Exposure to moral stressors and associated outcomes in healthcare workers: prevalence, correlates, and impact on job attrition.

Introduction: Healthcare workers (HCWs) often experience morally challenging situations in their workplaces that may contribute to job turnover and compromised well-being. This study aimed to characterize the nature and frequency of moral stressors experienced by HCWs during the COVID-19 pandemic, examine their influence on psychosocial-spiritual factors, and capture the impact of such factors and related moral stressors on HCWs' self-reported job attrition intentions.Methods: A sample of 1204 Canadian HCWs were included in the analysis through a web-based survey platform whereby work-related factors (e.g. years spent working as HCW, providing care to COVID-19 patients), moral distress (captured by MMD-HP), moral injury (captured by MIOS), mental health symptomatology, and job turnover due to moral distress were assessed.Results: Moral stressors with the highest reported frequency and distress ratings included patient care requirements that exceeded the capacity HCWs felt safe/comfortable managing, reported lack of resource availability, and belief that administration was not addressing issues that compromised patient care. Participants who considered leaving their jobs (44%; N = 517) demonstrated greater moral distress and injury scores. Logistic regression highlighted burnout (AOR = 1.59; p < .001), moral distress (AOR = 1.83; p < .001), and moral injury due to trust violation (AOR = 1.30; p = .022) as significant predictors of the intention to leave one's job.Conclusion: While it is impossible to fully eliminate moral stressors from healthcare, especially during exceptional and critical scenarios like a global pandemic, it is crucial to recognize the detrimental impacts on HCWs. This underscores the urgent need for additional research to identify protective factors that can mitigate the impact of these stressors.

This study explored the nature of moral stressors encountered by health care workers, along with impacts on moral injury and intentions to leave their jobs.Morally distressing encounters were common, with the most prevalent and distressing experiences being organizational or team-based in nature.Findings revealed that severity of moral injury, particularly related to trust violation or betrayal, was a key factor influencing healthcare workers' intentions to leave their jobs.

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.

Faculty-Wide Peer-Support Program During the COVID-19 Pandemic: Design and Preliminary Results.

BACKGROUND: Physicians experience higher rates of burnout relative to the general population. Concerns of confidentiality, stigma, and professional identities as health care providers act as barriers to seeking and receiving appropriate support. In the context of the COVID-19 pandemic, factors that contribute to burnout and barriers to seeking support have been amplified, elevating the overall risks of mental distress and burnout for physicians. OBJECTIVE: This paper aimed to describe the rapid development and implementation of a peer support program within a health care organization located in London, Ontario, Canada. METHODS: A peer support program leveraging existing infrastructures within the health care organization was developed and launched in April 2020. The "Peers for Peers" program drew from the work of Shapiro and Galowitz in identifying key components within hospital settings that contributed to burnout. The program design was derived from a combination of the peer support frameworks from the Airline Pilot Assistance Program and the Canadian Patient Safety Institute. RESULTS: Data gathered over 2 waves of peer leadership training and program evaluations highlighted a diversity of topics covered through the peer support program. Further, enrollment continued to increase in size and scope over the 2 waves of program deployments into 2023. CONCLUSIONS: Findings suggest that the peer support program is acceptable to physicians and can be easily and feasibly implemented within a health care organization. The structured program development and implementation can be adopted by other organizations in support of emerging needs and challenges.

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.

Resilience during times of enduring challenge: Brazilian Child Protection Professionals' resilience and psychological distress one year into the COVID-19 pandemic.

