The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic.

Background: Healthcare workers (HCWs) across the globe have reported symptoms of Post-Traumatic Stress Disorder (PTSD) during the COVID-19 pandemic. Moral Injury (MI) has been associated with PTSD in military populations, but is not well studied in healthcare contexts. Moral Distress (MD), a related concept, may enhance understandings of MI and its relation to PTSD among HCWs. This study examined the independent and combined impact of MI and MD on PTSD symptoms in Canadian HCWs during the pandemic.Methods: HCWs participated in an online survey between February and December 2021, with questions regarding sociodemographics, mental health and trauma history (e.g. MI, MD, PTSD, dissociation, depression, anxiety, stress, childhood adversity). Structural equation modelling was used to analyze the independent and combined impact of MI and MD on PTSD symptoms (including dissociation) among the sample when controlling for sex, age, depression, anxiety, stress, and childhood adversity.Results: A structural equation model independently regressing both MI and MD onto PTSD accounted for 74.4% of the variance in PTSD symptoms. Here, MI was strongly and significantly associated with PTSD symptoms (ß = .412, p < .0001) to a higher degree than MD (ß = .187, p < .0001), after controlling for age, sex, depression, anxiety, stress and childhood adversity. A model regressing a combined MD and MI construct onto PTSD predicted approximately 87% of the variance in PTSD symptoms (r2 = .87, p < .0001), with MD/MI strongly and significantly associated with PTSD (ß = .813, p < .0001), after controlling for age, sex, depression, anxiety, stress, and childhood adversity.Conclusion: Our results support a relation between MI and PTSD among HCWs and suggest that a combined MD and MI construct is most strongly associated with PTSD symptoms. Further research is needed better understand the mechanisms through which MD/MI are associated with PTSD.

MI and MD were each independently associated with PTSD symptoms (including dissociation), when controlling for sex, age, childhood adversity, depression, anxiety and stress.Combining both MI and MD constructs into a single latent variable accounted for the greatest proportion of variance explained in PTSD symptoms among HCWs during the COVID-19 pandemic.Results suggest that expanding the construct of MI to include team and systemic organisational MD may be appropriate in the healthcare context.

The mental health toll of service: an examination of self-reported impacts of public safety personnel careers in a treatment-seeking population.

Introduction: Public safety personnel (PSP), including firefighters, paramedics, and police officers, are exposed to traumatic events as part of their day-to-day jobs. These traumatic events often result in significant stress and increase the likelihood of negative mental health outcomes, including post-traumatic stress disorder (PTSD). The present study sought to develop an in-depth understanding of the lived experiences of PSPs as related to the mental health toll of their service. Through a series of targeted focus groups, Canadian PSP were asked to provide their perspectives on the PTSD-related symptoms that resulted as a by-product of their occupational service. The DSM-5-TR PSTD criteria (A-E) provided a thematic lens to map the self-described symptomatic expression of PSP's lived experiences.Methods: The present study employed a phenomenological focus-group approach with a treatment-seeking inpatient population of PSP. Participants included PSP from a variety of occupational backgrounds. Using semi-structured focus groups, fifty-one participants were interviewed. These focus groups were audio recorded, with consent, and transcribed verbatim. Using an interpretive phenomenological approach, emergent themes within the data were inductively developed, examined, and connected across individual cases.Results: Utilizing the primary criteria of PTSD (Criteria A-E) outlined by the DSM-5-TR, we identified qualitative themes that included exposure to a traumatic event, intrusion symptoms, avoidance symptoms, negative alterations in mood and cognition, and marked alterations in arousal and reactivity.Conclusion: PSP are exposed to extreme stressors as a daily part of their occupation and are at elevated risk of developing mental health difficulties, including PTSD. In the present study, focus groups were conducted with PSP about the mental health toll of their occupations. Their experiences mapped onto the five primary criteria of PTSD, as outlined by the DSM-5-TR. This study provides crucial descriptive information to guide mental health research aims and treatment goals for PSTD in PSP populations.

Repeated exposure to stressful and traumatic events is often a daily occurrence for public safety personnel, actively contributing to an increased risk of development of mental health disorders, including Post-Traumatic Stress Disorder, in this population.Through a series of interviews, the present study examined the subjective experiences of traumatic events in a treatment-seeking population of public safety personnel. Participants' narrative descriptions of their experiences were examined and analysed using the criteria of Post-Traumatic Stress Disorder, as outlined by the Diagnostic and Statistical Manual of Mental Illness-Version V ­ Text Revision, as a thematic lens. Analyses yielded rich descriptive information of the symptomatic expression of criterion-specific themes.The present study offers valuable insights into how a treatment-seeking population of public safety personnel experience their trauma-related symptoms. It also offers an opportunity for both researchers and practitioners to better understand the way public safety personnel may differ from other populations in how they express and understand their experience of Post-Traumatic Stress symptoms.

