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Nadav Liam Modlin,1 Michael Creed,1,2 Maria Sarang,1 Carolina Maggio,1 James J Rucker,1,2 Victoria Williamson3,4 1The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 8AF, UK; 2South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ, UK; 3King’s Centre for Military Health Research, King’s College London, London, SE5 9RJ, UK; 4Department of Experimental Psychology, Anna Watts Building, University of Oxford, Oxford, OX2 6 GG, UKCorrespondence: Nadav Liam Modlin, The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London, SE5 8AF, UK, Email nadav.modlin@kcl.ac.ukIntroduction: Post-traumatic stress disorder (PTSD) is associated with significant patient burden. While pharmacotherapies and evidence-based psychotherapy interventions (EBPI) are effective, studies consistently highlight inadequate outcomes and high treatment dropout. Psychedelic therapy (PT) has shown preliminary promise across difficult-to-treat conditions, including MDMA-assisted therapy for PTSD, however trials of classical psychedelics in PTSD are lacking. Understanding patients’ experiences of EBPI could help promote safety in PT.Aim: To systematically review qualitative research on patients’ subjective experience of EBPI for PTSD, and of PT, and examine areas of overlap and divergence between them.Methods: Systematic literature searches for studies published between 2010 and 2023 were conducted on OVID, PubMed, Web of Science, and PsycInfo. Included were original studies in English that presented qualitative data of patient experiences of EBPI in PTSD, or PT for any indication. Extracted data from included studies were analysed using thematic synthesis. Syntheses were completed separately for EBPI and PT, before similarities and differences between the therapies were identified.Results: 40 research articles were included for review: 26 studies on EBPI for PTSD, and 14 studies on PT. EBPI studied were CBT, EMDR, CPT and PE. Psychedelic compounds studied were psilocybin, ibogaine, LSD, MDMA and ketamine, for treatment of substance use disorders, anxiety relating to physical illness, depression, and PTSD. Core themes from patient experiences of EBPI: 1) patient burden in PTSD treatment; 2) readiness; 3) key mechanisms of change; 4) psychological safety and trust. Themes identified in the review of PT: 1) indirect trauma processing; 2) reorganisation of self-narratives via processes of relatedness and identification; 3) key treatment characteristics.Conclusion: This study suggests overlap between patients’ experience of EBPI and PT in terms of key mechanisms of change, the importance of psychological safety and readiness to engage in treatment. Trauma-informed care paradigms and practices may improve safety and acceptability of PT research.Keywords: trauma, PTSD, psychotherapy, psychedelic therapy, qualitative, review

Sarah Rabin,1 Natalia Kika,1 Danielle Lamb,2 Dominic Murphy,1,3 Sharon AM Stevelink,1 Victoria Williamson,1,4 Simon Wessely,1 Neil Greenberg1 1Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK; 2Department of Applied Health Research, University College London, London, UK; 3Research Department, Combat Stress, Leatherhead, UK; 4Department of Experimental Psychology, University of Oxford, Oxford, UKCorrespondence: Sarah Rabin, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, Weston Education Centre, London, SE5 9RJ, UK, Tel +44 02078485351, Email sarah.p.rabin@kcl.ac.ukAbstract: Moral injury (MI) refers to the persisting distress which may occur following exposure to potentially morally injurious events (PMIEs). The COVID-19 pandemic has drawn attention to MI in healthcare workers, who have been found to experience more frequent PMIEs in their day-to-day work than those in other occupational groups such as the military. These events may occur on an individual, team, organizational or system level and have been associated with increased clinician burnout and distress, and poor psychological wellbeing. This paper focuses on healthcare workers’ experiences of MI, including potential causes and ways to reduce them. There are myriad challenges that influence the development of MI, such as chronic understaffing and the pressure to treat high numbers of patients with limited resources. There are also multiple impacts of MI: at the individual-level, MI can lead to increased staff absences and understaffing, and prolonged patient contact with limited decision-making power. COVID-19 exacerbated such impacts, with a lack of organizational support during a time of increased patient mortality, and uncertainty and heightened pressure on the clinical frontline associated with scarce resources and understaffing. Potential methods for reduction of MI in healthcare workers include pre-exposure mitigation, such as fostering work environments which treat PMIEs in the same way as other occupational hazards and post-exposure mitigation, such as facilitating healthcare workers to process their experiences of PMIEs in peer support groups or with spiritual advisors and, if MI is associated with mental ill-health, talking therapies using trauma-focused and compassion-oriented frameworks.Keywords: moral injury, healthcare workers, causes, effects, mitigation, pandemic, prevention, treatment