BACKGROUND: The impact of the COVID-19 pandemic on Child Protection Professionals (CPPs) was widespread. Evidence regarding how those professionals dealt with the pandemic adversities and consequences for their wellbeing are scarce. OBJECTIVE: We sought to analyze whether predictors of resilience had changed one year into the COVID-19 pandemic in Brazil. Specifically, we explored the resiliency of CPPs as the stress of the pandemic evolved from an acute stressor to a more chronic and persistent stressor. PARTICIPANTS AND SETTING: 263 CPPs from the five regions of Brazil engaged in this study. Participants had a mean age of 40 years and, on average, 13 years of experience in their field. METHODS: CPPs were recruited between March and April of 2021 via professional social media outlets to complete an online survey. CPPs answered questions regarding their perceptions of their work conditions, psychological distress, and resilience. Survey questions were adopted from a prior survey distributed in 2020. RESULTS: We replicated findings from our earlier study in the pandemic: A model of CPPs' resilient behaviors showed good indices of fit even one year into the pandemic. Despite this, paths related to individual importance for personal resilient behavior were not significant in this model. Unmet resilient needs significantly predicted general psychological distress. CONCLUSIONS: CPPs revealed some changing resiliency needs as the pandemic progressed. Results revealed that meeting resilience-related needs is key to decreasing the psychological distress of this population. This work adds to the literature on the understudied topic of CPPs' psychological distress and resilience during international challenges.

"You can't un-ring the bell": a mixed methods approach to understanding veteran and family perspectives of recovery from military-related posttraumatic stress disorder.

BACKGROUND: Military-related posttraumatic stress disorder (PTSD) is a complex diagnosis with non-linear trajectories of coping and recovery. Current approaches to the evaluation of PTSD and treatment discontinuation often rely on biomedical models that dichotomize recovery based on symptom thresholds. This approach may not sufficiently capture the complex lived experiences of Veterans and their families. To explore conceptualizations of recovery, we sought perspectives from Veterans and their partners in a pilot study to understand: 1) how Veterans nearing completion of treatment for military-related PTSD and their partners view recovery; and 2) the experience of progressing through treatment towards recovery. METHODS: We employed a concurrent mixed methods design. Nine Veterans nearing the end of their treatment at a specialized outpatient mental health clinic completed quantitative self-report tools assessing PTSD and depressive symptom severity, and an individual, semi-structured interview assessing views on their treatment and recovery processes. Veterans' partners participated in a separate interview to capture views of their partners' treatment and recovery processes. Descriptive analyses of self-report symptom severity data were interpreted alongside emergent themes arising from inductive content analysis of qualitative interviews. RESULTS: While over half of Veterans were considered "recovered" based on quantitative assessments of symptoms, individual reflections of "recovery" were not always aligned with these quantitative assessments. A persistent narrative highlighted by participants was that recovery from military-related PTSD was not viewed as a binary outcome (i.e., recovered vs. not recovered); rather, recovery was seen as a dynamic, non-linear process. Key components of the recovery process identified by participants included a positive therapeutic relationship, social support networks, and a toolkit of adaptive strategies to address PTSD symptoms. CONCLUSIONS: For participants in our study, recovery was seen as the ability to navigate ongoing issues of symptom management, re-engagement with meaningful roles and social networks, and a readiness for discontinuing intensive, specialized mental health treatment. The findings of this study highlight important considerations in balancing the practical utility of symptom severity assessments with a better understanding of the treatment discontinuation-related needs of Veterans with military-related PTSD and their families, which align with a contemporary biopsychosocial approach to recovery.

Well-being of Canadian Veterans during the COVID-19 pandemic: cross-sectional results from the COVID-19 Veteran well-being study.

