effects. Specifically, the current paper will evaluate the relative efficacy of the CO2 challenge in eliciting both subjective and physiological arousal in healthy and non-clinical control populations. METHOD: A total of 16 articles with 35 independent samples were included in the meta-analysis, while 37 studies with 74 independent samples were included in the systematic review. RESULTS: Both the meta-analysis and systematic review found the CO2 challenge to elicit an increase in subjective distress via self-reported anxiety and fear. Physiological responses via blood pressure and heart rate were heterogeneous in studies sampled, with no significant changes observed across studies. Moderator analyses revealed the variations in findings may be attributed to participant screening and invasive sampling. DISCUSSION: Findings highlight the CO2 challenge as a useful tool in the provocation of subjective distress. Implications for both the use of the CO2 challenge and its anticipated effects in healthy and non-clinical control populations are discussed.

The effect of a very low calorie diet on subjective depressive symptoms and anxiety: meta-analysis and systematic review.

There are conflicting findings regarding the effect very low calorie diets (VLCDs) have on self-reported depressive symptoms and anxiety levels. Some studies have reported decreased subjective depressive symptoms and anxiety post-diet, whereas other studies have not. Further complicating matters, the protocol for VLCDs vary substantially across studies, which could account for the mixed findings. The primary goal of this meta-analysis and systematic review was to determine the effect VLCDs have on subjective depressive symptoms and anxiety pre- to post-diet. In addition, potential moderators (the presence/absence of behavioral therapy, duration of diet, inclusion/exclusion of low intensity exercise, and amount of weight lost) were examined to assess the effect of procedural deviations across VLCD studies on depressive symptoms and anxiety. A random-effects model was used for the meta-analysis and included nine studies with 16 independent samples. To further explain the results, study rigor was examined in the systematic review, which included 11 studies with 20 independent samples. Depressive symptoms significantly decreased pre- to post-diet when behavioral therapy was implemented during the diet, the duration of the diet was relatively long (8-16 weeks), low intensity exercise was included, and the dieters lost 14.1 kg or more post-diet. However, no difference in depressive symptoms were observed pre- to post-diet when behavioral therapy was not included, the diet was shorter (1-7 weeks), no exercise was implemented and dieters lost <14 kg of weight post-diet. There was no change in anxiety pre- to post-diet. Health care providers involved in supervising VLCDs should consider using a VLCD of at least 8 weeks that includes behavioral therapy and low intensity exercise in order to enhance the potential benefits of VLCDs on depressive symptoms. More research is required to examine the effect of VLCDs on anxiety.

Older Adults With Cognitive and/or Physical Impairments Can Benefit From Immersive Virtual Reality Experiences: A Feasibility Study.

Background: Older adults living in long term care, rehabilitation hospitals, and seniors' residences often experience reduced mobility, sometimes resulting in confinement indoors and isolation, which can introduce or aggravate symptoms of depression, anxiety, loneliness, and apathy. As Virtual Reality (VR) technologies become increasingly accessible and affordable, there is a unique opportunity to enable older adults to escape their restricted physical realities and be transported to both stimulating and calming places which may improve their general well-being. To date no robust evaluations of the use of immersive VR therapy [experienced through a head-mounted-display (HMD)] for older adults within these settings have been reported. VR-therapy may prove to be a safe, inexpensive, non-pharmacological means of managing depressive symptoms and providing engagement and enjoyment to this rapidly growing demographic. Objectives: Establish whether it is feasible to use immersive VR technology as therapy for older adults who have reduced sensory, mobility and/or impaired cognition. This includes evaluation of tolerability, comfort, and ease of use of the HMD, and of the potential for immersive VR to provide enjoyment/relaxation and reduce anxiety and depressive symptoms. Methods: Sixty-six older adults (mean age 80.5, SD = 10.5) with varying cognitive abilities (normal = 28, mild impairment = 17, moderate impairment = 12, severe impairment = 3, unknown cognitive score = 6), and/or physical impairments, entered a multi-site non-randomized interventional study in Toronto, Canada. Participants experienced 3 to 20 min of 360°-video footage of nature scenes displayed on Samsung GearVR HMD. Data was collected through pre/post-intervention surveys, standardized observations during intervention, and post-intervention semi-structured interviews addressing the VR experience. Results: All participants completed the study with no negative side-effects reported (e.g., No dizziness, disorientation, interference with hearing aids); the average time spent in VR was 8 min and 76% of participants viewed the entire experience at least once. Participants tolerated the HMD very well; most had positive feedback, feeling more relaxed and adventurous; 76% wanted to try VR again. Better image quality and increased narrative video content were suggested to improve the experience. Conclusion: It is feasible and safe to expose older adults with various levels of cognitive and physical impairments to immersive VR within these settings. Further research should evaluate the potential benefits of VR in different settings (e.g., home/community based) and explore better customization/optimization of the VR content and equipment for the targeted populations.

The effect of pet therapy on the physiological and subjective stress response: A meta-analysis.

Studies have reported that exposure to pet therapy (PT) can reduce physiological and subjective stress and anxiety levels. The aim of this meta-analysis is to examine the efficacy of PT as a method for reducing physiological stress levels (blood pressure and heart rate) and subjective stress and anxiety scores (self-reported stress/anxiety). Further, we examined the effects of sample characteristics and modifications to the PT (different age groups and health status of participants across samples, whether a stressor was present, and individual versus group PT) as potential moderators of the relationship between PT and stress reactivity. Our searches incorporated articles published from May 2017 and earlier in PsycINFO, MEDLINE, and PubMed. This meta-analysis included 28 articles with 34 independent samples and contained a total of 1,310 participants. Using a random effects model, we determined that significant differences occurred in heart rate, self-reported anxiety, and self-reported stress after PT exposure compared with before PT. However, we did not detect significant differences in blood pressure after PT. Sample characteristics and modifications to the PT significantly moderated the effect of PT on stress responses. Our results suggest that PT can be an effective program for reducing stress reactivity.

Sex differences in salivary cortisol reactivity to the Trier Social Stress Test (TSST): A meta-analysis.

Some, but not all studies using the Trier Social Stress Test (TSST) have demonstrated evidence in support of sex differences in salivary cortisol. The aim of the current meta-analysis is to examine sex differences in salivary cortisol following exposure to the TSST. We further explored the effects of modifications to the TSST protocol and procedural variations as potential moderators. We searched articles published from January, 1993 to February, 2016 in MedLine, PsychINFO, and ProQuest Theses and Dissertations. This meta-analysis is based on 34 studies, with a total sample size of 1350 individuals (640 women and 710 men). Using a random effects model, we found significant heterogeneity in salivary cortisol output across sexes, such that men were observed to have higher cortisol values at peak and recovery following the TSST compared to women. Modifications to the sampling trajectory of cortisol (i.e., duration of acclimation, peak sampling time, and duration of recovery) significantly moderated the heterogeneity across both sexes. Further, there are observed sex differences at various time points of the reactive cortisol following the TSST. Lastly, current results suggest that these sex differences can be, at least in part, attributed to variations in methodological considerations across studies. Future research could advance this line of inquiry by using other methods of analyses (e.g., area under the curve; AUC), in order to better understand the effects of methodological variations and their implications for research design.