Introduction: Moral injury (MI) significantly impacts the lives of many UK military veterans however, there is a lack of manualised treatment to address the needs of this population. To develop future treatments that are acceptable and well tolerated, veterans should be consulted on their experiences of existing psychological treatments and suggestions for future treatments., Methods: 10 UK military veterans were interviewed about their experiences of receiving treatment for psychological difficulties after MI, and beliefs about core components of future treatments. Thematic analysis of these interviews were conducted., Results: 2 superordinate themes were identified: experiences of previous mental health treatment and perceptions of the proposed treatments. Reflections on cognitive behavioural therapy were mixed, with some describing that it did not ameliorate their guilt or shame. In future treatments, focusing on values, using written letters and including therapy sessions with close companions were considered beneficial. Veterans reported that a strong rapport with therapist was key for MI treatment., Conclusion: Findings provide a useful account of how current post-trauma treatments may be experienced by patients with MI. Although limited by sample size, the results highlight therapeutic approaches that may be helpful in future and provide important considerations for therapists treating MI., Competing Interests: Competing interests: DM is a trustee at The Forces in Mind Trust, which funds this project., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Social neuroscientists have made marked progress in understanding the underlying neural mechanisms that contribute to self-esteem. However, these neural mechanisms have not been examined within the rich social contexts that theories in social psychology emphasize. Previous research has demonstrated that neural representations of the self are reflected in the brains of peers in a phenomenon called the 'self-recapitulation effect', but it remains unclear how these processes are influenced by self-esteem. In the current study, we used functional magnetic resonance imaging in a round-robin design within 19 independent groups of participants (total N = 107) to test how self-esteem modulates the representation of self-other similarity in multivariate brain response patterns during interpersonal perception. Our results replicate the self-recapitulation effect in a sample almost ten times the size of the original study and show that these effects are found within distributed brain systems underlying self-representation and social cognition. Furthermore, we extend these findings to demonstrate that individual differences in self-esteem modulate these responses within the medial prefrontal cortex, a region implicated in evaluative self-referential processing. These findings inform theoretical models of self-esteem in social psychology and suggest that greater self-esteem is associated with psychologically distanced self-evaluations from peer-evaluations in interpersonal appraisals., Competing Interests: Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Research in recent years has increasingly highlighted the relationship between exposure to potentially morally injurious events (PMIEs) and poor mental health outcomes. Human trafficking survivors often report exposure to many traumatic and PMIEs and given the complexities of trafficking exploitation, survivors may be especially vulnerable to moral injury. Despite this, no research has investigated experiences of PMIEs and moral injury in human trafficking survivors. The objective was to explore survivors' experiences of PMIEs, the impact of PMIEs on wellbeing and functioning and the factors that may influence outcomes following PMIEs., Method: Participants were seven human trafficking survivors from diverse backgrounds who had settled in the UK. In-depth semi-structured interviews were conducted via telephone. Data were analysed using thematic analysis., Results: Human trafficking survivors were found to experience multiple PMIEs, including transgressive acts committed by others and betrayal by trusted loved ones or those in positions of authority. Experiencing PMIEs contributed towards considerable psychological distress, including intense feelings of shame, anger and worthlessness, and negatively impacted survivors daily functioning. Formal support, especially practical help (e.g. warm clothing) and social support groups, were experienced as particularly beneficial., Conclusions: This study provides some of the first evidence that human trafficking survivors may be vulnerable to moral injury and indicates the impact that exposure to PMIEs can have on functioning. Future work is needed to ensure that statutory organisations consider the potential for causing moral injury when interacting with human trafficking survivors and clinical care teams are equipped to provide tailored guidance and support., Competing Interests: Declarations Ethical approval King’s College London Research Ethics Committee (HR-20/21-18272). Human ethics and consent to participate All participants provided informed consent to participate. This study was reviewed and approved by King’s College London Research Ethics Committee (HR-20/21-18272) in accordance with the Declaration of Helsinki. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Pre-prohibition psychedelic research with complex psychiatric patients generated a wealth of treatment methodologies and practices, providing invaluable clinical insights pertaining to the medical administration of psychedelics in various mental health diagnoses. Building upon these early studies, which lack the rigor and research tools available today, contemporary psychedelic research has focused on investigating the safety and efficacy of psychedelics in randomized controlled trials via psychometric measures and symptom assessments. Both then and now, the treatment context and the role of clinicians in psychedelic treatment has been recognized as an essential feature for positive patient outcomes. To broaden the knowledge base of modern psychedelic research and support the training of clinicians conducting medically supervised psychedelic research studies, this paper provides a review of pre-prohibition clinical research narratives pertaining to the phenomenology of psychedelic treatment and the role of the non-pharmacological treatment factors in the patient experience. Lastly, this paper explores a range of clinician perspectives and psychological interventions employed in pre-prohibition psychedelic research to inform future research directions and best practice guidelines., (© 2024. The Author(s).)

