Background: Since the armed conflict in Ukraine escalated in 2022, UK and US military veterans have volunteered in substantial numbers to support the Ukrainian Armed Forces. They are operating in an exceptionally intense and technologically advanced environment, often exposed to high levels of combat. Little is known about the health impact of this voluntary service.Method: We carried out a mixed-methods observational study of UK and US military veterans who self-reported travelling to Ukraine to support the Ukrainian Armed Forces. Participants were recruited between October and December 2025. Measures assessed probable post-traumatic stress disorder (PTSD), common mental health disorders (CMD), alcohol misuse, moral injury, and health-related quality of life. Open response items were used to qualitatively explore motivations for volunteering, experiences of service in Ukraine, and access to healthcare.Results: Thirty-one UK and US military veterans completed psychometric measures and 21 provided qualitative data. High levels of probable PTSD, CMD alcohol misuse, and moral injury-related distress were identified, alongside low health-related quality of life. Veterans described extremely intense combat exposure, including drone warfare and trench fighting, and frequent physical injury. Physical healthcare was often described as poor or inadequate. Mental health care was widely sought but rarely accessible, both in Ukraine and after return home, with veterans reporting being turned away from support services. Consequently, emotional support primarily came from peers rather than formal care systems.Conclusions: This study provides early evidence on the experiences and health needs of UK and US veterans who volunteered in Ukraine, an under-researched group falling outside existing military care structures. Many report significant unmet mental and physical health needs and face barriers to care both in Ukraine and after returning home. Without targeted support, these veterans risk remaining invisible within health systems, highlighting the need for coordinated pathways and prioritised clinical care.

BACKGROUND:Moral injury (MI), characterized by psychological distress from morally transgressive events, has been predominantly studied in military personnel but has gained increased attention in healthcare workers (HCWs) since the COVID-19 pandemic. SOURCES OF DATA:In this review, we narratively synthesize literature on the causes, risks, consequences, and interventions of MI in HCWs. AREAS OF AGREEMENT:There is consensus that the COVID-19 pandemic presented HCWs with unique challenges such as fear of infection and patients dying without family, which increased the risk of MI in HCWs. AREAS OF CONTROVERSY:Broader healthcare experiences, not unique to a pandemic, are less well understood. In this review, we discuss evidence of such experiences including restrictive practices in psychiatric settings and experiences of discrimination. GROWING POINTS:Recent studies have highlighted the importance of addressing MI through organizational change, training, and peer support initiatives. Emerging evidence also underscores the need to consider broader systemic factors, such as workplace culture and leadership, in mitigating MI. AREAS TIMELY FOR DEVELOPING RESEARCH:Future research should focus on longitudinal studies to explore in more detail risk factors for MI in HCWs. Additionally, there is a need for robust evaluations of interventions to prevent and treat MI and related disorders, including randomized controlled trials. Investigating the morally injurious effects of systemic issues like understaffing is particularly urgent as the field evolves beyond pandemic-specific challenges.

Objectives Studies have found that moral injury (MI) can be easily missed in clinical assessments and most measures of MI have been developed for and with US military samples. As MI is increasingly recognised in non-military samples, existing scales may not be appropriate to civilian experiences. Design To design and validate the Moral Injury Scale (MORIS), a self-report measure of exposure to potentially morally injurious events (PMIEs), moral injury-related distress, and associated risk and protective factors, in UK samples pre-screened for reporting morally or psychologically distressing experiences. Setting UK general population. Participants We administered an initial set of 47 items to 592 participants and conducted exploratory factor analysis. The reduced MORIS was then administered to an independent sample of 382 participants and confirmatory factor analysis was conducted. Primary outcome measures The validity and performance characteristics of the MORIS were assessed against validated measures of mental ill health. Receiver operating characteristic (ROC) curves were used to calculate a likely cut off score for detecting conditions that are associated with moral injury. Results Analysis yielded factors for assessing exposure to PMIEs; time since event; MI-related distress; and risk and protective factors. Good convergent validity was evidenced against the measure of MI and mental health symptoms. Confirmatory factor analysis demonstrated a good fit for the model. ROC analyses suggested that a score of ≥18 (ROC 0.83; 95% CI 0.77 - 0.90) on the MORIS Distress subscale may indicate elevated levels of moral injury-related distress within this sample; however, this finding should be considered exploratory at this stage. Conclusions This study provides preliminary evidence supporting the reliability, unidimensional factor structure, and convergent validity of the MORIS among UK adults reporting morally or psychologically distressing experiences. Data set information Please see data availability statement. Trial registration number N/A