Machine learning models predict PTSD severity and functional impairment: A personalized medicine approach for uncovering complex associations among heterogeneous symptom profiles.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is a debilitating psychiatric illness, experienced by approximately 10% of the population. Heterogeneous presentations that include heightened dissociation, comorbid anxiety and depression, and emotion dysregulation contribute to the severity of PTSD, in turn, creating barriers to recovery. There is an urgent need to use data-driven approaches to better characterize complex psychiatric presentations with the aim of improving treatment outcomes. We sought to determine if machine learning models could predict PTSD-related illness in a real-world treatment-seeking population using self-report clinical data. METHOD: Secondary clinical data from 2017 to 2019 included pretreatment measures such as trauma-related symptoms, other mental health symptoms, functional impairment, and demographic information from adults admitted to an inpatient unit for PTSD in Canada (n = 393). We trained two nonlinear machine learning models (extremely randomized trees) to identify predictors of (a) PTSD symptom severity and (b) functional impairment. We assessed model performance based on predictions in novel subsets of patients. RESULTS: Approximately 43% of the variance in PTSD symptom severity (R²avg = .43, R²median = .44, p = .001) was predicted by symptoms of anxiety, dissociation, depression, negative trauma-related beliefs about others, and emotion dysregulation. In addition, 32% of the variance in functional impairment scores (R²avg = .32, R²median = .33, p = .001) was predicted by anxiety, PTSD symptom severity, cognitive dysfunction, dissociation, and depressive symptoms. CONCLUSIONS: Our results reinforce that dissociation, cooccurring anxiety and depressive symptoms, maladaptive trauma appraisals, cognitive dysfunction, and emotion dysregulation are critical targets for trauma-related interventions. Machine learning models can inform personalized medicine approaches to maximize trauma recovery in real-world inpatient populations. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Canadian respiratory therapists who considered leaving their clinical position experienced elevated moral distress and adverse psychological and functional outcomes during the COVID-19 pandemic. / Détresse morale et conséquences psychologiques et fonctionnelles négatives chez les thérapeutes respiratoires canadiens ayant envisagé de quitter leur poste clinique pendant la pandémie de COVID-19.

INTRODUCTION: Respiratory therapists (RTs) faced morally distressing situations throughout the COVID-19 pandemic, including working with limited resources and facilitating video calls for families of dying patients. Moral distress is associated with a host of adverse psychological and functional outcomes (e.g. depression, anxiety, symptoms of posttraumatic stress disorder [PTSD] and functional impairment) and consideration of position departure. The purpose of this study was to understand the impact of moral distress and its associated psychological and functional outcomes on consideration to leave a clinical position among Canadian RTs during the COVID-19 pandemic. METHODS: Canadian RTs (N = 213) completed an online survey between February and June 2021. Basic demographic information (e.g. age, sex, gender) and psychometrically validated measures of moral distress, depression, anxiety, stress, PTSD, dissociation, functional impairment, resilience and adverse childhood experiences were collected. RESULTS: One in four RTs reported considering leaving their position. RTs considering leaving reported elevated levels of moral distress and adverse psychological and functional outcomes compared to RTs not considering leaving. Over half (54.5%) of those considering leaving scored above the cut-off for potential diagnosis of PTSD. Previous consideration to leave a position and having left a position in the past each significantly increased the odds of currently considering leaving, along with system-related moral distress and symptoms of PTSD, but the contribution of these latter factors was small. CONCLUSIONS: Canadian RTs considering leaving their position reported elevated levels of distress and adverse psychological and functional outcomes, yet these individual-level factors appear unlikely to be the primary factors underlying RTs' consideration to leave, because their effects were small. Further research is required to identify broader, organizational factors that may contribute to consideration of position departure among Canadian RTs.

'I am afraid you will see the stain on my soul': Direct gaze neural processing in individuals with PTSD after moral injury recall.