Background: The impacts of the COVID-19 pandemic have disproportionally affected different population groups. Veterans are more likely to have pre-existing mental health conditions compared to the general Canadian population, experience compounded stressors resulting from disruptions to familial, social, and occupational domains, and were faced with changes in health-care delivery (e.g. telehealth). The objectives of this study are to assess (a) the mental health impact of COVID-19 and related life changes on the well-being of Veterans and (b) perceptions of and satisfaction with changes in health-care treatments and delivery during the pandemic. Methods: A total of 1136 Canadian Veterans participated in an online survey. Participants completed questions pertaining to their mental health and well-being, lifestyle changes, and concerns relating to the COVID-19 pandemic, as well as experiences and satisfaction with health-care treatments during the pandemic. Results: Results showed that 55.9% of respondents reported worse mental health functioning compared to before the pandemic. The frequency of probable posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, alcohol use disorder, and suicidal ideation were 34.2%, 35.3%, 26.8%, 13.0%, and 22.0%, respectively. Between 38.6% and 53.1% of respondents attributed their symptoms as either directly related to or exacerbated by the pandemic. Approximately 18% of respondents reported using telehealth for mental health services during the pandemic, and among those, 72.8% indicated a choice to use telehealth even after the pandemic. Conclusions: This study found that Veterans experienced worsening mental health as a result of the COVID-19 pandemic. The use of telehealth services was widely endorsed by mental health treatment-seeking Veterans who transitioned to virtual care during the pandemic. Our findings have important clinical and programmeadministrator implications, emphasizing the need to reach out to support veterans, especially those with pre-existing mental health conditions and to enhance and maintain virtual care even post-pandemic.

Antecedentes: Los impactos de la pandemia del COVID-19 han afectado de manera desproporcionada a diferentes grupos de la población. Los veteranos tienen más probabilidades de tener afecciones de salud mental preexistentes en comparación con la población canadiense en general, experimentar factores estresantes agravados como resultado de las interrupciones en los dominios familiares, sociales, y ocupacionales, y se enfrentan a cambios en la prestación de la atención médica (por ejemplo, telesalud). Los objetivos de este estudio son evaluar (a) el impacto en la salud mental del COVID-19 y los cambios de vida relacionados en el bienestar de los Veteranos y (b) las percepciones y la satisfacción con los cambios en los tratamientos y la entrega de la atención médica durante la pandemia.Métodos: Un total de 1136 veteranos canadienses participaron en una encuesta en línea. Los participantes completaron preguntas relacionadas con su salud mental y bienestar, cambios en el estilo de vida, e inquietudes relacionadas con la pandemia del COVID-19, así como experiencias y satisfacción con los tratamientos de atención médica durante la pandemia.Resultados: Los resultados mostraron que el 55,9% de los encuestados informaron un peor funcionamiento de la salud mental en comparación con antes de la pandemia. La frecuencia de probable trastorno de estrés postraumático, trastorno depresivo mayor, trastorno de ansiedad generalizada, trastorno por consumo de alcohol, e ideación suicida fue del 34,2%, 35,3%, 26,8%, 13,0% y 22,0%, respectivamente. Entre el 38,6% y el 53,1% de los encuestados atribuyeron sus síntomas como directamente relacionados con la pandemia o agravados por ella. Aproximadamente el 18% de los encuestados informó haber utilizado la telesalud para los servicios de salud mental durante la pandemia, y entre ellos, el 72,8% indicó que había optado por utilizar la telesalud incluso después de la pandemia.Conclusiones: Este estudio encontró que los Veteranos experimentaron un empeoramiento de la salud mental como resultado de la pandemia del COVID-19. El uso de los servicios de telesalud fue ampliamente respaldado por los Veteranos en busca de tratamiento de salud mental que hicieron la transición a la atención virtual durante la pandemia. Nuestros hallazgos tienen importantes implicaciones clínicas y para los administradores de programas, enfatizando la necesidad de ayudar a los veteranos, especialmente a aquellos con condiciones de salud mental preexistentes, y de mejorar y mantener la atención virtual incluso después de una pandemia.

Exploring mental illness stigma among Asian men mobilized to become Community Mental Health Ambassadors in Toronto Canada.