Background: Exposure to potentially morally injurious events is increasingly recognised as a concern across a range of occupational groups, including UK military veterans. Moral injury-related mental health difficulties can be challenging for clinicians to treat and there is currently no validated treatment available for UK veterans. We developed Restore and Rebuild (R&R) as a treatment for UK veterans struggling with moral injury-related mental health difficulties. This trial aims to examine whether it is feasible to conduct a pilot randomised controlled trial (RCT) of R&R treatment compared with a treatment-as-usual (TAU) control group., Methods: We will use a feasibility single-blind, single-site RCT design. The target population will be UK military veterans with moral injury-related mental health difficulties. We will recruit N=46 veteran patients who will be randomly allocated to R&R (n=23) or TAU (n=23). Patients randomised to R&R will receive the 20-session one-to-one treatment, delivered online. Veterans allocated to TAU, as there are currently no manualised treatments for moral injury-related mental health problems available, will receive the one-to-one treatment (online) typically provided to veterans who enter the mental health service for moral injury-related mental health difficulties. We will collect outcome measures of moral injury, post-traumatic stress disorder (PTSD), alcohol misuse, common mental disorders and trauma memory at pretreatment baseline (before randomisation), end of treatment, 12 weeks and 24 weeks post-treatment. The primary outcome will be the proportion of patients who screen positive for PTSD and moral injury-related distress post-treatment., Ethics and Dissemination: This trial will establish whether R&R is feasible, well-tolerated and beneficial treatment for veterans with moral injury-related mental health difficulties. If so, the results of the trial will be widely disseminated and R&R may improve access to effective care for those who struggle following moral injury and reduce the associated negative consequences for veterans, their families and wider society., Trial Registration Number: ISRCTN99573523., Competing Interests: Competing interests: Authors had financial support from a grant from the Forces in Mind Trust for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. DM is a trustee for the funder of this project, the Forces in Mind Trust. DL is a reservist in the UK Armed Forces. This work has been undertaken as part of his civilian employment. For the purposes of open access, the author has applied a Creative Commons Attribution (CC BY) license to any Accepted Author Manuscript version arising from this submission., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Artificial intelligence (AI) is a developing field in the context of healthcare. As this technology continues to be implemented in patient care, there is a growing need to understand the thoughts and experiences of stakeholders in this area to ensure that future AI development and implementation is successful. The aim of this study was to conduct a literature search of qualitative studies exploring the opinions of stakeholders such as clinicians, patients, and technology experts in order to establish the most common themes and ideas that have been presented in this research., Methods: A literature search was conducted of existing qualitative research on stakeholder beliefs about the use of AI use in healthcare. Twenty-one papers were selected and analysed resulting in the development of four key themes relating to patient care, patient-doctor relationships, lack of education and resources, and the need for regulations., Results: Overall, patients and healthcare workers are open to the use of AI in care and appear positive about potential benefits. However, concerns were raised relating to the lack of empathy in interactions of AI tools, and potential risks that may arise from the data collection needed for AI use and development. Stakeholders in the healthcare, technology, and business sectors all stressed that there was a lack of appropriate education, funding, and guidelines surrounding AI, and these concerns needed to be addressed to ensure future implementation is safe and suitable for patient care., Conclusion: Ultimately, the results found in this study highlighted that there was a need for communication between stakeholder in order for these concerns to be addressed, mitigate potential risks, and maximise benefits for patients and clinicians alike. The results also identified a need for further qualitative research in this area to further understand stakeholder experiences as AI use continues to develop., Competing Interests: PL is a founder and shareholder of Ultromics Ltd. BT and CAF were employees of Ultromics Ltd at the time of submission., (© The Author(s) 2024.)

