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Background: Post-traumatic stress disorder (PTSD) occurs more commonly in military veterans than the general population. Whilst current therapies are effective, up to half of veterans commencing treatment do not complete it. Reconsolidation of Traumatic Memories (RTM) protocol is a novel, easy to train, talking therapy with promising findings. We examine the feasibility of undertaking an efficacy trial of RTM in veterans. Methods: A parallel group, single-centre randomised controlled feasibility trial with a post-completion qualitative interview study. Sixty military veterans were randomised 2:1 to RTM (n = 35) or Trauma Focussed Cognitive Behaviour Therapy (CBT) (n = 25). We aimed to determine the rate of recruitment and retention, understand reasons for attrition, determine data quality and size of efficacy signal. We explored veterans' perceptions of experiences of joining the trial, the research procedures and therapy, and design improvements for future veteran studies. Military veterans with a diagnosis of PTSD or complex PTSD, and clinically significant symptoms, were recruited between January 2020 and June 2021. Primary outcome was feasibility using pre-determined progression criteria alongside PTSD symptoms, with depression, recovery, and rehabilitation as secondary outcomes. Data were collected at baseline, 6, 12, and 20 weeks. Interviews (n = 15) were conducted after 20 weeks. Both therapies were delivered by trained charity sector provider therapists. Results: Participants' mean age was 53 years, the mean baseline PTSD symptoms score assessed by the Post-traumatic Stress Checklist (PCL-5) was 57 (range 0–80). Fifty had complex PTSD and 39 had experienced ≥ 4 traumas. Data were analysed at 20 weeks for feasibility outcomes (n = 60) and mental health outcomes (n = 45). Seven of eight progression criteria were met. The RTM group experienced a mean 18-point reduction on the PCL-5. TFCBT group participants experienced a mean reduction of eight points. Forty-eight percent of the RTM group no longer met diagnostic criteria for PTSD compared to 16% in the TFCBT group. All veterans reported largely positive experiences of the therapy and research procedures and ways to improve them. Conclusion: RTM therapy remains a promising psychological intervention for the treatment of PTSD, including complex PTSD, in military veterans. With specific strengthening, the research protocol is fit for purpose in delivering an efficacy trial. Trial registration: ISRCTN registration no 10314773 on 01.10.2019. Full trial protocol: available on request or downloadable at ISRCTN reg. no. 10314773. [ABSTRACT FROM AUTHOR]

Background Research has shown that of the myriad services available to veterans in the UK, very few have been independently evaluated. This report presents the results of a randomized controlled trial assessing the impact of Time Line Therapy™ delivered by the Warrior Programme (a third-sector organization). Aims This study was aimed to determine if the intervention is effective in reducing emotional and functional difficulties in ex-service personnel. Methods A mixed-design analysis of variance model was used to investigate whether the Warrior Programme had a statistically significant impact on self-reported scores. The intervention and control group provided data on measures prior to and immediately after the intervention, and at 3-month follow-up. Results Those in the intervention group (n = 23) reported statistically significant improvements in self-reported scores immediately following intervention: the Clinical Outcomes in Routine Evaluation (CORE) scores (CORE global distress mean difference [MD] = 45.0, 95% confidence interval [CI] 31–60) (CORE subjective well-being MD = 5.9, 95% CI 3.5–8.3) (CORE functioning MD = 16.7, 95% CI 11.4–21.9) (CORE problems/symptoms MD = 19.4, 95% CI 13.1–25.7), general self-efficacy (MD = −9.8, 95% CI −13.6 to –6.8), anxiety (MD = 8.6, 95% CI 5.2–12.1), depression (MD = 10, 95% CI 6.6–13.5), post-traumatic stress disorder (MD = 26.3, 95% CI 17–25) and functional impairment (MD = 11.1, 95% CI 5.3–16.8) over time, compared to the control group (n = 29). However, score improvement was not sustained over time or statistically significant at follow-up. Conclusions The Warrior Programme was effective in reducing emotional and functional difficulties in ex-service personnel immediately after the intervention, but the effect was not sustained at 3-month follow-up. [ABSTRACT FROM AUTHOR]

Background Healthcare workers (HCWs) are vulnerable to developing mental ill-health. Prior research has shown those in managerial or supervisory positions have pivotal roles in creating a healthy work environment, as well as recognizing and supporting HCWs with mental health symptoms to improve occupational outcomes and reduce sickness absence. Aims To evaluate the effectiveness of active listening skills training (REACTMH) for UK healthcare managers. Methods Managers of HCWs were voluntarily enrolled on a REACTMH active listening skills training package. Attendees anonymously completed questionnaires before and immediately after attending the 1-h remote training session and again 1 month later. The questionnaire asked about confidence in recognizing, conversing with and supporting distressed colleagues as well as perceived usefulness and importance of the training and how often they had used the taught active listening skills. Results Fifty-eight healthcare managers enrolled onto the REACTMH programme in July 2020 and 32 (55%) completed the 1-month follow-up. Just less than half reported feeling confident in being able to identify, speak to and support potentially distressed staff before the training; significantly more (>80%) reported feeling confident 1 month afterwards (P < 0.001). Around three-quarters of attendees reported the REACTMH programme as highly useful, highly important and said they had frequently used the learned skills. Conclusions A brief active listening skills training package was associated with significant improvements healthcare manager's confidence in recognizing, speaking with and supporting HCWs with suspected mental health conditions. Further research is needed to investigate the longer term effectiveness and acceptability of REACTMH training. [ABSTRACT FROM AUTHOR]

Background Recently, the UK Armed Forces have revised the ground close combat role to include women. Aims To assess the potential mental health impact of this initiative we examined gender differences in deployment patterns, work strain, occupational factors, mental health, alcohol use and help-seeking following operational deployment. Methods The study was a secondary analysis of self-report survey data; 8799 men (88%) and 1185 women (12%) provided data. A sub-sample (47%, n = 4659) provided data concerning post-deployment help-seeking. The latter consisted of 408 women (8.8%) and 4251 men (91%). Results With the exception of alcohol misuse, which was significantly lower for women, women reported significantly more common mental disorder symptoms, subjective depression and self-harm. Women were significantly more likely to seek help from healthcare providers. Men were significantly more likely to have deployed operationally and for longer cumulative periods. Subjective work strain, but not job control, was significantly lower for women whose military careers were significantly shorter. Post-traumatic stress disorder (PTSD) symptom intensity was similar to men. Conclusions With the exception of PTSD and alcohol misuse, UK military women experience more mental health-related problems than military men. This finding was not related to the more arduous aspects of military service as women served for shorter times, deployed less and for shorter cumulative periods and were less likely to report work-related stress. [ABSTRACT FROM AUTHOR]

Background: Most studies of the psychological impact of military deployment focus on the negative and traumatic aspects. Less is known about the full range of deployment experiences nor how these may impact on career intentions. Aims: To examine subjective operational experiences and career intentions in deployed UK military personnel using data gathered toward the end of an operational deployment. Methods: Data were gathered during deployment in Iraq and Afghanistan. A self-report survey collected data on sociodemographic, operational and military factors. Respondents provided their strength of agreement or disagreement with six potentially positive deployment experiences and their endorsement or rejection of six possible career intentions. Two mental health measures assessed symptoms of common mental disorder and post-traumatic stress disorder. Results: Responses were 681 in Iran 2009 (100% response rate); 1421 in Afghanistan in 2010 (100%), 1362 in 2011 (96%) and 860 in 2015 (91%). Five of the potentially positive outcomes were endorsed by >50% of the sample: confidence about remaining healthy after returning home, pride in accomplishments, increased confidence in abilities, improved unit cohesion and experiencing a positive life effect. Ninety per cent of respondents planned to continue in service after returning home. Fewer positive deployment experiences, poorer mental health, lesser unit cohesion and more negative impressions of leadership were significantly associated with intention to leave service. Conclusions: Contrary to the popular belief that UK military personnel deployed to Iraq or Afghanistan experience negative outcomes, this paper shows that deployment can be a positive experience for a substantial majority of deployed personnel. [ABSTRACT FROM AUTHOR]