Abstract Background Public services are increasingly delivered through digital platforms. Although digital health may improve access and scalability, they may also widen inequalities for people who lack reliable access, confidence, skills, affordability or trust. Objective This study examined the prevalence of self-reported digital exclusion among UK veterans and assessed its association with depression, anxiety and loneliness. Methods A cross-sectional online survey was conducted between July 2025 and March 2026. Participants were UK Armed Forces veterans and resident in the UK. The survey collected sociodemographic, military service, digital access and health data. Self-reported digital exclusion was defined as reporting feeling excluded or disadvantaged due to lack of digital access or skills. Probable depression, anxiety and loneliness were assessed using the PHQ-2, GAD-2 and three-item UCLA Loneliness Scale, respectively. Associations between digital exclusion and each outcome were examined using adjusted multivariable logistic regression. Results Of 1,911 responses received, 1,607 were included after data quality exclusions. Among participants with valid responses to the primary digital exclusion item, 553 (41.7%) reported digital exclusion. Digital exclusion was more common among females, younger veterans and those with lower household income. Probable depression, anxiety and loneliness were more prevalent among digitally excluded participants than among non-excluded participants. In adjusted models, self-reported digital exclusion was associated with higher odds of probable depression (AOR 1.38; 95% CI 1.04 to 1.83; p =0.028), probable anxiety (AOR 1.63, 95% CI 1.23 to 2.16; p <0.001), and probable loneliness (AOR 1.85; 95% CI 1.43 to 2.40; p <0.001). Conclusion More than two-fifths of veterans with valid exposure data reported digital exclusion, despite high reported device access and confidence. Self-reported digital exclusion was associated with poorer mental health and loneliness, although causality cannot be inferred from these cross-sectional data. Digital-first services for veterans should include routine digital needs screening, targeted support and clear non-digital routes to care.

Introduction Alcohol misuse remains a significant cause of morbidity among serving UK Armed Forces (UKAF) personnel, with prevalence exceeding that of comparable civilian populations. Digital interventions offer a potentially scalable approach to alcohol reduction, and the DrinksRation smartphone application has previously demonstrated effectiveness among UK military veterans. This study evaluated the effectiveness of DrinksRation in reducing alcohol consumption among serving UKAF personnel drinking at levels which risk alcohol related harm. Methods Military DrinksRation was a two-arm, parallel-group, superiority randomised controlled trial nested within the Drinking and Wellbeing study. Serving UKAF personnel screening positive for at-risk drinking (Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) score > 4) were randomised to receive either the DrinksRation smartphone application or treatment as usual. The primary outcome was alcohol consumption at 84 days. Secondary outcomes included motivations for drinking, barriers to changing alcohol use, common mental disorders and loneliness. Recruitment took place between October 2023 and July 2024. Results A total of 613 serving personnel completed AUDIT-C screening, of whom 338 (55.1%) met the eligibility criteria for the trial. 113 participants were randomised (58 treatment as usual; 55 DrinksRation). Personnel screening positive for at-risk drinking were significantly less likely to consent to participate than those drinking at lower risk levels (33.4% vs 42.2%; χ 2 = 4.96, p = 0.03 ). Recruitment and follow up were substantially lower than anticipated with no participants in the intervention arm completing the primary end point assessment at 84 days. Consequently, the prespecified comparative analyses of the primary and secondary outcomes could not be undertaken. Participants who activated the DrinksRation application demonstrated sustained engagement with the intervention despite poor completion of research follow up assessments. Conclusions The trial did not generate sufficient outcome data to evaluate effectiveness. However, it demonstrates that routine screening can identify serving personnel drinking alcohol at risky levels, while recruitment, intervention activation and research follow-up remain substantial barriers to evaluating digital alcohol interventions in serving military populations. Although routine screening successfully identified personnel drinking at-risk of alcohol-related harm, engaging those individuals with research participation and sustaining follow up proved considerably more challenging. Trial registration ISRCTN 14977034 1 . Prospectively registered. The study protocol was published prior to commencement of recruitment 2 .