BACKGROUND: Stigma of mental illness contributes to silence, denial and delayed help seeking. Existing stigma reduction strategies seldom consider gender and cultural contexts. PURPOSE: The Strengths in Unity study was a multi-site Canadian study that engaged Asian men in three stigma reduction interventions (ACT, CEE, psychoeducation) and mobilized them as Community Mental Health Ambassadors. Our participants included both men living with or affected by mental illness (LWA) as well as community leaders (CL). This paper will: (1) describe the baseline characteristics of the Toronto participants including their sociodemographic information, mental illness stigma (CAMI and ISMI), attitudes towards social change (SJS), and intervention-related process variables (AAQ-II, VLQ, FMI, Empowerment); (2) compare the differences among these variables between LWA and CL; and (3) explore factors that may correlate with socio-economic status and mental health stigma. RESULTS: A total of 609 Asian men were recruited in Toronto, Canada. Both CL and LWA had similar scores on measures of external and internalized stigma and social change attitudes, except that LWA had more positive views about the acceptance and integration of those with mental illness into the community on the CAMI, while CL had a higher level of perceived behavioral control on the SJS. Group differences were also observed between LWA and CL in some process-related variables. Exploratory analysis suggests that younger and more educated participants had lower stigma. CONCLUSION: Our findings underscore the importance of engaging both community leaders and people with lived experience as mental health advocates to address stigma.

Well-being of Canadian Armed Forces Veterans and Spouses of Veterans During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Survey.

BACKGROUND: The COVID-19 pandemic has resulted in significant changes to everyday life, including social distancing mandates, changes to health care, and a heightened risk of infection. Previous research has shown that Canadian Armed Forces (CAF) veterans are at higher risk of developing mental and physical health conditions. Veterans and their families may face unique social challenges that can compound with pandemic-related disruptions to negatively impact well-being. OBJECTIVE: This study aims to longitudinally characterize the mental health of CAF veterans and spouses of CAF veterans throughout the pandemic and to understand the dynamic influences of pandemic-related stressors on psychological health over time. METHODS: We employed a prospective longitudinal panel design using an online data collection platform. Study participation was open to all CAF veterans and spouses of CAF veterans residing in Canada. Participants were asked to complete a comprehensive battery of assessments representing psychological well-being, chronic pain, health care access patterns, physical environment, employment, social integration, and adjustment to pandemic-related lifestyle changes. Follow-up assessments were conducted every 3 months over an 18-month period. This study was approved by the Western University Health Sciences and Lawson Health Research Institute Research Ethics Boards. RESULTS: Baseline data were collected between July 2020 and February 2021. There were 3 population segments that participated in the study: 1047 veterans, 366 spouses of veterans, and 125 veterans who are also spouses of veterans completed baseline data collection. As of November 2021, data collection is ongoing, with participants completing the 9- or 12-month follow-up surveys depending on their date of self-enrollment. Data collection across all time points will be complete in September 2022. CONCLUSIONS: This longitudinal survey is unique in its comprehensive assessment of domains relevant to veterans and spouses of veterans during the COVID-19 pandemic, ranging from occupational, demographic, social, mental, and physical domains, to perceptions and experiences with health care treatments and access. The results of this study will be used to inform policy for veteran and veteran family support, and to best prepare for similar emergencies should they occur in the future. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34984.

Four Decades of Military Posttraumatic Stress: Protocol for a Meta-analysis and Systematic Review of Treatment Approaches and Efficacy.