Background In the UK, little is known about the perceived effects of deployment, on military families, from military personnel in theatre. Aims To investigate military personnel's perceptions of the impact of deployment on intimate relationships and children. Methods Deployed service personnel who were in a relationship, and who had children, completed a survey while deployed on combat operations. Data were taken from four mental health surveys carried out in Iraq in 2009 and Afghanistan in 2010, 2011 and 2014. Results Among 4265 participants, after adjusting for military and social-demographic covariates, perceiving that deployment had a negative impact on intimate relationships and children was associated with psychological distress, and traumatic stress symptoms. Military personnel who reported being in danger of being injured or killed during deployment, were more likely to report a perceived negative effect of deployment on their intimate relationships. Reservists were less likely to report a perceived negative impact of deployment on their children compared with regulars. Military personnel who themselves planned to separate from their partner were more likely to report psychological distress, and stressors at home. Perceived insufficient support from the Ministry of Defence was associated with poor mental health, and holding a junior rank. Conclusions Deployed UK military personnel with symptoms of psychological distress, who experienced stressors at home, were especially likely to perceive that their family were inadequately supported by the military. Those planning to separate from their partner were at increased risk of suffering with mental health problems while deployed. [ABSTRACT FROM AUTHOR]

Background Sleep difficulties, alcohol use and mental illness are often related; military studies suggest that postdeployment is a high-risk period for sleep problems. Aims To examine the prevalence of post-deployment sleep difficulties in UK Armed Forces (UKAF) personnel and associations with alcohol use disorders (AUD) and any mental disorder (AMD) symptoms. Methods A prospective, self-report, observational study of UKAF members returning from Afghanistan, questionnaire data were collected immediately following and 6 months post-deployment. Results A total of 1636 participants provided study data at both time points. Twenty-three per cent of personnel reported sleep difficulties at follow-up; 11% reported sleep-related interference with daily functioning. Sleep problems were significantly associated with AUD and AMD. Initial post-deployment sleep problems were predictive of AMD but not AUD at follow-up. Conclusions The disclosure of alcohol misuse and mental ill-health in UKAF personnel is often inhibited by stigmatizing beliefs; detection could be enhanced by inquiring about sleep problems which may be less stigmatizing than direct enquiries about alcohol misuse and psychological well-being. [ABSTRACT FROM AUTHOR]

Aims: To determine the prevalence of comorbid probable post-traumatic stress disorder and alcohol misuse in a UK military cohort study and to determine the level of co-occurrence between these disorders; further aims were to investigate the association between alcohol misuse and the different PTSD symptom clusters, and to assess what factors are associated with probable PTSD in participants with alcohol misuse.Methods: Data from 9984 participants of Phase 2 of the health and well-being survey of serving and ex-serving members of the UK Armed Forces were assessed for probable PTSD and alcohol misuse using the PTSD checklist (PCL-C) and the alcohol use disorders identification test (AUDIT), respectively.Results: 1.8 % [95 % confidence interval (CI) 1.5-2.1] of the sample met the criteria for both PTSD and alcohol misuse. All three symptom clusters of PTSD were significantly associated with alcohol misuse, with similar odds ranging from 2.46 to 2.85. Factors associated with probable PTSD in individuals reporting alcohol misuse were age [ages 30-34 (years): OR 2.51, 95 % CI 1.15-5.49; ages 40-44 years: OR 2.77, 95 % CI 1.18-6.47], officer rank (OR 0.36, 95 % CI 0.16-0.85), being in a combat role in parent unit (OR 1.99, 95 % CI 1.20-3.31) and common mental disorder (CMD) (OR 21.56, 95 % CI 12.00-38.74).Conclusions: This study provides strong evidence that PTSD and alcohol misuse are often co-occurring. CMD was highly associated with probable PTSD in individuals with alcohol misuse. [ABSTRACT FROM AUTHOR]

Background The UK military runs a comprehensive mental health service ordinarily accessed via primary care referrals. Aims To evaluate the feasibility of self-referral to mental health services within a military environment. Methods Three pilot sites were identified; one from each service (Royal Navy, Army, Air Force). Sociodemographic information included age, rank, service and career duration. Clinical data included prior contact with general practitioner (GP), provisional diagnosis and assessment outcome. Results Of the 57 self-referrals, 69% (n = 39) had not previously accessed primary care for their current difficulties. After their mental health assessment, 47 (82%) were found to have a formal mental health problem and 41 (72%) were offered a further mental health clinician appointment. The data compared favourably with a large military mental health department that reported 87% of primary care referrals had a formal mental health condition. Conclusions The majority of self-referrals had formal mental health conditions for which they had not previously sought help from primary care; most were offered further clinical input. This supports the view that self-referral may be a useful option to encourage military personnel to seek professional care over and above the usual route of accessing care through their GP. [ABSTRACT FROM AUTHOR]

Background Trauma Risk Management (TRiM) is a peer support system developed within the British Armed Forces. It aims to ensure that trauma-exposed personnel are properly supported and encouraged to seek timely help should they develop mental health problems that fail to resolve spontaneously. Aims To summarize current knowledge about TRiM and make recommendations for further research. Methods A search of PsychINFO, CINAHL and PubMed identified 13 published papers. Results TRiM outcomes were represented in different ways within the relevant studies suggesting that TRiM may have effects additional to those that it seeks to achieve. For example, a randomized controlled trial demonstrated that TRiM had a specific positive occupational effect and did no harm; a qualitative study suggested that TRiM enhanced liaison between mental health workers and line managers and a service evaluation suggested that it reduced sickness absence. In general, the process appears to enhance trauma-exposed personnel's reliance on peer support and TRiM was reportedly acceptable and sustainable. Conclusions Evidence suggests that TRiM's utility has moved beyond the military to other organizations where personnel risk occupational traumatic exposure. Further research would help to understand how TRiM is perceived by line managers and how it functions within the trauma-prone populations. [ABSTRACT FROM AUTHOR]

Background Recent epidemiological evidence suggests that military personnel commonly remain psychologically resilient in the face of adversity they face on deployment. However, the processes that promote resilience have not been well assessed within the UK military. For many years, the UK Armed Forces have operated a policy of rest and recuperation (R&R), which refers to the brief period during which troops return home when on an operational tour of duty. While R&R is thought to play an import ant role in promoting recovery and well-being, there is as yet no empirical evidence to support its effectiveness. Aims To explore whether R&R promotes well-being and recovery from the strains of deployment in military personnel. Methods Participants completed self-report measures of mental health and exposure to potentially traumatic events (PTEs), as well as an R&R Recovery Questionnaire (R&RRQ). Results Statistical analysis indicated that the R&RRQ was a reliable measure within the sample of 97 subjects. Participants who reported recovery following R&R reported fewer symptoms of mental health difficulties. However, increased deployment exposure to PTEs was associated with feeling less recovered at the end of R&R. Conclusions These preliminary data suggest that R&R can be useful for troops if they can use the time to recover. This study’s results are relevant to policymakers and leaders in the military and other groups placed in challenging environments but more work is needed to understand how R&R works and to maximize its capacity to promote well-being among military personnel. [ABSTRACT FROM AUTHOR]

Objective: The objective of the study was to elicit beliefs and experiences of the value of a screening programme for mental illness among UK military personnel. Method: Three months after returning from Afghanistan 21 army personnel participated in a qualitative study about mental health screening. One-to-one interviews were conducted and recorded. Data-driven thematic analysis was used. Researchers identified master themes represented by extracts of text from the 21 complete transcripts. Results: Participants made positive remarks on the advantages of screening. Noted barriers to seeking help included: unwillingness to receive advice, a wish to deal with any problems themselves and a belief that military personnel should be strong enough to cope with any difficulties. Participants believed that overcoming barriers to participating in screening and seeking help would be best achieved by making screening compulsory. Conclusions: Although respondents were positive about a screening programme for mental illness, the barriers to seeking help for mental illness appear deep rooted and reinforced by the value ascribed to hardiness. [ABSTRACT FROM AUTHOR]

Background Trauma-support programmes may benefit employees of organizations that routinely expose their staff to traumatic events. However, in order for such programmes to be effective, staff need to find them acceptable.Aims To investigate whether Trauma Risk Management (TRiM), an example of such a programme, is acceptable within a military population and whether it is viewed as complementing or replacing pre-existing personnel support systems.Methods Semi-structured interviews were undertaken with serving Royal Navy personnel who had served on one of six ships, which had received TRiM training some 12–18 months previously. Three hundred and thirty interview transcripts were subjected to qualitative analysis and themed categories were generated.Results The majority of personnel who were aware of TRiM were supportive of its aims. TRiM was also viewed as supplementing other personnel support measures rather than replacing them. Personnel interviewed thought that TRiM practitioners needed to be carefully selected, supported by line management and to pay particular attention to the issue of confidentiality.Conclusions The TRiM system appeared generally acceptable to military personnel and is seen to supplement rather than replace existing mechanisms. However, these data support careful selection of potential TRiM practitioners and demonstrate the need for senior management support for the system if it is to be accepted by those who might benefit from its use. [ABSTRACT FROM AUTHOR]