Direct eye contact is essential to understanding others' thoughts and feelings in social interactions. However, those with post-traumatic stress disorder (PTSD) and exposure to moral injury (MI) may exhibit altered theory-of-mind (ToM)/mentalizing processes and experience shame which precludes one's capacity for direct eye contact. We investigated blood oxygenation level-dependent (BOLD) responses associated with direct vs averted gaze using a virtual reality paradigm in individuals with PTSD (n = 28) relative to healthy controls (n = 18) following recall of a MI vs a neutral memory. Associations between BOLD responses and clinical symptomatology were also assessed. After MI recall, individuals with PTSD showed greater activation in the right temporoparietal junction as compared to controls (T = 4.83; pFDR < 0.001; k = 237) during direct gaze. No significant activation occurred during direct gaze after neutral memory recall. Further, a significant positive correlation was found between feelings of distress and right medial superior frontal gyrus activation in individuals with PTSD (T = 5.03; pFDR = 0.049; k = 123). These findings suggest that direct gaze after MI recall prompts compensatory ToM/mentalizing processing. Implications for future interventions aimed at mitigating the effects of PTSD on social functioning are discussed.

Changes in posttraumatic stress disorder symptom severity during the COVID-19 pandemic: Ten-wave findings from a longitudinal observational cohort study of community adults.

Few studies have examined changes in posttraumatic-stress disorder (PTSD) symptomatology across an extended time period during the COVID-19 pandemic. This study used a longitudinal cohort design to examine: (1) changes in overall PTSD symptoms and symptom clusters; (2) moderators of change; (3) the clinical significance of observed changes; and (4) correlates of clinically meaningful changes. Community adults (N = 1412) were assessed using the PTSD Checklist for DSM-5 (PCL-5) at 10 timepoints (October 2018 - April 2022). Changes in overall PCL-5 score and symptom clusters were substantially moderated by pre-pandemic clinical severity (i.e., above/below PCL-5 cut-off). Pre-pandemic non-clinical participants exhibited increases in overall scores, Cluster D (negative cognitions), and Cluster E (arousal), while clinically elevated participants exhibited decreases overall and in all clusters. Regarding clinical significance, 12% of pre-pandemic non-clinical participants exhibited clinically meaningful increases, and 4% exhibited decreases. Conversely, 42% of the pre-pandemic elevated group exhibited clinically meaningful decreases, while 6% exhibited increases. Pandemic impacts in numerous psychosocial domains were associated with clinically meaningful change. Collectively, these findings reveal substantively divergent trajectories by pre-pandemic severity and PTSD symptom cluster. The large proportion of pre-pandemic high-severity participants exhibiting sizable decreases was an unexpected notable observation.

Coping, Supports and Moral Injury: Spiritual Well-Being and Organizational Support Are Associated with Reduced Moral Injury in Canadian Healthcare Providers during the COVID-19 Pandemic.

Healthcare providers (HCPs) have described the onset of shame- and trust-violation-related moral injuries (MI) throughout the COVID-19 pandemic. Previous research suggests that HCPs may turn to various coping methods and supports, such as spirituality/religiosity, substance use, friends/family or organizational support, to manage workplace stress. It remains unknown, however, if similar coping methods and supports are associated with MI among this population. We explored associations between MI (including the shame and trust-violation presentations individually) and coping methods and supports. Canadian HCPs completed an online survey about their mental health and experiences during the COVID-19 pandemic, including demographic indices (e.g., sex, age, mental health history) and measures of MI, organizational support, social support, spiritual well-being, self-compassion, alcohol use, cannabis use and childhood adversity. Three hierarchical multiple linear regressions were conducted to assess the associations between coping methods/supports and (i) MI, (ii) shame-related MI and (iii) trust-violation-related MI, when controlling for age, mental health history and childhood adversity. One hundred and seventy-six (N = 176) HCPs were included in the data analysis. Spiritual well-being and organizational support were each significantly associated with reduced total MI (p's < 0.001), shame-related MI (p = 0.03 and p = 0.02, respectively) and trust-violation-related MI (p's < 0.001). Notably, comparison of the standardized beta coefficients suggests that the association between trust-violation-related MI and both spiritual well-being and organizational support was more than twice as great as the associations between these variables and shame-related MI, emphasizing the importance of these supports and the trust-violation outcomes particularly. Mental health history (p = 0.02) and self-compassion (p = 0.01) were additionally related to shame-related MI only. Our findings indicate that heightened levels of spiritual well-being and organizational support were associated with reduced MI among HCPs during the COVID-19 pandemic. Rather than placing sole responsibility for mental health outcomes on HCPs individually, organizations can instead play a significant role in mitigating MI among staff by implementing evidence-informed organizational policies and interventions and by considering how supports for spiritual well-being may be implemented into existing models of care where relevant for employees.

A randomized controlled trial of Deep Brain Reorienting: a neuroscientifically guided treatment for post-traumatic stress disorder.