Moral injury is a relatively new, but increasingly studied, construct in the field of mental health, particularly in relation to current and ex-serving military personnel. Moral injury refers to the enduring psychosocial, spiritual or ethical harms that can result from exposure to high-stakes events that strongly clash with one's moral beliefs. There is a pressing need for further research to advance understanding of the nature of moral injury; its relationship to mental disorders such as posttraumatic stress disorder and depression; triggering events and underpinning mechanisms; and prevalence, prevention and treatment. In the meantime, military leaders have an immediate need for guidance on how moral injury should be addressed and, where possible, prevented. Such guidance should be theoretically sound, evidence-informed and ethically responsible. Further, the implementation of any practice change based on the guidance should contribute to the advancement of science through robust evaluation. This paper draws together current research on moral injury, best-practice approaches in the adjacent field of psychological resilience, and principles of effective implementation and evaluation. This research is combined with the military and veteran mental health expertise of the authors to provide guidance on the design, implementation and evaluation of moral injury interventions in the military. The paper discusses relevant training in military ethical practice, as well as the key roles leaders have in creating cohesive teams and having frank discussions about the moral and ethical challenges that military personnel face., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Artificial intelligence (AI) is a rapidly developing field in healthcare, with tools being developed across various specialties to support healthcare professionals and reduce workloads. It is important to understand the experiences of professionals working in healthcare to ensure that future AI tools are acceptable and effectively implemented. The aim of this study was to gain an in-depth understanding of the experiences and perceptions of UK healthcare workers and other key stakeholders about the use of AI in the National Health Service (NHS)., Design: A qualitative study using semistructured interviews conducted remotely via MS Teams. Thematic analysis was carried out., Setting: NHS and UK higher education institutes., Participants: Thirteen participants were recruited, including clinical and non-clinical participants working for the NHS and researchers working to develop AI tools for healthcare settings., Results: Four core themes were identified: positive perceptions of AI; potential barriers to using AI in healthcare; concerns regarding AI use and steps needed to ensure the acceptability of future AI tools. Overall, we found that those working in healthcare were generally open to the use of AI and expected it to have many benefits for patients and facilitate access to care. However, concerns were raised regarding the security of patient data, the potential for misdiagnosis and that AI could increase the burden on already strained healthcare staff., Conclusion: This study found that healthcare staff are willing to engage with AI research and incorporate AI tools into care pathways. Going forward, the NHS and AI developers will need to collaborate closely to ensure that future tools are suitable for their intended use and do not negatively impact workloads or patient trust. Future AI studies should continue to incorporate the views of key stakeholders to improve tool acceptability., Trial Registration Number: NCT05028179; ISRCTN15113915; IRAS ref: 293515., Competing Interests: Competing interests: PL is a founder and shareholder of Ultromics Ltd and is an inventor on patents in the field of AI and healthcare. Ultromics Ltd uses Artificial Intelligence to build solutions that help meet the unmet needs of cardiovascular medicine, including EchoGo Pro, the Medical Device used in PROTEUS, the clinical trial associated with this qualitative research project., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Despite making up about 11% of the UK military, there remains limited investigation on the impact of adversity women experience during their service in the UK military. Military adversity can result in a range of well-being difficulties that may persist following transition out of military. The present study therefore examined the prevalence and correlates of different types of military adversity (defined as sexual harassment, sexual assault, emotional bullying and physical assault) within a community sample of UK women veterans., Methods: Participants were recruited from a UK charity supporting women veterans. 750 women veterans completed an online survey collecting information on sociodemographic and military factors, military adversity, as well as mental health and well-being difficulties. Associations between variables were explored using multivariate logistic regressions., Results: The findings indicate a high prevalence of military adversity (22.5% sexual harassment, 5.1% sexual assault, 22.7% emotional bullying and 3.3% physical assault). Younger women, those who held an officer rank during service and those who reported having a combat or combat support role during service were most at risk of military adversity. All types of adversity were significantly associated with probable post-traumatic stress disorder. Sexual harassment was additionally significantly associated with physical somatisation; sexual assault with alcohol difficulties; and emotional bullying with common mental health difficulties, low social support and loneliness., Conclusions: This study indicates that UK women veterans are at risk of a range of adverse experiences during military service and provides evidence of the impact of such adversities on mental health and well-being. Further research is required to better understand these relationships., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (© 2023 The Authors. Journal of Clinical Psychology published by Wiley Periodicals LLC.)

Background: Potentially morally injurious events (PMIEs) can negatively impact mental health. The COVID-19 pandemic may have placed healthcare staff at risk of moral injury., Aim: To examine the impact of PMIE on healthcare staff wellbeing., Methods: Twelve thousand nine hundred and sixty-five healthcare staff (clinical and non-clinical) were recruited from 18 NHS-England trusts into a survey of PMIE exposure and wellbeing., Results: PMIEs were significantly associated with adverse mental health symptoms across healthcare staff. Specific work factors were significantly associated with experiences of moral injury, including being redeployed, lack of PPE, and having a colleague die of COVID-19. Nurses who reported symptoms of mental disorders were more likely to report all forms of PMIEs than those without symptoms (AOR 2.7; 95% CI 2.2, 3.3). Doctors who reported symptoms were only more likely to report betrayal events, such as breach of trust by colleagues (AOR 2.7, 95% CI 1.5, 4.9)., Conclusion: A considerable proportion of NHS healthcare staff in both clinical and non-clinical roles report exposure to PMIEs during the COVID-19 pandemic. Prospective research is needed to identify the direction of causation between moral injury and mental disorder as well as continuing to monitor the longer term outcomes of exposure to PMIEs.