BackgroundEmployers such as the Armed Forces (AF) and emergency services, who predictably expose their staff to potentially traumatic events (PTEs), often provide psycho-educational briefings in an attempt to mitigate possible adverse psychological sequelae. Within the military, psycho-educational briefings are widely used, particularly following exposure to PTEs on operations. The aim of this review was to evaluate the efficacy of these interventions and make appropriate recommendations.MethodA search of Medline, PsycINFO and EMBASE was conducted, bibliographies of retrieved articles were searched and experts in the field were consulted.ResultsTwo surveys and seven intervention studies were identified for inclusion in the review. Only three studies were randomized controlled trials (RCTs). Overall, the review found some evidence of benefit of psycho-educational interventions but it was not consistent across studies or outcomes and effects were small. However, there was also little evidence to suggest that they caused harm. There was some evidence that the beneficial effects may be greater for those who have been exposed to a higher number of PTEs.ConclusionsGiven the high operational tempo currently faced by coalition forces personnel, there remains a pressing need to identify the most effective way of minimizing the impact of exposure to potentially traumatic deployment incidents. To date, few psycho-educational interventions designed to prevent deployment-related psychological ill-health have been evaluated systematically in methodologically robust studies. The review recommends that future interventions are theoretically based and evaluated in cluster RCTs that examine both process and outcome variables. [ABSTRACT FROM PUBLISHER]

Background Despite having high levels of combat exposure, commando and airborne forces may be at less risk of mental ill-health than other troops.Aims To examine differences in mental health outcomes and occupational risk factors between Royal Marines Commandos (RMCs), paratroopers (PARAs) and other army infantry (INF).Methods Three groups of personnel (275 RMCs, 202 PARAs and 572 INF) were generated from a UK military cohort study of personnel serving at the time of the 2003 Iraq war. Participants completed a questionnaire about their mental health and experiences on deployment. Differences in mental health outcomes between the groups were examined with logistic regression and negative binomial regression analyses.Results Both RMCs and PARAs were less likely to have multiple physical symptoms or to be fatigued, and RMCs also had lower levels of general mental health problems and lower scores on the Post-traumatic Checklist than INF personnel. Differences were not explained by the level of unit cohesion.Conclusions The effect of warfare on troops’ well-being is not universal across occupational groups. A possible explanation for this difference is that the high level of preparedness in RMCs and PARAs may lessen the psychological impact of war-zone deployment experiences. [ABSTRACT FROM AUTHOR]

Background. Mild traumatic brain injury (mTBI) is being claimed as the ' signature ' injury of the Iraq war, and is believed to be the cause of long-term symptomatic ill health (post-concussional syndrome; PCS) in an unknown proportion of military personnel. Method. We analysed cross-sectional data from a large, randomly selected cohort of UK military personnel deployed to Iraq (n=5869). Two markers of PCS were generated : 'PCS symptoms' (indicating the presence of mTBI-related symptoms: none, 1-2, 3+) and 'PCS symptom severity ' (indicating the presence of mTBI-related symptoms at either a moderate or severe level of severity : none, 1-2, 3+). Results. PCS symptoms and PCS symptom severity were associated with self-reported exposure to blast whilst in a combat zone. However, the same symptoms were also associated with other in-theatre exposures such as potential exposure to depleted uranium and aiding the wounded. Strong associations were apparent between having PCS symptoms and other health outcomes, in particular being a post-traumatic stress disorder or General Health Questionnaire case. Conclusions. PCS symptoms are common and some are related to exposures such as blast injury. However, this association is not specific, and the same symptom complex is also related to numerous other risk factors and exposures. Post-deployment screening for PCS and/or mTBI in the absence of contemporaneous recording of exposure is likely to be fraught with hazards. [ABSTRACT FROM AUTHOR]

BackgroundThere is considerable interest in understanding further the factors that increase the risk of post-traumatic stress disorder (PTSD) for military personnel. This study aimed to investigate the relative contribution of demographic variables; childhood adversity; the nature of exposure to traumatic events during deployment; appraisal of these experiences; and home-coming experiences in relation to the prevalence of PTSD ?caseness? as measured by a score of 50 on the PTSD Checklist (PCL) in UK Armed Forces personnel who have been deployed in Iraq since 2003.MethodData were drawn from the first stage of a retrospective cohort study comparing UK military personnel who were deployed to the 2003 Iraq War with personnel serving in the UK Armed Forces on 31 March 2003 but who were not deployed to the initial phase of war fighting. Participants were randomly selected and invited to participate. The response rate was 61%. We have limited these analyses to 4762 regular service individuals who responded to the survey and who have been deployed in Iraq since 2003.ResultsPost-traumatic stress symptoms were associated with lower rank, being unmarried, having low educational attainment and a history of childhood adversity. Exposure to potentially traumatizing events, in particular being deployed to a ?forward? area in close contact with the enemy, was associated with post-traumatic stress symptoms. Appraisals of the experience as involving threat to one''s own life and a perception that work in theatre was above an individual''s trade and experience were strongly associated with post-traumatic stress symptoms. Low morale and poor social support within the unit and non-receipt of a home-coming brief (psycho-education) were associated with greater risk of post-traumatic stress symptoms.ConclusionsPersonal appraisal of threat to life during the trauma emerged as the most important predictor of post-traumatic stress symptoms. These results also raise the possibility that there are important modifiable occupational factors such as unit morale, leadership, preparing combatants for their role in theatre which may influence an individual''s risk of post-traumatic stress symptoms. Therefore interventions focused on systematic preparation of personnel for the extreme stress of combat may help to lessen the psychological impact of deployment. [ABSTRACT FROM AUTHOR]

Background: Little is known about what support the United Kingdom (UK) armed forces require when they return from operations. Aims: To investigate the perceived psychological support requirements for service personnel on peacekeeping deployments when they return home from operations and examine their views on the requirement for formal psychological debriefings. Methods: A retrospective cohort study examined the perceived psychological needs of 1202 UK peacekeepers on return from deployment. Participants were sent a questionnaire asking about their perceived needs relating to peacekeeping deployments from April 1991 to October 2000. Results: Results indicate that about two-thirds of peacekeepers spoke about their experiences. Most turned to informal networks, such as peers and family members, for support. Those who were highly distressed reported talking to medical and welfare services. Overall, speaking about experiences was associated with less psychological distress. Additionally, two thirds of the sample was in favour of a formalised psychological debriefing on return to the UK. Conclusions: This study suggests that most peacekeepers do not require formalised interventions on homecoming and that more distressed personnel are already accessing formalised support mechanisms. Additionally social support from peers and family appears useful and the UK military should foster all appropriate possibilities for such support. Declaration of Interest: The Stage 1 study was funded by the US Department of Defence (DoD) and the follow up study by the Medical Research Counsel (MRC). Neither the DoD nor MRC had any input into the design, conduct, analysis or reporting of the study. The views expressed are not those of any US or UK governmental organisation. We thank Mr Nick Blatchley of MOD for help in identifying the cohorts. [ABSTRACT FROM AUTHOR]

Background The Department of Community Mental Health (DCMH) at RAF Brize Norton runs a regular anxiety management day (AMD) which is a group intervention for regular military personnel who have been diagnosed with anxiety-related disorders. The AMD is a 1 day course for up to 20 participants run by two community mental health nurses based at the DCMH. It contains a combination of psycho-education and generic anxiety management techniques. Aims To establish whether the AMD is acceptable to full time regular military personnel who have been referred to the DCMH. Methods The acceptability of the AMD was assessed using a standardized feedback form, which asked about the patient’s perception of the quality of the AMD and the course content. Feedback data were collected over a 12 month period between September 2010 and August 2011. Results Clinical and sociodemographic data were available for 91 of the 97 (94%) participants who participated in the AMD over the period from September 2010 to August 2011. Ninety-two per cent (89/97) of participants completed a post course survey immediately after they completed the AMD. Respectively, 95 and 93% considered the format and content of the AMD to be of good quality. Conclusions The AMD fits well with the stepped care approach of the Improving Access to Psychological Therapies programme and resulted in a good level of patient satisfaction. [ABSTRACT FROM PUBLISHER]