BACKGROUND: Over 85% of active members of the Canadian Armed Forces have been exposed to potentially traumatic events linked to the development of posttraumatic stress disorder (PTSD). At the time of transition to civilian life, as high as 1 in 8 veterans may be diagnosed with PTSD. Given the high prevalence of PTSD in military and veteran populations, the provision of effective treatment considering their unique challenges and experiences is critical for mental health support and the well-being of these populations. OBJECTIVE: This paper presents the protocol for a meta-analysis and systematic review that will examine the effectiveness of treatment approaches for military-related PTSD. METHODS: This PROSPERO-preregistered meta-analysis is being conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines. A comprehensive search of the literature was conducted using the databases PsycInfo, Medline, Embase, CINAHL, and ProQuest Dissertation & Theses. Effect sizes will be computed based on changes in PTSD symptom scores over time across studies using validated PTSD scales. A multilevel meta-analysis will examine the overall effects, between-study effects, and within-study effects of available evidence for PTSD treatments in military populations. Effect sizes will be compared between pharmacotherapeutic, psychotherapeutic, and alternative/emerging treatment interventions. Finally, meta-regression and subgroup analyses will explore the moderating roles of clinical characteristics (eg, PTSD symptom clusters), treatment approaches (eg, therapeutic orientations in psychotherapy and alternative therapies and classifications of drugs in pharmacotherapy), as well as treatment characteristics (eg, length of intervention) on treatment outcomes. RESULTS: The literature search was completed on April 14, 2021. After the removal of duplicates, a total of 12,002 studies were screened for inclusion. As of July 2021, title and abstract screening has been completed, with 1469 out of 12,002 (12.23%) studies included for full-text review. Full review is expected to be completed in the summer of 2021, with initial results expected for publication by early winter of 2021. CONCLUSIONS: This meta-analysis will provide information on the current state of evidence on the efficacy and effectiveness of various treatment approaches for military-related PTSD and identify factors that may influence treatment outcomes. The results will inform clinical decision-making for service providers and service users. Finally, the findings will provide insights into future treatment development and practice recommendations to better support the well-being of military and veteran populations. TRIAL REGISTRATION: PROSPERO CRD42021245754; https://tinyurl.com/y9u57c59. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33151.

Exploring the Well-being of Health Care Workers During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Study.

BACKGROUND: Health care workers (HCWs) have experienced several stressors associated with the COVID-19 pandemic. Structural stressors, including extended work hours, redeployment, and changes in organizational mandates, often intersect with interpersonal and personal stressors, such as caring for those with COVID-19 infections; worrying about infection of self, family, and loved ones; working despite shortages of personal protective equipment; and encountering various difficult moral-ethical dilemmas. OBJECTIVE: The paper describes the protocol for a longitudinal study seeking to capture the unique experiences, challenges, and changes faced by HCWs during the COVID-19 pandemic. The study seeks to explore the impact of COVID-19 on the mental well-being of HCWs with a particular focus on moral distress, perceptions of and satisfaction with delivery of care, and how changes in work structure are tolerated among HCWs providing clinical services. METHODS: A prospective longitudinal design is employed to assess HCWs' experiences across domains of mental health (depression, anxiety, posttraumatic stress, and well-being), moral distress and moral reasoning, work-related changes and telehealth, organizational responses to COVID-19 concerns, and experiences with COVID-19 infections to self and to others. We recruited HCWs from across Canada through convenience snowball sampling to participate in either a short-form or long-form web-based survey at baseline. Respondents to the baseline survey are invited to complete a follow-up survey every 3 months, for a total of 18 months. RESULTS: A total of 1926 participants completed baseline surveys between June 26 and December 31, 2020, and 1859 participants provided their emails to contact them to participate in follow-up surveys. As of July 2021, data collection is ongoing, with participants nearing the 6- or 9-month follow-up periods depending on their initial time of self-enrollment. CONCLUSIONS: This protocol describes a study that will provide unique insights into the immediate and longitudinal impact of the COVID-19 pandemic on the dimensions of mental health, moral distress, health care delivery, and workplace environment of HCWs. The feasibility and acceptability of implementing a short-form and long-form survey on participant engagement and data retention will also be discussed. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/32663.

The importance of bereavement cognitions on grief symptoms: Applications of cognitive processing therapy.

The experience of bereavement and trauma share some overlapping features, such as changes in the cognitive processing of information. This article explored the extent to which cognitive processes during bereavement influence coping outcomes in relation to grief in a sample of university students who had been previously bereaved (N = 104). First, we examined differences in bereavement outcomes based on whether cognitive processes associated with the bereavement were accommodated (n = 55), over-accommodated (n = 25), or assimilated (n = 24). Results indicate that grief-related outcomes significantly differed as a result of cognitive processes. We then compared the degree to which these cognitive processes accounted for grief outcomes in individuals with high and low grief symptoms. In individuals with low grief levels, both depressive symptoms and grief cognitions significantly accounted for grief levels. However, in individuals with high grief levels, only cognitive processes significantly accounted for levels of grief. Results from this study underscore the importance of examining cognitive processes during bereavement. Future research should further examine the underlying mechanisms that contextualize both the bereavement and cognitive processes surrounding the loss. Finally, results from this study highlight the associated cognitive processing of information as a potential topic for targeted treatment in bereavement.