BACKGROUND: Advanced neuroscientific insights surrounding post-traumatic stress disorder (PTSD) and its associated symptomatology should beget psychotherapeutic treatments that integrate these insights into practice. Deep Brain Reorienting (DBR) is a neuroscientifically-guided psychotherapeutic intervention that targets the brainstem-level neurophysiological sequence that transpired during a traumatic event. Given that contemporary treatments have non-response rates of up to 50% and high drop-out rates of >18%, DBR is investigated as a putative candidate for effective treatment of some individuals with PTSD. OBJECTIVE: To conduct an interim evaluation of the effectiveness of an eight-session clinical trial of videoconference-based DBR versus waitlist (WL) control for individuals with PTSD. METHOD: Fifty-four individuals with PTSD were randomly assigned to DBR (N = 29) or WL (N = 25). At baseline, post-treatment, and three-month follow-up, participants' PTSD symptom severity was assessed using the Clinician Administered PTSD Scale (CAPS-5). This is an interim analysis of a clinical trial registered with the U. S. National Institute of Health (NCT04317820). RESULTS: Significant between-group differences in CAPS-total and all subscale scores (re-experiencing, avoidance, negative alterations in cognitions/mood, alterations in arousal/reactivity) were found at post-treatment (CAPS-total: Cohen's d = 1.17) and 3-month-follow-up (3MFU) (CAPS-total: Cohen's d = 1.18). Significant decreases in CAPS-total and all subscale scores were observed within the DBR group pre - to post-treatment (36.6% CAPS-total reduction) and pre-treatment to 3MFU (48.6% CAPS-total reduction), whereas no significant decreases occurred in the WL group. After DBR, 48.3% at post-treatment and 52.0% at 3MFU no longer met PTSD criteria. Attrition was minimal with one participant not completing treatment; eight participants were lost to 3MFU. CONCLUSIONS: These findings provide emerging evidence for the effectiveness of DBR as a well-tolerated treatment that is based on theoretical advances highlighting alterations to subcortical mechanisms in PTSD and associated symptomatology. Additional research utilizing larger sample sizes, neuroimaging data, and comparisons or adjacencies with other psychotherapeutic approaches is warranted.Trial registration: ClinicalTrials.gov identifier: NCT04317820..

First study to evaluate the effects of Deep Brain Reorienting (DBR) therapy on PTSD symptoms.Eight internet-based DBR sessions resulted in significant decreases in PTSD symptoms post-treatment and at 3-month follow-up in comparison to a waitlist group.Large effect sizes and a low drop-out rate suggest that DBR may be an effective, well-tolerated neuroscientifically guided treatment for PTSD.

The effect of aerobic exercise alone and in combination with cognitive behavioural therapy on obsessive compulsive disorder: A randomized control study.

PURPOSE: Cognitive behavioural therapy (CBT) has been found to be an effective treatment for OCD, but there remains a significant proportion of individuals who fail to show a treatment response. Aerobic exercise has previously been associated with decreases in anxiety and depression, as well as improvements in OCD symptoms in small-scale studies. The purpose of the present research was to use a randomized control trial design to examine the effects of exercise alone and in combination with CBT, on OCD symptoms and secondary symptoms. METHOD: 125 participants were randomly assigned to one of four treatment groups: waitlist control, exercise, CBT, and CBT with exercise. OCD symptom severity was measured at four points over the course of treatment, secondary outcome measures were gathered at three points over treatment. RESULTS: CBT alone and combined with exercise was associated with significantly greater OCD symptom reduction than exercise alone or the control groups. Total exercise frequency predicted OCD symptom reduction in the groups in which exercise was measured. Group membership did not significantly predict reductions in secondary outcome measures. CONCLUSION: Exercise frequency, rather than the presence or absence of exercise, appears to predict OCD symptom reduction, as did participation in CBT.

Periodicity and severity of changes in depression and anxiety during the COVID-19 pandemic: Ten-wave longitudinal findings from an observational cohort study of community adults.

AIMS: Few multi-wave longitudinal studies have examined mental health changes across the coronavirus 2019 (COVID-19) pandemic. The current study examined: (a) overall changes in depression and anxiety over 10-waves of data collection; (b) subgroup moderators of changes; (c) clinical severity of the changes via minimally important differences (MIDs); and (d) correlates of clinically important changes. METHODS: Using a longitudinal observational cohort design, 1412 non-clinical adults (Mage=36; 60% female) were assessed for depression and anxiety via the PHQ-9 and GAD-7 from October 2018 to April 2022 (3 pre-pandemic, 7 intra-pandemic waves; M retention = 92%). RESULTS: Depression and anxiety exhibited significant intra-pandemic changes, reflecting initial increases, followed by decreases. Pre-pandemic severity moderated changes, with low severity participants exhibiting increases and high severity participants exhibiting non-significant change or decreases. For depression and anxiety, respectively, 10% and 11% exhibited MID increases, while 4% and 6% exhibited MID decreases. Divergent patterns were present by severity subgroup, with the lowest severity exhibiting higher rates of MID increases and the highest severity subgroup exhibiting higher rates of MID decreases. CONCLUSIONS: These findings illuminate the periodicity of depression and anxiety during the COVID-19 pandemic and reveal an unexpected inverse relationship between increases and decreases based on pre-pandemic severity.