Introduction: Working on the frontline during the COVID-19 pandemic has been associated with increased risk to mental health and wellbeing in multiple occupations and contexts. The current study aimed to provide an insight into the rate of probable mental health problems amongst United Kingdom (UK) Government employees who contributed to the COVID-19 response whilst working from home, and to ascertain what factors and constructs, if any, influence mental health and wellbeing in the sample population., Method: This paper reports on the findings from two studies completed by UK Government employees. Study 1: A cross-sectional online survey, containing standardised and validated measures of common mental health disorders of staff who actively contributed to the COVID-19 response from their own homes. Binary logistic regression was used to assess factors associated with mental health outcomes. Study 2: A secondary data analysis of cross-sectional survey data collected across three timepoints (May, June, and August) in 2020 focusing on the wellbeing of employees who worked from home during the COVID-19 pandemic., Results: Study 1: 17.9% of participants met the threshold criteria for a probable moderate anxiety disorder, moderate depression, or post-traumatic stress disorder. Younger, less resilient, less productive individuals, with lower personal wellbeing and less enjoyment of working from home, were more likely to present with poorer mental health. Study 2: Found lower wellbeing was consistently associated with having less opportunities to look after one's physical and mental health, and having unsupportive line managers and colleagues., Conclusion: It is important to ensure UK Government employees' psychological needs are met whilst working from home and responding to enhanced incidents. It is recommended that workplaces should be seeking to continually build and improve employee resilience (e.g., through opportunities to increase social ties and support networks), essentially ensuring employees have necessary resources and skills to support themselves and others., (© 2024. The Author(s).)

Background: The link between poor cardiovascular health (CVH), lifestyle and mild cognitive impairment (MCI) has been well established in the general population. However, there is limited research exploring these associations in ageing UK veterans., Aims: This study explored the risk of MCI and its association with nine CVH and lifestyle risk factors (including diabetes, heart disease, high cholesterol, high blood pressure, obesity, stroke, physical inactivity, the frequency of alcohol consumption and smoking) in UK veterans and non-veterans., Methods: This prospective cohort study comprised data from the PROTECT study between 2014 and 2022. Participants comprised of UK military veterans and non-veterans aged ≥50 years at baseline. Veteran status was defined using the Military Service History Questionnaire. CVH and lifestyle risk factors were defined using a combination of self-report measures, medication history or physical measurements. MCI was defined as the presence of subjective and objective cognitive impairment., Results: Based on a sample of 9378 veterans (n = 488) and non-veterans (n = 8890), the findings showed the risk of MCI significantly reduced in veterans with obesity, those who frequently consumed alcohol and were physically inactive compared to non-veterans. The risk of MCI significantly increased in veterans with diabetes (hazards ratio [HR] = 2.22, 95% confidence interval [CI] 1.04-4.75, P ≤ 0.05) or high cholesterol (HR = 3.11, 95% CI 1.64-5.87, P ≤ 0.05) compared to veterans without., Conclusions: This study identified CVH and lifestyle factors of MCI in UK veterans and non-veterans. Further work is needed to understand these associations and the underpinning mechanisms which could determine intervention strategies to reduce the risk of MCI., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society of Occupational Medicine.)

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.)

Aims: Police employees may experience high levels of stress due to the challenging nature of their work which can then lead to sickness absence. To date, there has been limited research on sickness absence in the police. This exploratory analysis investigated sickness absence in UK police employees., Methods: Secondary data analyses were conducted using data from the Airwave Health Monitoring Study (2006-2015). Past year sickness absence was self-reported and categorised as none, low (1-5 days), moderate (6-19 days) and long-term sickness absence (LTSA, 20 or more days). Descriptive statistics and multinomial logistic regressions were used to examine sickness absence and exploratory associations with sociodemographic factors, occupational stressors, health risk behaviours, and mental health outcomes, controlling for rank, gender and age., Results: From a sample of 40,343 police staff and police officers, forty-six per cent had no sickness absence within the previous year, 33% had a low amount, 13% a moderate amount and 8% were on LTSA. The groups that were more likely to take sick leave were women, non-uniformed police staff, divorced or separated, smokers and those with three or more general practitioner consultations in the past year, poorer mental health, low job satisfaction and high job strain., Conclusions: The study highlights the groups of police employees who may be more likely to take sick leave and is unique in its use of a large cohort of police employees. The findings emphasise the importance of considering possible modifiable factors that may contribute to sickness absence in UK police forces.

Purpose: Structural and attitudinal barriers often hinder treatment-seeking for mental health problems among members of the Armed Forces. However, little is known about potential gender differences in structural and attitudinal barriers among members of the UK Armed Forces. The current study aimed to explore how men and women differ in terms of these barriers to care among a sample of UK Armed Forces personnel and veterans with self-reported mental health problems., Methods: Currently serving and ex-serving members of the UK Armed Forces who self-reported a mental health problem were invited to participate in a semi-structured phone interview on mental health and treatment-seeking. The final sample included 1448 participants (1229 men and 219 women). All participants reported on their current mental health, public stigma, self-stigma, and barriers to mental healthcare., Results: Overall, men and women reported similar levels of both structural and attitudinal barriers, with no significant differences detected. The highest scores for both men and women were observed in attitudinal barriers relating to self-stigma domains, which encapsulate internalised attitudes and beliefs about mental illness and treatment., Conclusions: Findings suggest that anti-stigma campaigns can be targeted simultaneously at both men and women within the Armed Forces. In particular, targeting self-stigma may be beneficial for health promotion campaigns., (© 2023. The Author(s).)

Introduction: This is the fourth phase of a longitudinal cohort study (2022-2023) to investigate the health and well-being of UK serving (Regulars and Reservists) and ex-serving personnel (veterans) who served during the era of the Iraq and Afghanistan conflicts. The cohort was established in 2003 and has collected data over three previous phases including Phase 1 (2004-2006), Phase 2 (2007-2009) and Phase 3 (2014-2016)., Methods and Analysis: Participants are eligible to take part if they completed the King's Centre for Military Health Research Health and Wellbeing Cohort Study at Phase 3 (2014-2016) and consented to be recontacted (N=7608). Participants will be recruited through email, post and text message to complete an online or paper questionnaire. Data are being collected between January 2022 and September 2023. Health and well-being measures include measures used in previous phases that assess common mental disorders, post-traumatic stress disorder (PTSD) and alcohol misuse. Other areas of interest assess employment, help-seeking and family relationships. New topics include the impact of the British withdrawal from Afghanistan in 2021, complex PTSD (C-PTSD), illicit drug use, gambling and loneliness. Analyses will describe the effect size between groups deployed to Iraq and/or Afghanistan or not deployed, and those who are currently in service versus ex-service personnel, respectively, reporting prevalences with 95% CIs, and ORs with 95% CI. Multivariable logistic and multiple linear regression analyses will be conducted to assess various health and well-being outcomes and associations with risk and protective factors., Ethics and Dissemination: Ethical approval has been granted by the Ministry of Defence Research Ethics Committee (Ref: 2061/MODREC/21). Participants are provided with information and agree to a series of consent statements before taking part. Findings will be disseminated to UK Armed Forces stakeholders and international research institutions through stakeholder meetings, project reports and scientific publications., Competing Interests: Competing interests: M-LS, MJ, LH, SF and NM salaries are funded through a grant by the Office for Veterans’ Affairs (OVA). RL and HB salaries are part funded through a grant by the OVA. AS is a serving Regular member of the British Army, salaried and seconded by the Ministry of Defence (MOD) to King’s College London. DL is a Reservist in the UK Armed Forces. This work has been undertaken as part of his civilian employment. NG is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King’s College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University and is also a trustee with the Faculty and Society of Occupational Medicine. DMu is a trustee of the Forces in Mind Trust (unpaid) and is employed as the Head of Research for Combat Stress, a UK veterans mental health charity. DMa is employed as joint head of service of the London NHS Veterans Mental Health and Wellbeing Service (Op Courage). SS is supported by the NIHR Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and funded by the National Institute for Health and Care Research, NIHR Advanced Fellowship, Dr Sharon Stevelink, NIHR300592. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. SW is Honorary Civilian Consultant Advisor in Psychiatry for the British Army (unpaid) and is a board member of NHS England. SW is affiliated to the NIHR HPRU in Emergency Preparedness and Response at King’s College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University. NTF is a trustee of Help for Heroes—a charity supporting the well-being of veterans and their families, and their salary is part grant funded by the MOD. SP declares no competing interests., (© 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.)

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.