Examining Different Strategies for Stigma Reduction and Mental Health Promotion in Asian Men in Toronto.

Mental illness stigma has detrimental effects on health and wellbeing. Approaches to address stigma in racialized populations in Western nations need to emphasize inclusivity, social justice, and sociocultural intersectionality of determinants of health. The current paper evaluates three intervention approaches to reduce stigma of mental illness among Asian men in Toronto, Canada. Participants received one of four group interventions: psychoeducation, Acceptance and Commitment Therapy (ACT), Contact-based Empowerment Education (CEE), and a combination of ACT+CEE. Self-report measures on stigma (CAMI, ISMI) and social change (SJS) were administered before and after the intervention. A total of 535 Asian men completed the interventions. Overall analyses found that all intervention approaches were successful in reducing stigma and promoting social change. Subscale differences suggest that CEE may be more broadly effective in reducing mental illness stigmatizing attitudes while ACT may be more specifically effective in reducing internalized stigma. More work needs to be done to elucidate mechanisms that contribute to socioculturally-informed mental illness stigma interventions for racialized communities and traditionally marginalized populations.

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.

Advancements to the Multi-System Model of Resilience: updates from empirical evidence.

In this paper, we discuss further advancements to the Multi-System Model of Resilience through examining empirical factor structures of the Multi-System Model of Resilience Inventory along with other measures of resilience. Evidence from multiple sampled populations provided support for the three-systems organization of the model and highlight its similarities and differences in relation to other measures of resilience. The MSMR conceptualizes resilience as a capacity that enables functioning across a continuum from vulnerability to resilience, whereby internal and external resources interface with dynamic coping processes in response to varying needs and goals. Meaningful applications of this model and future steps in model and measurement developments 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.

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.

Re-conceptualizing stress: Shifting views on the consequences of stress and its effects on stress reactivity.

BACKGROUND: The consequences of stress are typically regarded from a deficit-oriented approach, conceptualizing stress to be entirely negative in its outcomes. This approach is unbalanced, and may further hinder individuals from engaging in adaptive coping. In the current study, we explored whether negative views and beliefs regarding stress interacted with a stress framing manipulation (positive, neutral and negative) on measures of stress reactivity for both psychosocial and physiological stressors. METHOD: Ninety participants were randomized into one of three framing conditions that conceptualized the experience of stress in balanced, unbalanced-negative or unbalanced-positive ways. After watching a video on stress, participants underwent a psychosocial (Trier Social Stress Test), or a physiological (CO2 challenge) method of stress-induction. Subjective and objective markers of stress were assessed. RESULTS: Most of the sampled population regarded stress as negative prior to framing. Further, subjective and objective reactivity were greater to the TSST compared to the CO2 challenge. Additionally, significant cubic trends were observed in the interactions of stress framing and stress-induction methodologies on heart rate and blood pressure. Balanced framing conditions in the TSST group had a significantly larger decrease in heart rate and diastolic blood pressure following stress compared to the positive and negative framing conditions. CONCLUSION: Findings confirmed a deficit-orientation of stress within the sampled population. In addition, results highlighted the relative efficacy of the TSST compared to CO2 as a method of stress provocation. Finally, individuals in framing conditions that posited stress outcomes in unbalanced manners responded to stressors less efficiently. This suggests that unbalanced framing of stress may have set forth unrealistic expectations regarding stress that later hindered individuals from adaptive responses to stress. Potential benefits of alternative conceptualizations of stress on stress reactivity are discussed, and suggestions for future research are made.