How the body remembers: Examining the default mode and sensorimotor networks during moral injury autobiographical memory retrieval in PTSD.

Neural representations of sensory percepts and motor responses constitute key elements of autobiographical memory. However, these representations may remain as unintegrated sensory and motor fragments in traumatic memory, thus contributing toward re-experiencing and reliving symptoms in trauma-related conditions such as post-traumatic stress disorder (PTSD). Here, we investigated the sensorimotor network (SMN) and posterior default mode network (pDMN) using a group independent component analysis (ICA) by examining their functional connectivity during a script-driven memory retrieval paradigm of (potentially) morally injurious events in individuals with PTSD and healthy controls. Moral injury (MI), where an individual acts or fails to act in a morally aligned manner, is examined given its inherent ties to disrupted motor planning and thus sensorimotor mechanisms. Our findings revealed significant differences in functional network connectivity across the SMN and pDMN during MI retrieval in participants with PTSD (n = 65) as compared to healthy controls (n = 25). No such significant group-wise differences emerged during retrieval of a neutral memory. PTSD-related alterations included hyperconnectivity between the SMN and pDMN, enhanced within-network connectivity of the SMN with premotor areas, and increased recruitment of the supramarginal gyrus into both the SMN and the pDMN during MI retrieval. In parallel with these neuroimaging findings, a positive correlation was found between PTSD severity and subjective re-experiencing intensity ratings after MI retrieval. These results suggest a neural basis for traumatic re-experiencing, where reliving and/or re-enacting a past morally injurious event in the form of sensory and motor fragments occurs in place of retrieving a complete, past-contextualized narrative as put forth by Brewin and colleagues (1996) and Conway and Pleydell-Pearce (2000). These findings have implications for bottom-up treatments targeting directly the sensory and motoric elements of traumatic experiences.

Altered Resting-State functional connectivity in the anterior and posterior hippocampus in Post-traumatic stress disorder: The central role of the anterior hippocampus.

BACKGROUND: Post-traumatic stress disorder can be viewed as a memory disorder, with trauma-related flashbacks being a core symptom. Given the central role of the hippocampus in autobiographical memory, surprisingly, there is mixed evidence concerning altered hippocampal functional connectivity in PTSD. We shed light on this discrepancy by considering the distinct roles of the anterior versus posterior hippocampus and examine how this distinction may map onto whole-brain resting-state functional connectivity patterns among those with and without PTSD. METHODS: We first assessed whole-brain between-group differences in the functional connectivity profiles of the anterior and posterior hippocampus within a publicly available data set of resting-state fMRI data from 31 male Vietnam war veterans diagnosed with PTSD (mean age = 67.6 years, sd = 2.3) and 29 age-matched combat-exposed male controls (age = 69.1 years, sd = 3.5). Next, the connectivity patterns of each subject within the PTSD group were correlated with their PTSD symptom scores. Finally, the between-group differences in whole-brain functional connectivity profiles discovered for the anterior and posterior hippocampal seeds were used to prescribe post-hoc ROIs, which were then used to perform ROI-to-ROI functional connectivity and graph-theoretic analyses. RESULTS: The PTSD group showed increased functional connectivity of the anterior hippocampus with affective brain regions (anterior/posterior insula, orbitofrontal cortex, temporal pole) and decreased functional connectivity of the anterior/posterior hippocampus with regions involved in processing bodily self-consciousness (supramarginal gyrus). Notably, decreased anterior hippocampus connectivity with the posterior cingulate cortex/precuneus was associated with increased PTSD symptom severity. The left anterior hippocampus also emerged as a central locus of abnormal functional connectivity, with graph-theoretic measures suggestive of a more central hub-like role for this region in those with PTSD compared to trauma-exposed controls. CONCLUSIONS: Our results highlight that the anterior hippocampus plays a critical role in the neurocircuitry underlying PTSD and underscore the importance of the differential roles of hippocampal sub-regions in serving as biomarkers of PTSD. Future studies should investigate whether the differential patterns of functional connectivity stemming from hippocampal sub-regions is observed in PTSD populations other than older war veterans.

Characterizing the mental health and functioning of Canadian respiratory therapists during the COVID-19 pandemic.