Objective: The current study examined links between adverse mental health, job strain, and likelihood and frequency of primary care consultations among police employees., Methods: We conducted secondary data analysis on the Airwave Health Monitoring Study data ( n = 33,730). Measures included self-report data on mental health, job strain, job support, and primary care consultations in the past 12 months. Data were analyzed using a zero-inflated Poisson regression framework., Results: Findings showed that overall, help seeking was low based on mental health status and job strain. Adverse mental health was associated with more primary care consultations. Police employees with high, active, or passive job strain reported more primary care consultation compared with police employees with low strain., Conclusions: Findings suggest that more work to reduce stigma of taking the initial step of help seeking would be beneficial., Competing Interests: Conflict of Interest: N.T.F. reports grants from the UK MoD and Office for Veterans' Affairs (Cabinet Office), is a trustee (unpaid) of Help for Heroes, is a member of the Emergency Responders Senior Leaders Board, the Gallipoli Medical Research Foundation, and is an independent advisor to the Independent Group Advising NHS Digital on the Release of patient Data (IGARD). N.G. runs a psychological health consultancy that provides training and support to some UK police forces. S.W. is Dean IOPPN KCL, a NED on the local mental health trust, SLAM, on the ESRC Council, the JAC, and others. None are relevant to this article. S.A.M.S. is supported by the National Institute for Health and Care Research (NIHR) Maudsley Biomedical Research Centre at South London, Maudsley NHS Foundation Trust, and the NIHR Advanced Fellowship (NIHR300592). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Occupational and Environmental Medicine.)

Objectives: Excessive alcohol use can bring about adverse health and work-related consequences in civilian and military populations. Screening for excessive drinking can help identify individuals at risk for alcohol-related problems who may require clinical interventions. The brief validated measures of alcohol use such as the Alcohol Use Disorders Identification Test (AUDIT), or abbreviated AUDIT-Consumption (AUDIT-C), are often included in military deployment screening and epidemiologic surveys, but appropriate cut-points must be used to effectively identify individuals at risk. Although the conventional AUDIT-C cut-points ≥4 for men and ≥3 for women are commonly used, recent validation studies of veterans and civilians recommend higher cut-points to minimise misclassification and overestimation of alcohol-related problems. This study aims to ascertain optimal AUDIT-C cut-points for detecting alcohol-related problems among serving Canadian, UK and US soldiers., Design: Cross-sectional pre/post-deployment survey data were used., Settings: Comprised Army locations in Canada and UK, and selected US Army units., Participants: Included soldiers in each of the above-mentioned settings., Outcome Measures: Soldiers' AUDIT scores for hazardous and harmful alcohol use or high levels of alcohol problems served as a benchmark against which optimal sex-specific AUDIT-C cut-points were assessed., Results: Across the three-nation samples, AUDIT-C cut-points of ≥6/7 for men and ≥5/6 for women performed well in detecting hazardous and harmful alcohol use and provided comparable prevalence estimates to AUDIT scores ≥8 for men and ≥7 for women. The AUDIT-C cut-point ≥8/9 for both men and women performed fair-to-good when benchmarked against AUDIT ≥16, although inflated AUDIT-C-derived prevalence estimates and low positive predictive values were observed., Conclusion: This multi-national study provides valuable information regarding appropriate AUDIT-C cut-points for detecting hazardous and harmful alcohol use, and high levels of alcohol problems among soldiers. Such information can be useful for population surveillance, pre-deployment/post-deployment screening of military personnel, and clinical practice., Competing Interests: Competing interests: NTF is a trustee (unpaid) of Help for Heros and is a specialist advisor to the Advisory Group for Data (for NHS England). Materials for this study has been reviewed by the Walter Reed Army Institute of Research, and the Surgeon General Health Research Program of Canada. This research has been coordinated by the DND/CAF Social Science Research Review Board. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of Defense. The investigators have adhered to the policies for protection of human subjects as prescribed in AR 70–25., (© 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.)

Background: The British Police Service and Armed Forces are male-dominated occupations, characterised by frequent trauma exposure and intensive demands. Female police employees and military personnel may have unique experiences and face additional strains to their male counterparts. This analysis compared the levels of post-traumatic stress disorder (PTSD), hazardous/harmful alcohol consumption, and comorbidity in female police employees and military personnel., Methods: Police data were obtained from the Airwave Health Monitoring Study (N = 14,145; 2007-2015) and military data from the Health and Wellbeing Cohort Study (N = 928; phase 2: 2007-2009 and phase 3: 2014-2016). Multinomial/logistic regressions analysed sample differences in probable PTSD, hazardous (14-35 units per week) and harmful (35 + units per week) alcohol consumption, and comorbid problems. We compared covariate adjustment and entropy balancing (reweighting method controlling for the same covariates) approaches., Results: There were no significant differences in probable PTSD (police: 3.74% vs military: 4.47%) or hazardous drinking (police: 19.20% vs military: 16.32%). Female military personnel showed significantly higher levels of harmful drinking (4.71%) than police employees (2.42%; Adjusted Odds Ratios [AOR] = 2.26, 95% Confidence Intervals [CIs] = 1.60-3.21), and comorbidity (1.87%) than police employees (1.00%, AOR = 2.07, 95% CI = 1.21-3.54). Entropy balancing and covariate-adjustments obtained the same results., Conclusions: Comparable levels of probable PTSD were observed, which are slightly lower than estimates observed in the female general population. Future research should explore the reasons for this. However, female military personnel showed higher levels of harmful drinking than police employees, emphasising the need for alcohol interventions in military settings., (© 2022. The Author(s).)

Background: Partners and family can play a key role in encouraging military service and ex-service personnel to seek help for their mental health. Community Reinforcement Approach and Family Training (CRAFT) was developed to equip concerned significant others (CSOs) of those experiencing substance use disorders with skills to encourage their loved one to enter treatment and improve their own well-being. It was adapted in the US for CSOs of ex-service personnel with post-traumatic stress disorder (PTSD) (VA-CRAFT). Objective: This study aimed to evaluate an adaptation of VA-CRAFT for use with CSOs of serving and ex-service personnel experiencing PTSD and Common Mental Disorders in the UK (UKV-CRAFT). Method: Acceptability of UKV-CRAFT was assessed with interviews with experts, namely key stakeholders ( n  = 15) working in support provision for serving and ex-service personnel. In addition, individuals who took part in a small-scale demonstrative trial of UKV-CRAFT (three CSOs and three facilitators who delivered UKV-CRAFT) provided feedback. Results: UKV-CRAFT was viewed positively, with interviewees highlighting that programmes like UKV-CRAFT filled a gap in provision for UK Armed Forces families as most services were only available to the serving or ex-service personnel. Interviewees praised how UKV-CRAFT enhanced CSO well-being and communication with their loved one. Concerns over the confidentiality of taking part in UKV-CRAFT were raised due to the perceived negative effects of highlighting a loved one's mental ill health, especially for CSOs of serving personnel. Ideas for improvement included broadening access to all CSOs regardless of whether their loved one was seeking treatment. Conclusion: Interviewees regarded UKV-CRAFT as a potentially useful intervention suggesting it could be proactively offered universally to support timely help-seeking if required. We recommend further evaluation of UKV-CRAFT on a wider scale, incorporating our recommendations, to assess its effectiveness accurately.