BACKGROUND:Workers in specialist and other high-risk roles can experience secondary traumatic stress and related symptoms through routine exposure to distressing material, yet organisational responses vary widely. Evidence for the effectiveness of commonly used approaches (e.g. screening, training, counselling/debriefing, mindfulness/resilience) remains uncertain and fragmented. AIMS:To evaluate the effectiveness of mental health screening, training and psychological interventions in reducing psychological harm for employees exposed to potentially traumatic material. METHODS:Five databases (Web of Science, Medline, PsycInfo, Embase, Scopus) were searched in March 2025, using a rapid review approach. A total of 9581 citations were screened for relevance; 28 studies were included in the final review. RESULTS:Quantitative findings showed no benefit of mental health screening, routine counselling, monitoring/periodic assessment, mindfulness or resilience programs; mixed effects for training and neutral-to-adverse findings for debriefing. Qualitative findings favoured supervision and access to informal support; debriefing/counselling results were mixed. Cross-sectional studies suggested associations between better organisational support and fewer psychological stress symptoms. CONCLUSIONS:Overall, efficacy evidence is limited and inconsistent across approaches. However, the strongest evidence suggests that organisations should avoid mandating psychological debriefing.

Background The COVID-19 pandemic raised concerns about the mental health of an already burdened healthcare workforce. This study examined mental health trajectories among healthcare workers (HCWs) across the pandemic and identified personal and employment factors associated with different symptom patterns.Methods Longitudinal data were drawn from the NHS CHECK cohort, including clinical and non-clinical staff from 18 NHS Trusts in England (April 2020-April 2023). Growth curve and growth mixture models identified latent classes of HCWs characterized by distinct trajectories of probable common mental disorders. Secondary outcomes included anxiety, depression, alcohol misuse, and post-traumatic stress symptoms. Logistic regression examined associations between baseline personal and employment characteristics and class membership.Results The analytical sample included 22,764 participants. For each outcome, growth mixture models identified two latent classes. Approximately 31% of HCWs experienced persistently high symptoms of probable common mental disorders, while 69% experienced persistently low symptoms. Similar patterns were observed for secondary outcomes, with small subgroups demonstrating worsening symptoms followed by improvement. Logistic regression analyses showed that being female, younger, single, working as a nurse, or having a pre-existing mental health diagnosis increased the odds of belonging to a high symptom class. Perceived support from colleagues and managers was protective.Conclusions While many HCWs reported consistently low mental health symptom levels, almost a third belonged to a latent class characterized by persistently high symptoms across all time points. These findings underscore the need for mental health support for vulnerable HCW groups, embedded within routine NHS practice rather than limited to crisis periods.

INTRODUCTION:Remotely piloted aircraft systems (RPAS) are integral to military operations. Although geographically removed from the battlefield, RPAS personnel are exposed to operational, organisational and moral stressors. This review synthesises evidence on the mental health and well-being of military RPAS personnel. METHODS:This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Cochrane methodology. The protocol was preregistered on PROSPERO. Searches were conducted in MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science, ScienceDirect and PILOTS for studies from January 2002 to June 2025. Peer-reviewed studies examining mental health outcomes among military RPAS personnel were included while grey literature and technical repositories were screened for context. Study quality was assessed using NICE (National Institute for Health and Care Excellence) public health guidance checklists. Given variation in study designs and outcome measures, findings were synthesised narratively. RESULTS:Fourteen studies met the inclusion criteria, comprising nine cross-sectional surveys, two retrospective record analyses, one cohort study, one physiological experiment and one qualitative study. The prevalence of probable post-traumatic stress disorder (PTSD) ranged from 3.3% to 6.7%, which is broadly comparable to other military populations. Psychological distress was reported in 13.0%-16.0% of personnel, and high emotional exhaustion in 25.0%-37.0%. Suicidal ideation ranged from 4.4% to 8.0%. Subthreshold PTSD symptoms, sleep disturbance and functional impairment were frequently reported. The identified risk factors were predominantly organisational rather than combat-related, including long working hours, shift instability, understaffing, role conflict and sleep disruption. Protective factors included leadership support, team cohesion, adequate sleep and positive help-seeking attitudes. CONCLUSIONS:RPAS personnel do not show significantly higher rates of diagnosable mental disorder than other military groups. However, they do experience considerable occupational strain. Across the literature, adverse outcomes were more often linked to chronic organisational stressors than to direct battlefield exposure. Future research should prioritise longitudinal designs, comparative cohorts and the evaluation of targeted occupational interventions. PROSPERO REGISTRATION NUMBER:CRD42022329937.