Background: Stress echocardiography (SE) is one of the most commonly used diagnostic imaging tests for coronary artery disease (CAD) but requires clinicians to visually assess scans to identify patients who may benefit from invasive investigation and treatment. EchoGo Pro provides an automated interpretation of SE based on artificial intelligence (AI) image analysis. In reader studies, use of EchoGo Pro when making clinical decisions improves diagnostic accuracy and confidence. Prospective evaluation in real world practice is now important to understand the impact of EchoGo Pro on the patient pathway and outcome., Methods: PROTEUS is a randomized, multicenter, 2-armed, noninferiority study aiming to recruit 2,500 participants from National Health Service (NHS) hospitals in the UK referred to SE clinics for investigation of suspected CAD. All participants will undergo a stress echocardiogram protocol as per local hospital policy. Participants will be randomized 1:1 to a control group, representing current practice, or an intervention group, in which clinicians will receive an AI image analysis report (EchoGo Pro, Ultromics Ltd, Oxford, UK) to use during image interpretation, indicating the likelihood of severe CAD. The primary outcome will be appropriateness of clinician decision to refer for coronary angiography. Secondary outcomes will assess other health impacts including appropriate use of other clinical management approaches, impact on variability in decision making, patient and clinician qualitative experience and a health economic analysis., Discussion: This will be the first study to assess the impact of introducing an AI medical diagnostic aid into the standard care pathway of patients with suspected CAD being investigated with SE., Trial Registration: Clinicaltrials.gov registration number NCT05028179, registered on 31 August 2021; ISRCTN: ISRCTN15113915; IRAS ref: 293515; REC ref: 21/NW/0199., Competing Interests: Declaration of Competing Interest GW, RS, WH, TD, ES, MB, OH, LT, JL, RU are all employees of Ultromics Ltd GW, RS, WH, BT, JL hold share options for Ultromics Ltd PL and RU are founders and shareholders of Ultromics Ltd and have patents in the field of AI and imaging. SEP provides consultancy to Circle Cardiovascular Imaging, Inc, Calgary, Alberta, Canada. All other authors declare that they have no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Evidence is growing regarding the impact of potentially morally injurious events (PMIEs) on mental health; yet how moral injury may affect an individual's occupational and familial functioning remains poorly understood., Method: Thirty male veterans who reported exposure to either traumatic or morally injurious events and 15 clinicians were recruited for semi-structured qualitative interviews., Results: While many veterans experienced psychological distress postevent, those who experienced PMIEs especially reported social withdrawal and engagement in aggressive, risk-taking behaviours. This was highly distressing for family members and created a tense, volatile home and workplace environment that was difficult for others to navigate. Following PMIEs, employment could be used as a cognitive avoidance strategy or as a means to atone for transgressive acts. In cases of moral injury, clinicians considered that targeted support for spouses and accessible guidance to help children to better understand how their military parent may be feeling would be beneficial., Conclusions: This study provides some of the first evidence of the pervasive negative impact of PMIEs on veterans' familial and occupational functioning. These findings highlight the need to comprehensively screen for the impact of moral injury on daily functioning in future studies that goes beyond just an assessment of psychological symptoms., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Anxiety problems are extremely common and have an early age of onset. We previously found, in a study in England, that fewer than 3% of children with an anxiety disorder identified in the community had accessed an evidence-based treatment (Cognitive Behavioural Therapy; CBT). Key ways to increase access to CBT for primary school-aged children with anxiety problems include (a) proactive identification through screening in schools, (b) supporting parents and (c) the provision of brief, accessible interventions (and capitalising on technology to do this)., Method: We provided a brief, therapist guided treatment called Online Support and Intervention (OSI) to parents/carers of children identified, through school-based screening, as likely to have anxiety problems. Fifty out of 131 children from 17 Year 4 classes in schools in England screened positive for 'possible anxiety problems' and 42 (84%) of these (and 7 who did not) took up the offer of OSI. We applied quantitative and qualitative approaches to assess children's outcomes and families' experiences of this approach., Results: Inbuilt outcome monitoring indicated session on session improvements throughout the course of treatment, with substantial changes across measures by the final module (e.g. Child Outcome Rating Scale d = 0.84; Goal Based Outcomes d = 1.52). Parent engagement and satisfaction was high as indicated by quantitative and qualitative assessments, and intervention usage., Conclusions: We provide promising preliminary evidence for the use of OSI as an early intervention for children identified as having anxiety problems through school-based screening., (© 2022 The Authors. Child and Adolescent Mental Health published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.)

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.