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: Healthcare workers (HCWs) have provided vital services during the COVID-19 pandemic, but existing research consists of quantitative surveys (lacking in depth or context) or qualitative interviews (with limited generalisability). Structural Topic Modelling (STM) of large-scale free-text survey data offers a way of capturing the perspectives of a wide range of HCWs in their own words about their experiences of the pandemic., Methods: In an online survey distributed to all staff at 18 geographically dispersed NHS Trusts, we asked respondents, "Is there anything else you think we should know about your experiences of the COVID-19 pandemic?". We used STM on 7,412 responses to identify topics, and thematic analysis on the resultant topics and text excerpts., Results: We identified 33 topics, grouped into two domains, each containing four themes. Our findings emphasise: the deleterious effect of increased workloads, lack of PPE, inconsistent advice/guidance, and lack of autonomy; differing experiences of home working as negative/positive; and the benefits of supportive leadership and peers in ameliorating challenges. Themes varied by demographics and time: discussion of home working decreasing over time, while discussion of workplace challenges increased. Discussion of mental health was lowest between September-November 2020, between the first and second waves of COVID-19 in the UK., Discussion: Our findings represent the most salient experiences of HCWs through the pandemic. STM enabled statistical examination of how the qualitative themes raised differed according to participant characteristics. This relatively underutilised methodology in healthcare research can provide more nuanced, yet generalisable, evidence than that available via surveys or small interview studies, and should be used in future research., Competing Interests: MH, RR, and SW are senior NIHR Investigators. SW has received speaker fees from Swiss Re for two webinars on the epidemiological impact of COVID 19 pandemic on mental health. RR reports grants from DHSC/UKRI/ESRC COVID-19 Rapid Response Call, grants from Rosetrees Trust, grants from King’s Together rapid response call, grants from UCL (Wellcome Trust) rapid response call, during the conduct of the study; & grants from NIHR outside the submitted work. MH reports grants from DHSC/UKRI/ESRC COVID-19 Rapid Response Call, grants from Rosetrees Trust, grants from King’s Together rapid response call, grants from UCL Partners rapid response call, during the conduct of the study; grants from Innovative Medicines Initiative and EFPIA, RADAR-CNS consortium, grants from MRC, grants from NIHR, outside the submitted work. SS reports grants from UKRI/ESRC/DHSC, grants from UCL, grants from UKRI/MRC/DHSC, grants from Rosetrees Trust, grants from King’s Together Fund, and an NIHR Advanced Fellowship [ref: NIHR 300592] during the conduct of the study. NG reports a potential COI with NHSEI, during the conduct of the study; and I am the managing director of March on Stress Ltd which has provided training for a number of NHS organisations although I am not clear if the company has delivered training to any of the participating trusts or not as I do not get directly involved in commissioning specific pieces of work. DL is funded by the NIHR ARC North Thames. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. Other authors report no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Mental disorders and alcohol misuse are often comorbid, and this comorbidity is more common in those who develop mental disorders following exposure to traumatic events., Aims: To investigate the relationship between combat exposure and operational role (support versus combat) with mental disorders and associated comorbidity in a UK military cohort., Methods: 4896 participants from a UK military cohort reported their operational role and frequency of exposure to combat events during deployment. Outcome measures included self-reported post-traumatic stress disorder, common mental disorder and alcohol misuse., Results: Personnel reporting higher levels of combat exposure were more likely to meet criteria for two or more co-occurring mental disorders (odds ratio [OR] 3.90, 95% confidence interval [CI] 2.73-5.58). While having a combat role increased the risk of developing co-occurring disorders compared to having a support role (OR 1.67, 95% CI 1.26-2.23), this effect diminished following adjustment for variables including combat exposure (OR 0.89, 95% CI 0.62-1.27)., Conclusions: Combat exposure may play a greater role in the development of comorbid mental disorders than operational role, i.e. job title. Clinicians treating military personnel should be alert to the increased risk of comorbid mental disorders and alcohol misuse among those with a history of combat exposure.

Competing Interests: The authors have read the journal’s policy and have the following conflicts: SAMS, MH and SW are supported by the National Institute for Health Research (NIHR) Maudsley Biomedical Research Centre at South London and Maudsley NHS Foundation Trust. SAMS is supported by the National Institute for Health Research, NIHR Advanced Fellowship, Dr Sharon Stevelink, NIHR300592. NTF salaries are part funded by the UK Ministry of Defence (MoD). NTF is a trustee with a military charity, and is an independent advisor to the Independent Group Advising on the Release of Data (IGARD) for NHS Digital. NG is a trustee with two military charities, undertakes voluntary roles with the Royal College of Psychiatrists and runs his own psychological health consultancy. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, MoD or the Department of Health and Social Care.

Background: Healthcare workers (HCWs) are frontline responders to emergency infectious disease outbreaks such as COVID-19. To avoid the rapid spread of disease, adherence to protective measures is paramount. We investigated rates of correct use of personal protective equipment (PPE), hand hygiene and physical distancing in UK HCWs who had been to their workplace at the start of the COVID-19 pandemic and factors associated with adherence., Methods: We used an online cross-sectional survey of 1035 UK healthcare professionals (data collected 12-16 June 2020). We excluded those who had not been to their workplace in the previous 6 weeks, leaving us with a sample size of 831. Respondents were asked about their use of PPE, hand hygiene and physical distancing in the workplace. Frequency of uptake was reported descriptively; adjusted logistic regressions were used to separately investigate factors associated with adherence to use of PPE, maintaining good hand hygiene and physical distancing from colleagues., Results: Adherence to personal protective measures was suboptimal (PPE use: 80.0%, 95% CI 77.3 to 82.8; hand hygiene: 67.8%, 95% CI 64.6 to 71.0; coming into close contact with colleagues: 74.7%, 95% CI 71.7 to 77.7). Adherence to PPE use was associated with having received training about health and safety in the workplace for COVID-19, greater perceived social pressure to adopt the behaviour and availability of PPE. Non-adherence was associated with fatalism about COVID-19 and greater perceived difficulty of adopting protective measures. Workplace design using markings to facilitate distancing was associated with adherence to physical distancing., Conclusions: Uptake of personal protective behaviours among UK HCWs at the start of the pandemic was variable. Factors associated with adherence provide insight into ways to support HCWs to adopt personal protective behaviours, such as ensuring that adequate PPE is available and designing workplaces to facilitate physical distancing., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: For a small minority of personnel, military service can have a negative impact on their mental health. Yet no studies have assessed how the mental health of UK veterans (who served during the recent operations in Afghanistan or Iraq) compares to non-veterans, to determine if they are at a disadvantage. We examine the prevalence of mental disorders and alcohol misuse in UK veterans compared to non-veterans., Methods: Veteran data were taken from the third phase of the King's Centre for Military Health Research cohort study (n = 2917). These data were compared with data on non-veterans taken from two large general population surveys: 2014 Adult Psychiatric Morbidity Survey (n = 5871) and wave 6 of the UK Household Longitudinal Study (UKHLS, n = 22 760)., Results: We found that, overall, UK veterans who served at the time of recent military operations were more likely to report a significantly higher prevalence of common mental disorders (CMD) (23% v. 16%), post-traumatic stress disorder (PTSD) (8% v. 5%) and alcohol misuse (11% v. 6%) than non-veterans. Stratifying by gender showed that the negative impact of being a veteran on mental health and alcohol misuse was restricted to male veterans. Being ill or disabled was associated with a higher prevalence of CMD and PTSD for both veterans and non-veterans., Conclusion: Whilst the same sociodemographic groups within the veteran and non-veteran populations seemed to have an increased risk of mental health problems (e.g. those who were unemployed), male veterans, in particular, appear to be at a distinct disadvantage compared to those who have never served.

