were defined, measured, analysed and reported. An assessment was conducted for each individual study with regard to the quality and risk of bias criteria utilising a modified version of the Chalmers Checklist for appraising the quality of studies of interventions (see Appendix 3). Three independent raters rated each study according to these criteria, and together a consensus agreement was reached as to an overall rating of ‘Good’, ‘Fair’, or ‘Poor’. Quantity of evidence reflected the number of studies that were included as the evidence base for each ranking. The quantity assessment also took into account the number of participants in relation to the frequency of the outcomes measured (i.e. the statistical power of the studies). Small underpowered studies that were otherwise sound may have been included in the evidence base if their findings were generally similar- but at least some of the studies cited as evidence must have been large enough to detect the size and direction of any effect. Level of evidence reflected the study design. Details of the study designs included in this REA were assessed against a hierarchy of evidence commonly used in Australia: Level I: A systematic review of randomised controlled trials (RCTs) Level II: A RCT Level III-1: A pseudo-RCT (i.e. a where a pseudo-random method of allocation is utilised, such as alternate allocation). Level III-2: A comparative study with concurrent controls. This can be any one of the following: Non-randomised experimental [this includes controlled (pre-test/post-test) studies, as well as adjusted indirect comparisons (i.e. utilise A vs B and B vs C to determine A vs C with statistical adjustment for B)] Cohort study after
context or specific local settings include organisational factors (e.g. availability of trained staff) and cultural factors (e.g. attitudes to health issues, including those that may affect compliance). 4 3 2 1 Directly applicable to the Australian context Applicable to the Australian context with few caveats Applicable to the Australian context with some caveats Not applicable to the Australian context Ranking the evidence On balance, this next step takes into account the considerations of the strength of the evidence (quantity and risk of bias, quantity of evidence and level of evidence), consistency, generalisability and applicability. The total body of the evidence is then ranked into one of four categories: ‘Supported’, ‘Promising’, ‘Unknown’ and ‘Not Supported’ (see Figure 1). Agreement on ranking is sought between all three independent raters. Figure 1: Categories within the intervention ranking system SUPPORTED consistent evidence of beneficial effect PROMISING Evidence suggestive of beneficial effect but further research required UNKNOWN Insufficient evidence of beneficial effect and further research is required NOT SUPPORTED Clear, consistent evidence of no effect or negative / harmful effect Results
Appendix 2 Example search strategy The following is an example of the search strategy conducted in the EMBASE database: Step Search Terms No of records S1 “moral injury” OR “moral attitudes” OR “moral attitude” OR “moral belief” OR “military ethics” OR “moral ethics” OR morals OR morality 28,504 S2 treatment OR therapy OR psychological OR counselling OR intervention OR psychotherapy OR psychology OR clinical OR “adaptive disclosure” OR “prolonged exposure” OR “mental health service” OR spiritual OR religion OR religious OR religiosity OR spirituality OR theology OR social OR family OR sociology 13,676,370 S3 “mental health” OR “PTSD” OR “posttraumatic stress” OR stress” OR “traumatic stress” OR “stress disorder” OR traumati*ation” OR alcohol OR drugs OR “drug abuse” OR OR self*harm OR “depression” OR “depressive” OR “anxiety” OR “well-being” OR shame OR guilt OR forgiveness OR OR self*destructive OR aggression OR anger 2,026,856 S4 veterans OR veteran OR military OR army OR soldiers OR war OR deployment OR combat 424,116 S5 #1 AND #2 AND #3 AND #4 164 S6 #1 AND #2 AND #3 AND #4 AND [2004-2014]/py 122
Outcomes (Measure(s)) - Posttraumatic Stress Disorder Checklist- Military version (PCL-M) -Complicated grief – thematic analysis only i.e. no qualitative analysis - Posttraumatic Stress Disorder Checklist- Military version (PCL-M) - Depression (PHQ-9) - Alcohol use (AUDIT -Traumatic appraisal (PTCI) - Posttraumatic Growth Inventory (PTGI)