Background: Exposure to potentially morally injurious events (PMIE) has been found to be associated with negative mental health outcomes. Veterinary professionals (VPs) often experience challenging workplace events, but whether they experience PMIEs and the impact of exposure on their wellbeing is poorly understood. The objective of the study was to explore UK VPs experiences of PMIEs, the impact of PMIEs on VPs' wellbeing and beliefs about factors that influence VPs' exposure to PMIEs., Methods: Ten VPs were recruited. Semi-structured interviews were carried out, and data were analysed using thematic analysis., Results: VPs were found to experience PMIEs, including transgressive acts of commission or omission (e.g., being involved in or witnessing convenience euthanasia) or betrayal by trusted colleagues (e.g., bullying). Experiences of PMIEs evoked considerable psychological distress, including guilt, shame and loss of confidence in one's abilities. Several risk factors for experiencing psychological distress following a PMIE were described., Conclusions: This study provides some of the first evidence that VPs may be vulnerable to moral injury and illustrates the impact that PMIEs may have on VPs' wellbeing., Limitations: Future studies are needed to design and evaluate effective pathways for the prevention of and intervention for VPs who experience moral injury., (© 2022 British Veterinary Association.)

The COVID-19 pandemic has touched the lives of adolescents around the world. This short-term longitudinal, observational study followed 1,334 adolescents (11-17 yo) to investigate whether social-ecological resilience relates to intra- and inter-personal resources and/or the caregiver relationship relates to changes in internalizing symptoms during five stressful weeks of COVID-19 lockdown in Perú. In this work, we contextualize social-ecological resilience in relation to culturally-relevant personal and caregiver resources that youth can use to adapt to stressful situations. We found that adolescents who reported higher levels of personal, caregiver, and overall resilience had lower levels of anxiety and depressive symptoms at week six. We also find that personal, caregiver, and overall resilience moderated the change in anxiety symptoms from week 6 to week 11 of lockdown in 2020. Our findings underscore the importance of social-ecological resilience related to both intra/interpersonal resources and the caregiver relationship for minimizing the harmful impacts of COVID-19 on adolescent internalizing symptoms., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

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., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Systematically screening for child anxiety problems, and offering and delivering a brief, evidence-based intervention for children who are identified as likely to benefit would minimise common barriers that families experience in accessing treatment. We have developed a short parent-report child anxiety screening questionnaire, and procedures for administering screening questionnaires, sharing screening outcomes with families, and offering and delivering a brief parent-led online intervention (OSI: Online Support and Intervention for child anxiety) through schools. This trial aims to evaluate clinical and health economic outcomes for (1) children (aged 8-9) who screen positive for anxiety problems at baseline (target population) and (2) the wider population of all children in participating classes (total population) in schools randomly allocated to receive identification-to-intervention procedures and usual school practice ('screening and intervention'), compared to assessment and usual school practice only ('usual school practice').  METHODS: The trial design is a parallel-group, superiority cluster randomised controlled trial, with schools (clusters) randomised to 'screening and intervention' or 'usual school practice' arms in a 1:1 ratio stratified according to the level of deprivation within the school. We will recruit schools and participants in two phases (a pilot phase (Phase 1) and Phase 2), with progression criteria assessed prior to progressing to Phase 2. In total, the trial will recruit 80 primary/junior schools in England, and 398 children (199 per arm) who screen positive for anxiety problems at baseline (target population). In schools allocated to 'screening and intervention': (1) parents/carers will complete a brief parent-report child anxiety screening questionnaire (at baseline) and receive feedback on their child's screening outcomes (after randomisation), (2) classes will receive a lesson on managing fears and worries and staff will be provided with information about the intervention and (3) parents/carers of children who screen positive for anxiety problems (target population) will be offered OSI. OSI will also be available for any other parents/carers of children in participating classes (total population) who request it. We will collect child-, parent- and teacher-report measures for the target population and total population at baseline (before randomisation), 4 months, 12 months and 24 months post-randomisation. The primary outcome will be the proportion of children who screen positive for anxiety problems at baseline (target population) who screen negative for anxiety problems 12 months post-randomisation., Discussion: This trial will establish if systematic screening for child anxiety problems, sharing screening outcomes with families and delivering a brief parent-led online intervention through schools is effective and cost-effective., Trial Registration: ISRCTN registry ISRCTN76119074. Prospectively registered on 4.1.2022., (© 2022. The Author(s).)