Introduction: Healthcare professionals (HCPs) appear to be at increased risk for negative psychological outcomes [e.g. depression, anxiety, post-traumatic stress disorder (PTSD), moral distress] and associated impacts on functioning throughout the COVID-19 pandemic. HCPs working on designated COVID-19 units may be further impacted than their colleagues not on these units given added demands of patient care and risk of contracting COVID-19. Little is known, however, about the mental health and functioning of specific professional groups beyond nurses and physicians, including respiratory therapists (RTs), over the course of the pandemic. Accordingly, the purpose of the present study was to characterize the mental health and functioning of Canadian RTs and compare profiles between RTs working on and off designated COVID-19 units.Methods: Canadian RTs completed an online survey between February and June 2021, including demographic information (e.g. age, sex, gender,) and measures of depression, anxiety, stress, PTSD, moral distress and functional impairment. Descriptive statistics, correlation analyses and between-groups comparisons were conducted to characterize RTs and compare profiles between those on and off COVID-19 units.Results: Two hundred and eighteen (N = 218) RTs participated in this study. The estimated response rate was relatively low (6.2%) Approximately half of the sample endorsed clinically relevant symptoms of depression (52%), anxiety (51%) and stress (54%) and one in three (33%) screened positively for potential PTSD. All symptoms correlated positively with functional impairment (p's < .05). RTs working on COVID-19 units reported significantly greater patient-related moral distress compared to those not on these units (p < .05).Conclusion: Moral distress and symptoms of depression, anxiety, stress and PTSD were prevalent among Canadian RTs and were associated with functional impacts. These results must be interpreted with caution given a low response rate, yet raise concern regarding the long-term impacts of pandemic service among RTs.

Research on RTs' mental health prior to and during the COVID-19 pandemic is scant, especially in comparison to other HCPs.RTs in the present study reported experiencing moral distress and clinically significant symptoms of depression, anxiety and PTSD, with associated functional impairment.One in three RTs screened positive for likely PTSD on the PCL-5.There is a need to provide RTs with adequate mental health supports and to understand the long-term impacts of pandemic service among RTs.

Associations between trauma and substance use among healthcare workers and public safety personnel during the SARS-CoV-2 (COVID-19) pandemic: the mediating roles of dissociation and emotion dysregulation.

BACKGROUND: Given the highly stressful environment surrounding the SARS-CoV-2 pandemic, healthcare workers (HCW) and public safety personnel (PSP) are at an elevated risk for adverse psychological outcomes, including posttraumatic stress disorder (PTSD) and alcohol/substance use problems. As such, the study aimed to identify associations between PTSD severity, related dissociation and emotion dysregulation symptoms, and alcohol/substance use problems among HCWs and PSP. METHODS: A subset of data (N = 498; HCWs = 299; PSP = 199) was extracted from a larger study examining psychological variables among Canadian HCWs and PSP during the pandemic. Structural equation modelling assessed associations between PTSD symptoms and alcohol/substance use-related problems with dissociation and emotion dysregulation as mediators. RESULTS: Among HCWs, dissociation fully mediated the relation between PTSD and alcohol-related problems (indirect effect ß = .133, p = .03) and emotion dysregulation partially mediated the relation between PTSD and substance-related problems (indirect effect ß = .151, p = .046). In PSP, emotion dysregulation fully mediated the relation between PTSD and alcohol-related problems (indirect effects ß = .184, p = .005). For substance-related problems among PSP, neither emotion dysregulation nor dissociation (ps >.05) had any effects. CONCLUSION: To our knowledge, this is the first study examining associations between PTSD severity and alcohol/substance use-related problems via mediating impacts of emotion dysregulation and dissociation among HCWs and PSP during the SARS-CoV-2 pandemic. These findings highlight dissociation and emotion dysregulation as important therapeutic targets for structured interventions aimed at reducing the burden of PTSD and/or SUD among Canadian HCWs or PSP suffering from the adverse mental health impacts of the SARS-CoV-2 pandemic.

Among healthcare workers, dissociation mediated relation between posttraumatic stress disorder (PTSD) severity and alcohol-related problems and emotion dysregulation mediated relation between PTSD severity and substance-related problems.Among public safety personnel, emotion dysregulation mediated relation between PTSD severity and alcohol-related problems. Neither dissociation nor emotion dysregulation mediated relation between PTSD severity and substance-related problems.Results underscore dissociation and emotion dysregulation as potential key therapeutic targets for intervention for healthcare workers and public safety personnel struggling with PTSD and comorbid alcohol/substance use-related problems.

Moral injury associated with increased odds of past-year mental health disorders: a Canadian Armed Forces examination.

