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Liu JJ, Ein N, Forchuk C, Wanklyn SG, Ragu S, Saroya S, Nazarov A, Richardson JD. A meta-analysis of internet-based cognitive behavioral therapy for military and veteran populations. BMC Psychiatry 2023; 23:223. [PMID: 37013501 PMCID: PMC10068715 DOI: 10.1186/s12888-023-04668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 03/09/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Military and veteran populations are unique in their trauma exposures, rates of mental illness and comorbidities, and response to treatments. While reviews have suggested that internet-based Cognitive Behavioral Therapy (iCBT) can be useful for treating mental health conditions, the extent to which they may be appropriate for military and veteran populations remain unclear. The goals of the current meta-analysis are to: (1) substantiate the effects of iCBT for military and veteran populations, (2) evaluate its effectiveness compared to control conditions, and (3) examine potential factors that may influence their effectiveness. METHODS This review was completed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting and Cochrane review guidelines. The literature search was conducted using PsycInfo, Medline, Embase, and Proquest Dissertation & Theses on June 4, 2021 with no date restriction. Inclusion criteria included studies that: (1) were restricted to adult military or veteran populations, (2) incorporated iCBT as the primary treatment, and (3) evaluated mental health outcomes. Exclusion criteria included: (1) literature reviews, (2) qualitative studies, (3) study protocols, (4) studies that did not include a clinical/analogue population, and (5) studies with no measure of change on outcome variables. Two independent screeners reviewed studies for eligibility. Data was pooled and analyzed using random-effects and mixed-effects models. Study data information were extracted as the main outcomes, including study condition, sample size, and pre- and post-treatment means, standard deviations for all assessed outcomes, and target outcome. Predictor information were also extracted, and included demographics information, the types of outcomes measured, concurrent treatment, dropout rate, format, length, and delivery of intervention. RESULTS A total of 20 studies and 91 samples of data were included in the meta-analysis. The pooled effect size showed a small but meaningful effect for iCBT, g = 0.54, SE = 0.04, 95% CI (0.45, 0.62), Z = 12.32, p < .001. These effects were heterogenous across samples, (I2 = 87.96), Q(90) = 747.62, p < .001. Predictor analyses found length of intervention and concurrent treatment to influence study variance within sampled studies, p < .05. Evaluation of iCBT on primary outcomes indicated a small but meaningful effect for PTSD and depression, while effects of iCBT on secondary outcomes found similar results with depression, p < .001. CONCLUSIONS Findings from the meta-analysis lend support for the use of iCBT with military and veteran populations. Conditions under which iCBT may be optimized are discussed.
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Affiliation(s)
- Jenny Jw Liu
- The MacDonald Franklin OSI Research Centre, Parkwood Institute Research, Lawson Health Research Institute, Mental Health Building, 550 Wellington Road, RM F4-367, London, ON, N6C 0A7, Canada.
- Schulich School of Medicine, University of Western Ontario, London, ON, Canada.
| | - Natalie Ein
- The MacDonald Franklin OSI Research Centre, Parkwood Institute Research, Lawson Health Research Institute, Mental Health Building, 550 Wellington Road, RM F4-367, London, ON, N6C 0A7, Canada
| | - Callista Forchuk
- The MacDonald Franklin OSI Research Centre, Parkwood Institute Research, Lawson Health Research Institute, Mental Health Building, 550 Wellington Road, RM F4-367, London, ON, N6C 0A7, Canada
| | - Sonya G Wanklyn
- Operational Stress Injury Clinic, Parkwood lnstitute, Greater Toronto Area (GTA), ON, Canada
| | - Suriya Ragu
- The MacDonald Franklin OSI Research Centre, Parkwood Institute Research, Lawson Health Research Institute, Mental Health Building, 550 Wellington Road, RM F4-367, London, ON, N6C 0A7, Canada
| | - Samdarsh Saroya
- The MacDonald Franklin OSI Research Centre, Parkwood Institute Research, Lawson Health Research Institute, Mental Health Building, 550 Wellington Road, RM F4-367, London, ON, N6C 0A7, Canada
| | - Anthony Nazarov
- The MacDonald Franklin OSI Research Centre, Parkwood Institute Research, Lawson Health Research Institute, Mental Health Building, 550 Wellington Road, RM F4-367, London, ON, N6C 0A7, Canada
- Schulich School of Medicine, University of Western Ontario, London, ON, Canada
| | - J Don Richardson
- The MacDonald Franklin OSI Research Centre, Parkwood Institute Research, Lawson Health Research Institute, Mental Health Building, 550 Wellington Road, RM F4-367, London, ON, N6C 0A7, Canada
- Schulich School of Medicine, University of Western Ontario, London, ON, Canada
- Operational Stress Injury Clinic, Parkwood lnstitute, Greater Toronto Area (GTA), ON, Canada
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Richardson JD, Roth M, Liu JJ. Clinical utility of moral injury in a treatment-seeking military-Veteran mental health population. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2023. [DOI: 10.3138/jmvfh-2022-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
LAY SUMMARY Moral injury (MI) can be defined as a diverse set of outcomes associated with actions that transgress one’s moral beliefs or values. MI can be distressing for an individual at the interpersonal level (e.g., shifting relationships, feelings of betrayal) and the intrapersonal level (e.g., internalized guilt and shame). Indeed, these transgressions of moral beliefs and values have been associated with a high prevalence of mental illnesses, such as posttraumatic stress disorder (PTSD) and depression. Although various forms of assessment exist to identify MI in the individual, treatments for MI are often interlinked or embedded in evidence-based treatments for PTSD and depression. As such, unique contributions of MI as a target of treatment remain largely unclear. In this article, the authors explore existing treatments that may be used to treat MI as a distinct mental health construct and examine their utility in reducing symptoms of MI in military and Veteran populations.
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