Background: Moral injury is defined as the strong emotional and cognitive reactions following events which clash with someone's moral code, values or expectations. During the COVID-19 pandemic, increased exposure to Potentially Morally Injurious Events (PMIEs) has placed healthcare workers (HCWs) at risk of moral injury. Yet little is known about the lived experience of cumulative PMIE exposure and how NHS staff respond to this. Objective: We sought to rectify this knowledge gap by qualitatively exploring the lived experiences and perspectives of clinical frontline NHS staff who responded to COVID-19. Methods: We recruited a diverse sample of 30 clinical frontline HCWs from the NHS CHECK study cohort, for single time point qualitative interviews. All participants endorsed at least one item on the 9-item Moral Injury Events Scale (MIES) [Nash et al., 2013. Psychometric evaluation of the moral injury events scale. Military Medicine , 178 (6), 646-652] at six month follow up. Interviews followed a semi-structured guide and were analysed using reflexive thematic analysis. Results: HCWs described being routinely exposed to ethical conflicts, created by exacerbations of pre-existing systemic issues including inadequate staffing and resourcing. We found that HCWs experienced a range of mental health symptoms primarily related to perceptions of institutional betrayal as well as feeling unable to fulfil their duty of care towards patients. Conclusion: These results suggest that a multi-facetted organisational strategy is warranted to prepare for PMIE exposure, promote opportunities for resolution of symptoms associated with moral injury and prevent organisational disengagement. HIGHLIGHTS Clinical frontline healthcare workers (HCWs) have been exposed to an accumulation of potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic, including feeling betrayed by both government and NHS leaders as well as feeling unable to provide duty of care to patients.HCWs described the significant adverse impact of this exposure on their mental health, including increased anxiety and depression symptoms and sleep disturbance.Most HCWs interviewed believed that organisational change within the NHS was necessary to prevent excess PMIE exposure and promote resolution of moral distress., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Anxiety disorders are common among primary-school aged children, but few affected children receive evidence-based treatment. Identifying and supporting children who experience anxiety problems through schools would address substantial treatment access barriers that families and school staff often face. We have worked with families and school staff to co-design procedures that incorporate screening, feedback for parents, and the offer of a brief intervention in primary schools. This study sets out to assess the feasibility of a subsequent school-based cluster randomised controlled trial to evaluate these procedures. Our objectives are to ensure our procedures for identifying and supporting children with anxiety difficulties through primary schools are acceptable and there are no negative impacts, to estimate recruitment and retention rates, and to identify any changes needed to study procedures or measures., Methods: We will recruit six primary/junior schools in England (2 classes per school), and invite all children (aged 8-9) (n = 360) and their parent/carer and class teacher in participating classes to take part. Children, parents and class teachers will complete questionnaires at baseline and 12-week follow-up. Children who 'screen positive' on a 2-item parent-report child anxiety screen at baseline will be the target population (expected n = 43). Parents receive feedback on screening questionnaire responses, and where the child screens positive the family is offered support (OSI: Online Support and Intervention for child anxiety). OSI is a brief, parent-led online intervention, supported by short telephone sessions with a Children's Wellbeing Practitioner. Participants' experiences of study procedures will be assessed through qualitative interviews/discussion groups., Discussion: Evidence-based procedures for identifying and supporting children with anxiety difficulties through primary schools would improve children's access to timely, effective intervention for anxiety difficulties., Trial Registration: ISRCTN registry: ISRCTN30032471 . Retrospectively registered on 18 May 2021., (© 2022. The Author(s).)

Objectives: A very small proportion of children with anxiety problems receive evidence-based treatment. Barriers to access include difficulties with problem identification, concerns about stigma and a lack of clarity about how to access specialist services and their limited availability. A school-based programme that integrates screening to identify those children who are most likely to be experiencing anxiety problems with the offer of intervention has the potential to overcome many of these barriers. This article is a process-based account of how we used codesign to develop a primary school-based screening and intervention programme for child anxiety problems., Design: Codesign., Setting: UK primary schools., Participants: Data were collected from year 4 children (aged 8-9 years), parents, school staff and mental health practitioners., Results: We report how the developed programme was experienced and perceived by a range of users, including parents, children, school staff and mental health practitioners, as well as how the programme was adapted following user feedback., Conclusions: We reflect on the mitigation techniques we employed, the lessons learnt from the codesign process and give recommendations that may inform the development and implementation of future school-based screening and intervention programmes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