Background. Alcohol use has historically been higher among UK Armed Forces personnel than in the general population, but much of the evidence was generated during sustained military campaigns in Iraq and Afghanistan. Contemporary patterns of alcohol use following substantial changes in the operational context are less well understood. Aims. To assess the prevalence of at-risk drinking and associated demographic and military factors among serving regular UK Armed Forces personnel. Methods. A cross-sectional study used AUDIT-C screening to categorise alcohol consumption as low, increasing, higher risk or potentially dependent. Demographic and military factors associated with at-risk drinking were examined using multivariable logistic regression. Results. Of 613 personnel screened, 229 (37.4%) consented to the full study. Overall, 338 (55.1%) screened at risk (AUDIT-C ≥ 5), including 110 (17.9%) meeting criteria for higher-risk or potentially dependent drinking. Female personnel had lower adjusted odds of at-risk drinking than males (aOR 0.36, 95% CI 0.14–0.93), while single personnel (aOR 3.63, 95% CI 1.18–11.16) and those with previous combat deployment (aOR 2.43, 95% CI 1.01–5.83) had higher odds. Personnel meeting criteria for higher-risk or potentially dependent drinking were less likely to consent to the full study (26.4% versus 39.8%; p = 0.009). Conclusions. At-risk drinking remains common in the contemporary UK Armed Forces, with most alcohol-related risk occurring below thresholds for high risk and potential dependence. Occupational health approaches should address increasing-risk drinking as well as the heaviest consumption. Lower participation among higher-risk drinkers also warrants consideration in future alcohol research.

Background Moral injuries (MIs) may result from individuals being exposed to potentially morally injurious events (PMIEs). PMIEs have been a feature of work within much of the National Health Service (NHS) for many years, and the understanding of MI is now more commonplace, having been highlighted during the COVID-19 pandemic; however, understanding of how such events affect workers over the long term is lacking.Objective To understand the development of healthcare workers’ (HCWs) experiences of PMIEs over a period of 3 years.Design and participants We carried out follow-up semistructured qualitative interviews with 15 NHS staff who were previously interviewed on the same topic in 2021. All interviews were recorded, transcribed and analysed using reflexive thematic analysis following an inductive approach.Results Three main themes and six subthemes were identified: (1) internal context and subjective experiences, (1.i) control in a rigid system, (1.ii) psychosocial dynamics, (2) external context and the moral cost of culture, (2.i) organisational culture, (2.ii) sources of MI, (3) responses to PMIEs, (3.i) maladaptive responses, (3.ii) adaptive responses. Key issues identified included perceptions of insufficient control over their work and work environment, low psychological safety and perceived misunderstanding of the value of their work from patients and colleagues, leading to a challenging organisational culture. We found that in the 3 years between the interviews many staff reported developing ‘secondary’ feelings of betrayal as a result of perceived ongoing governmental neglect of recognition for HCWs’ sacrifices during the pandemic and a lack of acknowledgement of governmental mistakes made in the acute period.Conclusion Findings show an interplay between individual and organisational factors that HCWs faced while working in the NHS, underlining the need for wide-ranging intervention strategies. Since the HCWs’ original interviews in 2021, a secondary betrayal has developed, emphasising the need for interventions that can restore trust in the system.

BACKGROUND:Workplace mental health is a growing global priority. Traditional approaches to intervention delivery often face barriers of scalability and engagement. Recent advances in artificial intelligence (AI) offer new opportunities for dynamic, personalized support, but their effectiveness and implementation in occupational settings remain unclear. SOURCES OF DATA:This systematic review included 17 studies published between 2018 and 2024, identified from six databases. Studies were appraised using Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, and risk of bias was assessed with Cochrane Risk of Bias 2.0 (RoB 2.0) and ROBINS-I tools. AREAS OF AGREEMENT:AI-based interventions, such as chatbot using cognitive behavioural therapy and predictive analytics, show promise for improving worker's mental health, enhancing resilience, and improving engagement. Acceptability was generally high across studies. AREAS OF CONTROVERSY:Despite positive findings, intervention maturity remains low, and outcome reporting is inconsistent. Few studies systematically addressed adverse events, rollout scalability, or ethical concerns, and the added value of AI over traditional approaches is uncertain. GROWING POINTS:AI interventions may offer flexible, adaptive solutions for improving workplace mental health, with strong engagement indicators. There is a pressing need to support clinicians and occupational health teams in evaluating potentially useful AI tools. AREAS TIMELY FOR DEVELOPING RESEARCH:Future research must prioritize high quality randomized trials, long-term follow-up, and real-world implementation studies. Standardized frameworks for reporting effectiveness, harms, and ethical considerations are important for safe, trustable, and sustainable adoption in occupational health.