Objectives: This study reports preliminary findings on the prevalence of, and factors associated with, mental health and well-being outcomes of healthcare workers during the early months (April-June) of the COVID-19 pandemic in the UK., Methods: Preliminary cross-sectional data were analysed from a cohort study (n=4378). Clinical and non-clinical staff of three London-based NHS Trusts, including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire. Secondary outcomes are probable anxiety (seven-item Generalised Anxiety Disorder), depression (nine-item Patient Health Questionnaire), post-traumatic stress disorder (PTSD) (six-item Post-Traumatic Stress Disorder checklist), suicidal ideation (Clinical Interview Schedule) and alcohol use (Alcohol Use Disorder Identification Test). Moral injury is measured using the Moray Injury Event Scale., Results: Analyses showed substantial levels of probable CMDs (58.9%, 95% CI 58.1 to 60.8) and of PTSD (30.2%, 95% CI 28.1 to 32.5) with lower levels of depression (27.3%, 95% CI 25.3 to 29.4), anxiety (23.2%, 95% CI 21.3 to 25.3) and alcohol misuse (10.5%, 95% CI 9.2 to 11.9). Women, younger staff and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one's moral code) was strongly associated with increased levels of probable CMDs, anxiety, depression, PTSD symptoms and alcohol misuse., Conclusions: Our findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic., Competing Interests: Competing interests: RoR reports grants from DHSC/UKRI/ESRC COVID-19 Rapid Response Call, grants from Rosetrees Trust, grants from King’s Together rapid response call, grants from UCL (Wellcome Trust) rapid response call, during the conduct of the study; grants from Innovative Medicines Initiative and EFPIA, RADAR-CNS consortium, grants from MRC, grants from NIHR, outside the submitted work. SH reports grants from NIHR, grants from Wellcome Trust, grants from ESRC, grants from Guy’s and St. Thomas’ Charity, grants from MRC, grants from UKRI, outside the submitted work; and a member of the following advisory groups: The Health Foundation – COVID-19 Research Programme Panel, NHS England and NHS Improvement – Patient and Carers Race Equalities Framework (PCREF) Steering Group, NHS England and NHS Improvement – Advancing Mental Health Equalities Taskforce, Health Education England – Mental Health Workforce Equalities Subgroup, Maudsley Learning – Maudsley Learning Advisory Board, South London and Maudsley NHS Foundation Trust (SLaM) – Independent Advisory Groups, the SLaM Partnership Group, Lambeth Public Health – Serious Youth Violence Public Health Task and Finish Group, NHS England – Workforce Race Equality Standard Advisory Group, Thrive London – Thrive London Advisory Board, Black Thrive – Black Thrive Advisory Board. Commissions: Welsh Government’s Race Equality Plan; contribution to the evidence review for Health and Social Care and Employment and Income policy areas. SAMS reports grants from UKRI/ESRC/DHSC, grants from UCL, grants from UKRI/MRC/DHSC, grants from Rosetrees Trust, grants from King’s Together Fund, during the conduct of the study. NG reports a potential COI with NHSEI, during the conduct of the study; and the managing director of March on Stress Ltd, which has provided training for a number of NHS organisations although NG is not clear if the company has delivered training to any of the participating trusts or not as NG does not get directly involved in commissioning specific pieces of work., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Reservists often have different experiences to regular military personnel which may impact their mental health., Aims: To investigate the incidence of mental health problems in both active and veteran reservists and determine how this compares to regular service personnel and ex-regular veterans., Method: Five studies which included reservist and/or veteran participants, a validated assessment of mental health problems, and provided primary data were included in the synthesis. Common mental health disorders, post-traumatic stress disorder and alcohol use disorder were examined., Results: Nondeployed mobilized reservists were significantly less likely to report common mental health disorders than nondeployed regulars. There were no other significant differences between groups. Regardless deployed reservists reported more mental health problems than nondeployed reservists. Similarly, ex-regular deployed veterans were more likely to experience mental health difficulties than nondeployed ex-regular veterans. Notably, a large proportion of non-deployed reservists reported probable alcohol use disorders, indicating that problematic alcohol consumption may not be due to deployment in this group., Conclusion: These results highlight the need for ongoing support for military regular, ex-regular and reservist personnel. Additional research is needed to examine potential risk and protective factors for mental health problems in both deployed and nondeployed reservists.Key pointsOverall, mobilized deployed reservists were more likely to experience mental health problems than non-deployed reservists. Nondeployed regulars reported significantly more common mental health problems than nondeployed mobilized reservists.Reservists and (ex-)regulars reported similar rates of PTSD. This suggests reservists are vulnerable to developing PTSD following non-combat related trauma that may not lead to PTSD in regulars and this warrants future research.Reservists were less likely to report problematic alcohol consumption compared to regular personnel and ex-regular veterans. The greatest amount of reservist problematic drinking was reported in non-deployed veteran reservists. This indicates problematic alcohol consumption is not deployment related in this group and highlights the need for ongoing formal support for alcohol use disorders in the UK Armed Forces.

Objectives: While most UK military personnel transition successfully into civilian life, some experience unemployment and disability, which may be partly attributable to in-service factors. This study aims to determine the degree to which in-service mental health problems impact on postservice benefit claims., Methods: Using data from a cohort of 5598 recent leavers from regular service in the UK Armed Forces linked with data from the Department for Work and Pensions, we assessed associations between in-service mental health and postservice benefit claims, and the population attributable fraction (PAF) of benefit claims related to in-service mental health. An analysis with postservice mental ill health as mediator was performed to determine the degree to which the observed effects were a consequence of persistent illness, as opposed to remitted., Results: Mental illness occurring in-service predicted both unemployment and disability claims, partly mediated by postservice health (23%-52% total effects mediated), but alcohol misuse did not. Common mental disorder (CMD) (PAF 0.07, 95% CI: 0.02 to 0.11) and probable post-traumatic stress disorder (PTSD) (PAF 0.05, 95% CI 0.01 to 0.09) contributed to unemployment claims. Probable PTSD was the largest contributor to disability claims (PAF 0.25, 95% CI 0.13 to 0.36), with a smaller contribution from CMD (PAF 0.16, 95% CI 0.03 to 0.27)., Conclusions: In-service mental ill health gives rise to benefit claims. These effects are only partly mediated by postservice mental health, implying that in-service (or pre-service) mental issues have carry-over effects into civilian life even if remitted. Better prevention and treatment of in-service PTSD symptoms may well reduce postservice disability claims., Competing Interests: Competing interests: RJR and HB report grants from ministry of defence and grants from Forces in Mind Trust during the conduct of the study. NG reports personal fees from King’s College London, during the conduct of the study, and is the Royal College of Psychiatrists Lead for Military and Veterans Health and also a trustee for two military charities. He was not required to act in any particular way by these organisations in relation to the paper. NTF and SW have nothing to disclose., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

(1) Background: UK Armed Forces personnel provide first response, support and protection during national and international disasters and conflicts. They thus have a psychologically challenging role which requires them to maintain a good state of mental health and wellbeing. HeadFIT is a preventative initiative developed to help foster mental fitness through various self-help tools and resources online including techniques to de-stress and increase drive. This paper reports on an independent service evaluation of HeadFIT to examine feasibility and acceptability among Ministry of Defence (MOD) personnel. (2) Methods: Qualitative interviews were held with the HeadFIT beneficiaries, including military personnel and civil servants. The beneficiaries provided feedback on HeadFIT through questionnaires and interviews, and website traffic data were also collected. Qualitative data were analysed using framework analysis. (3) Results: Beneficiaries generally reported positive views on the HeadFIT initiative, with most agreeing that the tools could support them to foster their mental fitness. However, concerns were raised around the uptake of HeadFIT and participants suggested methods to improve usability. (4) Conclusions: Several recommendations were made to improve the resources, usability, uptake, and implementation and communication of HeadFIT.

Background: Experiences of potentially morally injurious events (PMIEs) have been found to negatively impact the mental health of US personnel/veterans, yet little is known about the effect of PMIEs on the mental health of the UK Armed Forces (AF). This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of UK AF veterans., Method: Assessments of PMIE exposure and self-report measures of common mental disorders were administered using an online questionnaire to 204 UK veterans. Subjects were classified as having experienced a morally injurious event (n = 66), a non-morally injurious traumatic event (n = 57), a 'mixed' event (n = 31), or no event (n = 50)., Results: Potentially morally injurious experiences were associated with adverse mental health outcomes, including likely anxiety disorders and suicidal ideation, compared to those who reported no event exposure. The likelihood of meeting criteria for probable PTSD was greatest in those who had experienced a non-morally injurious trauma. No statistically significant association between alcohol misuse and experiencing a PMIE or traumatic event was observed., Conclusions: The results provide preliminary evidence that potentially morally injurious experiences are associated with adverse mental health outcomes in UK AF veterans. Further work is needed to better understand the interplay between morally injurious events and threat-based trauma in order to design effective pathways for prevention and intervention for people exposed to highly challenging events.

