The role of PTSD, guilt and shame in predicting moral injury in veterans that have experienced active deployment.

Paper one is a literature review of ten empirical studies. It reviews what is known about the relationship between killing in combat and PTSD, exploring the question within a military and veteran population. The findings highlighted that those who kill in combat are more likely to report greater severity of PTSD symptoms, although there is some disparity. Other factors, such as victim characteristics and gender, may influence this relationship. Some of the studies were limited by lack of a representative sample and generalisability. There were also issues with transparency, which limits the reliability of some of the conclusions made. Paper two is an empirical study. This was internet-mediated research which explored the relationship between PTSD, guilt, shame and moral injury in a British veteran population. 104 participants took part in the study. A standard multiple regression analysis was conducted on the data. Findings indicated a significant relationship between PTSD and moral injury. The results did not support the hypothesis that guilt and shame would predict moral injury. The findings are discussed, along with their clinical implications, limitations and direction for future research. Paper three is an executive summary. This has been written as an accessible document intended for dissemination of the findings of the empirical study to a veteran and general population. The research method, findings and clinical implications have been summarised within this report

Post-Traumatic Stress Disorder and Killing in Military Combat: A review of existing literature on serving military and veteran populations

Background: Killing during combat is a unique experience and, for the majority, is limited to military service. For those working with military and veteran populations, it is essential to be able to understand this experience and any psychological ramifications.Purpose: This review provides a synthesis of existing literature, addressing the specific question: what is known about the relationship between post-traumatic stress disorder and killing in combat? It summarises what is known of the relationship between these variables and the clinical implications of these findings.Method: A search of existing literature was conducted in a systematic manner in 2017 using electronic databases. A critical appraisal tool was used to inform data extraction and guide the literature review.Results: The literature suggests that those who kill during combat are more likely to report symptoms of PTSD; however, disparity exists as to the statistical significance of this relationship. Factors such as gender and victim characteristics may be influencing factors.Conclusion: The impact of killing during combat must be considered when working therapeutically with military and veteran populations. Future research should aim to recruit military participants from different populations and address some of the difficulties with recruitment—ensuring samples are representative and generalisable

Post-Traumatic Stress Disorder and Killing in Combat: A Review of Existing Literature

Background: Killing during combat is a unique experience and, for the majority, is limited to military service. For those working with military and veteran populations, it is essential to be able to understand this experience and any psychological ramifications. Purpose: This review provides a synthesis of existing literature, addressing the specific question: what is known about the relationship between post-traumatic stress disorder and killing in combat? It summarises what is known of the relationship between these variables and the clinical implications of these findings. Method: A search of existing literature was conducted in a systematic manner in 2017 using electronic databases. A critical appraisal tool was used to inform data extraction and guide the literature review. Results: The literature suggests that those who kill during combat are more likely to report symptoms of PTSD; however, disparity exists as to the statistical significance of this relationship. Factors such as gender and victim characteristics may be influencing factors. Conclusion: The impact of killing during combat must be considered when working therapeutically with military and veteran populations. Future research should aim to recruit military participants from different populations and address some of the difficulties with recruitment—ensuring samples are representative and generalisable. Key words: Post-traumatic stress, combat, killing, military, vetera

Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial.

BACKGROUND: Staphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection. METHODS: In this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants. FINDINGS: Between Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18-45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference -1·4%, 95% CI -7·0 to 4·3; hazard ratio 0·96, 0·68-1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3-4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005). INTERPRETATION: Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia. FUNDING: UK National Institute for Health Research Health Technology Assessment

Investigating the relationship between guilt and shame proneness and moral injury in veterans that have experienced active deployment

Moral injury accounts for the intense negative emotions, such as guilt and shame which some military personnel experience following exposure to events which transgress their deeply held moral beliefs. This study investigated the role of PTSD, guilt and shame in predicting moral injury in a sample of ex-military personnel that had been exposed to active deployment. This was an internet-mediated research design; participants were recruited through an online social media site. British military veterans (n = 104) completed an online battery of self-report measures. Participants were male (n=99) and female (n=5) with a mean age of 47 years. Fifty-one percent of participants achieved scores on a measure of PTSD which would indicate a probable PTSD diagnosis. Guilt and shame were not predictors of moral injury. PTSD was the only significant predictor, accounting for 42% of the variance, with a medium effect size. Clinicians may find it useful to assess veterans for moral injury, particularly those presenting with PTSD. In order to provide detailed assessments it may be helpful for clinicians to further their own understanding of moral injury. Future research should look to establish an evidence base for psychological interventions for moral injury. Closer consideration of contributing factors, such as type of trauma and historical trauma is also needed to develop the construct of moral injury

Development of an intervention for moral injury-related mental health difficulties in UK military veterans: a feasibility pilot study protocol

Background: Experiencing potentially morally injurious events (PMIEs) has been found to be significantly associated with poor mental health outcomes in military personnel/veterans. Currently, no manualised treatment for moral injury-related mental health difficulties for UK veterans exists. This article describes the design, methods and expected data collection of the Restore & Rebuild (R&R) protocol, which aims to develop procedures to treat moral injury related mental ill health informed by a codesign approach. Methods: The study consists of three main stages. First, a systematic review will be conducted to understand the best treatments for the symptoms central to moral injury-related mental ill health (stage 1). Then the R&R manual will be co-designed with the support of UK veteran participants with lived experience of PMIEs as well as key stakeholders who have experience of supporting moral injury affected individuals (stage 2). The final stage of this study is to conduct a pilot study to explore the feasibility and acceptability of the R&R manual (stage 3). Results: Qualitative data will be analysed using thematic analysis. Conclusions: This study was approved by the King's College London's Research Ethics Committee (HR-20/21-20850). The findings will be disseminated in several ways, including publication in academic journals, a free training event and presentation at conferences. By providing information on veteran, stakeholder and clinician experiences, we anticipate that the findings will not only inform the development of an acceptable evidence-based approach for treating moral injury-related mental health problems, but they may also help to inform broader approaches to providing care to trauma exposed military veterans

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

ABSTRACTBackground: 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

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

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. 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. 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. 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. 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.</p