As the largest longitudinal study of adolescent brain development and behavior to date, the Adolescent Brain Cognitive Development (ABCD) Study® has provided immense opportunities for researchers across disciplines since its first data release in 2018. The size and scope of the study also present a number of hurdles, which range from becoming familiar with the study design and data structure to employing rigorous and reproducible analyses. The current paper is intended as a guide for researchers and reviewers working with ABCD data, highlighting the features of the data (and the strengths and limitations therein) as well as relevant analytical and methodological considerations. Additionally, we explore justice, equity, diversity, and inclusion efforts as they pertain to the ABCD Study and other large-scale datasets. In doing so, we hope to increase both accessibility of the ABCD Study and transparency within the field of developmental cognitive neuroscience., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Veterinary professionals (VPs) are often exposed to distressing and ethically challenging events in their line of work, yet little is known about whether they may experience moral injury and the impact potentially morally injurious events (PMIEs) may have on their wellbeing. This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of U.K. VPs., Method: Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an anonymous online questionnaire to 90 U.K. VPs between December 2020 and May 2021., Results: Exposure to PMIEs was reported by almost all VPs (89.0%), with acts of omission most frequently reported. Experiences of PMIEs were significantly associated with symptoms of PTSD ( p  < 0.01) and experiencing a betrayal event was significantly associated with PTSD symptoms (p<0.05). However, there was no significant association found between PMIE exposure and alcohol misuse or CMD ( p  > 0.05)., Conclusions: This study provides some of the first evidence that experiences of moral injury are significantly associated with adverse mental health outcomes in U.K. VPs. Future work is needed to design effective pathways for prevention and intervention for VPs exposed to highly challenging events., Highlights: U.K. veterinary professionals were found to experience moral injury.Experiences of moral injury were significantly associated with symptoms of PTSD., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Streptococcus pneumoniae (the pneumococcus) is a leading cause of pneumonia in children under 5 years of age. Coinfection by pneumococci and respiratory viruses enhances disease severity. Little is known about pneumococcal coinfections with respiratory syncytial virus (RSV). Here, we developed a novel infant mouse model of coinfection using pneumonia virus of mice (PVM), a murine analogue of RSV, to examine the dynamics of coinfection in the upper respiratory tract, an anatomical niche that is essential for host-to-host transmission and progression to disease. Coinfection increased damage to the nasal tissue and increased production of the chemokine CCL3. Nasopharyngeal pneumococcal density and shedding in nasal secretions were increased by coinfection. In contrast, coinfection reduced PVM loads in the nasopharynx, an effect that was independent of pneumococcal strain and the order of infection. We showed that this "antagonistic" effect was absent using either ethanol-killed pneumococci or a pneumococcal mutant deficient in capsule production and incapable of nasopharyngeal carriage. Colonization with a pneumococcal strain naturally unable to produce capsule also reduced viral loads. The pneumococcus-mediated reduction in PVM loads was caused by accelerated viral clearance from the nasopharynx. Although these synergistic and antagonistic effects occurred with both wild-type pneumococcal strains used in this study, the magnitude of the effects was strain dependent. Lastly, we showed that pneumococci can also antagonize influenza virus. Taken together, our study has uncovered multiple novel facets of bacterial-viral coinfection. Our findings have important public health implications, including for bacterial and viral vaccination strategies in young children. IMPORTANCE Respiratory bacterial-viral coinfections (such as pneumococci and influenza virus) are often synergistic, resulting in enhanced disease severity. Although colonization of the nasopharynx is the precursor to disease and transmission, little is known about bacterial-viral interactions that occur within this niche. In this study, we developed a novel mouse model to examine pneumococcal-viral interactions in the nasopharynx with pneumonia virus of mice (PVM) and influenza. We found that PVM infection benefits pneumococci by increasing their numbers in the nasopharynx and shedding of these bacteria in respiratory secretions. In contrast, we discovered that pneumococci decrease PVM numbers by accelerating viral clearance. We also report a similar effect of pneumococci on influenza. By showing that coinfections lead to both synergistic and antagonistic outcomes, our findings challenge the existing dogma in the field. Our work has important applications and implications for bacterial and viral vaccines that target these microbes.

Early pubertal timing has consistently been associated with internalizing psychopathology in adolescent girls. Here, we aimed to examine whether the association between timing and mental health outcomes varies by measurement of pubertal timing and internalizing psychopathology, differs between adrenarcheal and gonadarcheal processes, and is stronger concurrently or prospectively. We assessed 174 female adolescents (age 10.0-13.0 at Time 1) twice, with an 18-month interval. Participants provided self-reported assessments of depression/anxiety symptoms and pubertal development, subjective pubertal timing, and date of menarche. Their parents/guardians also reported on the adolescent's pubertal development and subjective pubertal timing. We assessed salivary dehydroepiandrosterone (DHEA), testosterone, and estradiol levels and conducted clinical interviews to determine the presence of case level internalizing disorders. From these data, we computed 11 measures of pubertal timing at both time points, as well as seven measures of internalizing psychopathology, and entered these in a Specification Curve Analysis. Overall, earlier pubertal timing was associated with increased internalizing psychopathology. Associations were stronger prospectively than concurrently, suggesting that timing of early pubertal processes might be especially important for later risk of mental illness. Associations were strongest when pubertal timing was based on the Tanner Stage Line Drawings and when the outcome was case-level Diagnostic and Statistical Manual of Mental Disorders, 4th edition ( DSM-IV ) depression or Hierarchical Taxonomy of Psychopathology (HiTOP) distress disorders. Timing based on hormone levels was not associated with internalizing psychopathology, suggesting that psychosocial mechanisms, captured by timing measures of visible physical characteristics might be more meaningful determinants of internalizing psychopathology than biological ones in adolescent girls. Future research should precisely examine these psychosocial mechanisms. (PsycInfo Database Record (c) 2022 APA, all rights reserved).