Background: Moral injury is known to be associated with mental health difficulties in US military populations, however its impact on wellbeing in a UK Armed Forces (AF) context is less well understood. Additionally, it is not clear whether other factors known to affect service personnel's mental health, such as adverse childhood experiences (ACEs) or military trauma, may influence whether personnel experience moral injury., Aim: To examine the relationship between moral injury and ACEs, adverse military events as well as the impact of moral injury on the mental health of UK AF veterans., Method: A nationally representative sample of UK AF veterans seeking psychological treatment (n = 177) were recruited. Participants completed self-report psychometric measures and expressions of moral injury, ACEs and traumatic in-service events., Results: Analyses yielded a significant association between ACEs and veteran expressions of moral injury (p < .001). A significant although weak relationship was found between veteran expressions of moral injury and experiencing adverse events during military service, including physical abuse (AOR 1.04; 95 % CI 1.02-1.06) and emotional abuse (AOR 1.03; 1.01-1.05). Those meeting criteria for mental health disorders, including probable posttraumatic stress disorder (AOR 1.09; 95 % CI 1.05-1.12), were significantly more likely to report expressions of moral injury., Conclusions: These results illustrate the relationship between traumatic life events, including childhood adversity, and experiencing moral injury in UK AF veterans. The findings underscore the need for a validated measurement tool appropriate for the UK AF to better understand the impact of moral injury on wellbeing and to ensure that appropriate treatment can be given to those identified as suffering post-trauma., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Predeployment stress management/mental health training is routinely delivered in an effort to mitigate potential adverse psychological effects. Little is known about the effectiveness of such interventions., Methods: A systematic literature review explored research outcomes related to this subject, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. An electronic database search using key terms identified studies published between January 2007 and March 2019. Comprehensive inclusion/exclusion criteria were applied and study quality was appraised by two reviewers using 12 criteria adapted from the Critical Appraisal Skills Programme (CASP) checklist. Papers were excluded if they were allocated CASP scores ≤10 out of 24., Results: 2003 references were identified; 15 papers fulfilled inclusion criteria and quality threshold requirements. Included studies were randomised controlled trial design (n=8), quasi-experimental (n=5), case report (n=1) and cross-sectional (n=1). Duration of follow-up assessment varied from immediately postintervention to 24 months. The included studies were heterogeneous so clear recommendations relating to predeployment training for military personnel could not be made. Although somewhat disparate, predeployment interventions shared the aim of promoting prior to, during and after deployment health and well-being. Social benefits such as improved cohesion and improved stress management skills were identified in some studies, although substantial mental health and well-being benefits were not found., Conclusions: Evidence for the effectiveness of predeployment psychological interventions is scant. Every attempt should be made to use methods and measures to facilitate comparisons across studies, to attempt a longer follow-up timescale and to clarify key trainer characteristics., Competing Interests: Competing interests: NJ is a full-time reserve member of the British Army currently seconded to King’s College London. AS is a full-time member of the British Army similarly seconded. NG is the Royal College of Psychiatrists Lead for Military and Veterans Health and trustee with two military charities; however, he was not directed by these organisations in any way in relation to his contribution to this paper. He is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King’s College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University. AP, CW and LH received funding from the Ministry of Defence for the duration of the study but were not instructed in any way in the production of this manuscript., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Police employees undertake challenging duties which may adversely impact their health. This study explored the prevalence of and risk factors for probable mental disorders amongst a representative sample of UK police employees. The association between mental illness and alterations in blood pressure was also explored., Methods: Data were used from the Airwave Health Monitoring Study which was established to monitor the possible physical health impacts of a new communication system on police employees. Data included sociodemographic characteristics, lifestyle habits, depression, anxiety, and post-traumatic stress disorder (PTSD) symptoms and blood pressure. Descriptive statistics were used to explore the prevalence of probable mental disorders and associated factors. Stepwise linear regression was conducted, controlling for confounding variables, to examine associations between mental disorders and blood pressure., Results: The sample included 40,299 police staff, police constable/sergeants and inspectors or above. Probable depression was most frequently reported (9.8%), followed by anxiety (8.5%) and PTSD (3.9%). Groups at risk for probable mental disorders included police staff, and police employees who reported drinking heavily. Police employees exposed to traumatic incidents in the past six months had a doubling in rates of anxiety or depression and a six-fold increase in PTSD compared to those with no recent trauma exposure. Adjusted logistic regression models did not reveal any significant association between probable mental disorders and systolic blood pressure but significantly elevated diastolic blood pressure (≈1mmHg) was found across mental disorders., Conclusions: These results show lower rates of probable mental disorders, especially PTSD, than reported in other studies focusing on police employees. Although mental ill health was associated with increased diastolic blood pressure, this was unlikely to be clinically significant. These findings highlight the importance of continued health monitoring of members of the UK police forces, focusing on employees recently exposed to traumatic incidents, heavy drinkers and police staff., Competing Interests: The authors have read the journal's policy and have the following conflicts: SAMS and NTF salaries are part funded by the UK Ministry of Defence (MoD). NTF is a trustee (unpaid) of The Warrior Programme and the ADVANCE study charity, and is an independent advisor to the Independent Group Advising on the Release of Data (IGARD) for NHS Digital. NG is a trustee with two military charities, undertakes voluntary roles with the Royal College of Psychiatrists and runs his own psychological health consultancy. PE is associate director of the Health Data Research UK London funded by a consortium led by the UK Medical Research Council. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

Background: Awareness of domestic violence and abuse (DVA) as a problem among military personnel (serving and veterans) has grown in recent years, and there is a need for research to inform improvements in the identification of and response to DVA in this population. This study aimed to explore the experience of health and welfare professionals in identifying and responding to DVA among the UK military population (serving personnel and veterans)., Methods: Thirty-five semi-structured telephone interviews were conducted with health and welfare staff who work with serving UK military personnel and veterans. Interviews were analysed using thematic analysis., Results: Three superordinate themes were identified: i) patterns of DVA observed by health and welfare workers (perceived gender differences in DVA experiences and role of mental health and alcohol); (ii) barriers to identification of and response to DVA (attitudinal/knowledge-based barriers and practical barriers), and iii) resource issues (training needs and access to services). Participants discussed how factors such as a culture of hypermasculinity, under-reporting of DVA, the perception of DVA as a "private matter" among military personnel, and lack of knowledge and awareness of emotional abuse and coercive controlling behaviour as abuse constitute barriers to identification and management of DVA. Healthcare providers highlighted the need for more integrated working between civilian and military services, to increase access to support and provide effective care to both victims and perpetrators. Furthermore, healthcare and welfare staff reflected on their training needs in the screening and management of DVA to improve practice., Conclusions: There is a need for increased awareness of DVA, particularly of non-physical forms of abuse, and of male victimisation in the military. Standardised protocols for DVA management and systematic training are required to promote a consistent and appropriate response to DVA. There is a particular training need among healthcare and first-line welfare staff, who are largely relied upon to identify cases of DVA in the military. Employing DVA advocates within military and civilian healthcare settings may be useful in improving DVA awareness, management and access to specialist support.

Introduction: Research suggests that moral injury (MI) in US veterans is associated with poor psychological outcomes and disruption in functioning. However, little is known about how MI may impact UK Armed Forces (AF) veterans. This study aimed to explore the impact of MI on veteran psychological well-being and functioning., Methods: Six veterans identified as having had exposure to MI and four clinicians who treated veterans with MI were recruited from a UK charitable organisation which provides psychological care for veterans. Data were analysed using thematic analysis., Results: MI was perceived to cause substantial psychological distress in this sample. Our data suggest that some veterans held extremely negative self-appraisals which appeared to contribute towards and maintain their distress. Issues relating to spirituality following MI were thought to be infrequent; however, a loss of faith was perceived by clinicians to be more common in morally injured veterans than heightened spiritual/religious views. Several difficulties relating to employment were described, including increased trouble coping with occupational stress and authority figures. Interpersonal difficulties were frequently reported, with withdrawal from others often leading to relationship breakdown with spouses and children., Conclusion: This study provides some of the first evidence of the impact of MI on UK AF veterans' psychological, spiritual, social and day-to-day functioning all of which would pose challenges to clinicians aiming to manage such difficulties. These findings highlight several gaps in existing care provision for morally injured veterans, including addressing issues related to spirituality, employment and family functioning, which could ultimately improve veteran well-being., Competing Interests: Competing interests: NG is the Royal College of Psychiatrists Lead for Military and Veterans’ Health but was free to provide his independent views on this research., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Internationally, women are about to undertake combat duties alongside their male colleagues. The psychological effect of this policy change is largely unknown., Aims: To explore the mental health impact of combat exposure among military women., Methods: Self-report, between-subjects survey data were collected in Iraq and Afghanistan on four occasions between 2009 and 2014 (n = 4139). Differences in mental health, stigmatization, deployment experiences, intimate relationship impact, perception of family support levels, unit cohesion, leadership and help-seeking were compared between deployed men and women. Comparisons were repeated with the study sample stratified by level of combat exposure. Outcomes were examined using logistic regression adjusted for socio-demographic, mental health and military factors., Results: Overall, 4.1% of women and 4.3% of men reported post-traumatic stress disorder (PTSD) (odds ratio (OR) 1.31, 95% confidence interval (95% CI) 0.70-2.46); 22% of women and 16% of men reported symptoms of common mental disorder (CMD) (OR 1.52, 95% CI 1.11-2.08). Women were less likely to report mental health-related stigmatization (OR 0.68, 95% CI 0.53-0.87), negative relationship impact from deployment (OR 0.69, 95% CI 0.49-0.98) and subjective unit cohesion (OR 0.69, 95% CI 0.53-0.90). Help-seeking for emotional problems was similar by gender (OR 1.22, 95% CI 0.84-1.77). Overall, outcomes were minimally impacted by level of combat exposure., Conclusions: Although women experienced more CMD symptoms, PTSD symptoms were similar by gender. Subject to confirmation of the study findings, women may not require enhanced mental healthcare during deployment for exposure-based conditions such as PTSD when undertaking the ground close combat role., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)