Background: Potentially morally injurious experiences (PMIEs) are common during military service. However, it is unclear to what extent PMIEs are related to well-established adverse mental health outcomes.Objective: The objective of this study was to use a population-based survey to determine the associations between moral injury endorsement and the presence of past-year mental health disorders in Canadian Armed Forces (CAF) personnel and Veterans.Methods: Data were obtained from the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (CAFVMHS). With a sample of 2,941 respondents, the weighted survey sample represented 18,120 active duty and 34,380 released CAF personnel. Multiple logistic regressions were used to assess the associations between sociodemographic characteristics (e.g. sex), military factors (e.g. rank), moral injury (using the Moral Injury Events Scale [MIES]) and the presence of specific mental health disorders (major depressive episode, generalized anxiety disorder, panic disorder, social anxiety disorder, PTSD, and suicidality).Results: While adjusting for selected sociodemographic and military factors, the odds of experiencing any past-year mental health disorder were 1.97 times greater (95% CI = 1.94-2.01) for each one-unit increase in total MIES score. Specifically, PTSD had 1.91 times greater odds (95% CI = 1.87-1.96) of being endorsed for every unit increase in MIES total score, while odds of past-year panic disorder or social anxiety were each 1.86 times greater (95% CI = 1.82-1.90) for every unit increase in total MIES score. All findings reported were statistically significant (p < .001).Conclusion: These findings emphasize that PMIEs are robustly associated with the presence of adverse mental health outcomes among Canadian military personnel. The results of this project further underscore the necessity of addressing moral injury alongside other mental health concerns within the CAF.

Potentially morally injurious experiences are common during military service, but it is poorly understood how these experiences are related to other mental health disorders in Canadian Armed Forces members and Veterans.Following a series of multiple logistic regressions, the odds of experiencing a past-year mental health disorder were 1.97 (95% CI: = 1.94­2.01) times greater per unit increase in total Moral Injury Events Scale score.This emphasizes the association between morally injurious events and deleterious mental health outcomes in Canadian military personnel, and further highlights the importance of addressing moral injury in this population.

The Hidden Crisis: Understanding Potentially Morally Injurious Events Experienced by Healthcare Providers during COVID-19 in Canada.

BACKGROUND: Healthcare providers (HCPs) may be at elevated risk for moral injury due to increased exposure to potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic. Identifying PMIEs experienced during the COVID-19 pandemic is a critical first step for understanding moral injury in HCPs. Accordingly, the purpose of the present study was to gain a deeper understanding of the work-related PMIEs experienced by HCPs in Canada during the pandemic. METHODS: Canadian HCPs completed an online survey between February and December 2021 about mental health and functioning, including demographics and the Moral Injury Outcome Scale (MIOS). We conducted a qualitative thematic analysis of PMIEs described extemporaneously by HCPs in the open-text field of the MIOS. RESULTS: One-hundred and twenty-four (N = 124) HCPs were included in analysis. Eight PMIE-related themes were identified, comprising patients dying alone; provision of futile care; professional opinion being ignored; witnessing patient harm; bullying, violence and divided opinions; resources and personal protective equipment; increased workload and decreased staffing; and conflicting values. CONCLUSIONS: Understanding broad categories of PMIES experienced by Canadian HCPs during the COVID-19 pandemic provides an opportunity to enhance cultural competency surrounding their experiences which will aid the development of targeted prevention and intervention approaches.

A Qualitative Approach to Understanding Canadian Healthcare Workers' Use of Coping Strategies during the COVID-19 Pandemic.

Throughout the COVID-19 pandemic, healthcare workers (HCWs) have been exposed to highly stressful situations, including increased workloads and exposure to mortality, thus posing a risk for adverse psychological outcomes, including acute stress, moral injury, and depression or anxiety symptoms. Although several reports have sought to identify the types of coping strategies used by HCWs over the course of the pandemic (e.g., physical activity, religion/spirituality, meditation, and alcohol), it remains unclear which factors may influence HCWs' choice of these coping strategies. Accordingly, using a qualitative approach, the purpose of the present study was to gain a deeper understanding of the factors influencing HCWs' choice of coping strategies during the COVID-19 pandemic in Canada. Fifty-one HCWs participated in virtual, semi-structured interviews between February and June 2021. Interview transcripts were analysed through an inductive thematic approach, yielding two primary themes. First, HCWs described an ongoing shift in their approach to coping depending on their mental "bandwidth", ranging from "quick fix" to more "intentional effort" strategies to engage in proactive strategies to improve mental health. Second, many HCWs identified various barriers to desired coping strategies during the pandemic, including the preponderance of pandemic- and other circumstantial-related barriers. The findings from this study offer a unique understanding of the factors influencing HCWs' choice of coping strategies under novel and increased stress. This knowledge will be central to developing appropriate forms of support and resources to equip HCWs throughout and after the pandemic period, and in mitigating the potential adverse mental health impacts of this period of prolonged stress and potential trauma.

Psychometric Evaluation of the Moral Injury Events Scale in Two Canadian Armed Forces Samples.

Moral injury (MI) is defined as the profound psychological distress experienced in response to perpetrating, failing to prevent, or witnessing acts that transgress personal moral standards or values. Given the elevated risk of adverse mental health outcomes in response to exposure to morally injurious experiences in military members, it is critical to implement valid and reliable measures of MI in military populations. We evaluated the reliability, convergent, and discriminant validity, as well as the factor structure of the commonly used Moral Injury Events Scale (MIES) across two separate active duty and released Canadian Armed Forces samples. In Study 1, convergent and discriminant validity were demonstrated through correlations between MIES scores and depression, anxiety, posttraumatic stress disorder, anger, adverse childhood experiences, and combat experiences. Across studies, internal consistency reliability was high. However, dimensionality of the MIES remained unclear, and model fit was poor across active and released Canadian Armed Forces samples. Practical and theoretical implications are discussed.

The Vestibulocerebellum and the Shattered Self: a Resting-State Functional Connectivity Study in Posttraumatic Stress Disorder and Its Dissociative Subtype.

The flocculus is a region of the vestibulocerebellum dedicated to the coordination of neck, head, and eye movements for optimal posture, balance, and orienting responses. Despite growing evidence of vestibular and oculomotor impairments in the aftermath of traumatic stress, little is known about the effects of chronic psychological trauma on vestibulocerebellar functioning. Here, we investigated alterations in functional connectivity of the flocculus at rest among individuals with post-traumatic stress disorder (PTSD) and its dissociative subtype (PTSD + DS) as compared to healthy controls. Forty-four healthy controls, 57 PTSD, and 32 PTSD + DS underwent 6-min resting-state MRI scans. Seed-based functional connectivity analyses using the right and left flocculi as seeds were performed. These analyses revealed that, as compared to controls, PTSD and PTSD + DS showed decreased resting-state functional connectivity of the left flocculus with cortical regions involved in bodily self-consciousness, including the temporo-parietal junction, the supramarginal and angular gyri, and the superior parietal lobule. Moreover, as compared to controls, the PTSD + DS group showed decreased functional connectivity of the left flocculus with the medial prefrontal cortex, the precuneus, and the mid/posterior cingulum, key regions of the default mode network. Critically, when comparing PTSD + DS to PTSD, we observed increased functional connectivity of the right flocculus with the right anterior hippocampus, a region affected frequently by early life trauma. Taken together, our findings point toward the crucial role of the flocculus in the neurocircuitry underlying a coherent and embodied self, which can be compromised in PTSD and PTSD + DS.

Estradiol Replacement as a Potential Enhancer of Working Memory and Neuroplasticity in Hypogonadal Trans Women.

INTRODUCTION: The cognitive effects of cross-sex hormone therapy (CSHT) are not well understood. In cisgender individuals, sex hormone therapy can impact neurotransmitter levels and structural anatomy. Similarly, in gender-diverse persons, CSHT has been associated with neural adaptations, such as growth in brain structures resembling those observed in cisgender individuals of the same sex. Hormone-related changes in learning and memory, as seen in menopause, are associated with physiological hypogonadism or a decline in hormones, such as estradiol. The present study examined the effect of estradiol administration in humans on glutamate concentration in brain regions involved in semantic and working memory (i.e., the dorsolateral prefrontal cortex [DLPFC], the posterior hippocampus, and the pregenual anterior cingulate cortex) and its relationship with memory. METHODS: Eighteen trans women (male biological sex assigned at birth) ceased CSHT for 30 days for a washout phase (t1) upon study enrollment to reach a hypogonadal state. Working and semantic memory, cognition, hormonal assays, and brain imaging were assessed. Participants resumed CSHT for 60 days for a replacement phase (t2), after which the same evaluations from t1 were repeated. RESULTS: Estradiol increased among trans women after 60 days of resumed CSHT with significant improvements in semantic memory compared to the hypogonadal phase. Working memory recall was significantly and positively correlated to glutamate in the DLPFC during the reinstatement phase, although the relationship was not moderated by levels of estradiol. DISCUSSION: These results may have clinical implications for the therapeutic effects of estradiol replacement, serving as a protective factor against cognitive decline and impairment for trans women post-gonadectomy.