The COVID-19 pandemic altered alcohol consumption across civilian populations, but evidence among serving military personnel remains limited. In a cross-sectional survey of 227 UK Armed Forces personnel, individuals currently classified in increasing- and higher-risk AUDIT-C categories were more likely to retrospectively report drinking more than before the pandemic, while demographic and military characteristics showed little association apart from younger age.

Background: Potentially morally injurious events (PMIEs) are experiences that violate deeply held moral values through one's own transgressive actions (commission), failing to prevent or witnessing wrongdoing (omission), or betrayal by a trusted person. PMIE exposure has been linked to psychological distress, but it is unclear whether different PMIE subtypes confer distinct patterns of risk. This systematic review examined associations between specific PMIE subtypes and key psychological outcomes.Methods: Multiple databases were searched for quantitative studies that assessed PMIE subtypes in relation to PTSD or complex PTSD, depression, anxiety, alcohol misuse, and suicidal ideation or self-injurious behaviour. Fifteen studies published in the last seven years (total N ≈ 21,700) in military, healthcare, veteran, and civilian samples met inclusion criteria. A Population-Exposure-Outcome framework guided data extraction, and findings were synthesised narratively by outcome and subtype.Results: Betrayal-type PMIEs were frequently associated with PTSD, depression, and anxiety across included studies. Commission-type events were associated with several outcomes, including PTSD, depression, and suicidality, although findings varied across samples and analytic approaches. Omission-type exposures showed more variable associations overall, although several studies reported significant links with PTSD, depression, anxiety, or suicidality.Conclusions: PMIE subtypes showed overlapping but potentially different patterns of associations with psychological distress. Across the available literature, betrayal-related PMIEs emerge as the most prominent and consistent correlate of PTSD, depression, and anxiety, while commission-related events were also linked with distress, particularly suicidality, and omission-related findings were less consistent. These findings support considering PMIE subtypes separately in assessment and future research.

OBJECTIVE:This study assessed the feasibility of delivering and evaluating the Group Responses After Disasters and Emergencies (GRADE) training intervention among managers in trauma-exposed roles. METHOD:A pre-registered two-arm randomised controlled feasibility trial was conducted with managers from UK Government ( https://osf.io/4jt7f ). Outcomes were assessed via online surveys at three time points. Qualitative interviews explored participants' experiences of the training. RESULTS:Recruitment generated interest, but participant uptake and retention were limited. Although underpowered, peer literacy was responsive to the intervention showing a large immediate effect. There was not a reliable intervention effect on attitudes towards mental health, but qualitative findings suggest that this could be due to high pre-existing attitudes. CONCLUSION:This study suggests that the GRADE training intervention is feasible and had a positive impact on increasing managers' confidence to speak with their employees.

Background Maintaining healthcare workers’ (HCWs) mental health is vital to reduce staff absences and turnover, ultimately improving patient care. Most research focuses on clinical staff and single timepoints, overlooking non-clinical contributions. Aims To examine mental health variations among all staff types over three years and identify those most at risk of poor mental health outcomes. Methods Our prospective cohort study followed 22,092 HCWs from 17 English NHS Trusts. Online surveys assessed common mental disorders (CMDs), depression, anxiety, alcohol misuse, PTSD, moral injury, burnout, wellbeing, resilience, and post-traumatic growth at four timepoints from April 2020 to March 2023. Data were analysed cross-sectionally and weighted to represent Trust demographics. Results Approximately 50% of participants reported probable CMDs at all timepoints. The most consistent predictor of poor mental health was having met the baseline cut-off for that outcome. No consistent differences emerged between clinical and non-clinical staff. Younger, female, lower-paid staff, those feeling unsupported by colleagues/managers, and exposed to morally injurious events were most at risk of poor mental health outcomes. Conclusions All NHS staff types face persistent mental health struggles, with no significant improvement post-pandemic restrictions. Structural inequalities must be addressed long-term, alongside targeted, flexible support for staff in the short term.

Objectives During the COVID-19 pandemic, National Health Service staff support services were implemented to promote healthcare workers' (HCWs) well-being, alongside informal support from colleagues and managers. Certain groups may be less likely to access support, including HCWs from ethnic minority and migrant groups. These HCWs are more likely to experience discrimination and abuse at work, which may also erode access to positive and protective resources. Therefore, this study examined variation in formal support programme use and perceptions of support from managers and colleagues by ethnicity and migration status.Methods This study analysed survey data from 9769 HCWs in England who completed the baseline survey (launched April 2020) and the 6-month follow-up using descriptive statistics and binary logistic regression.Results At 6 months, 51% of participants met the threshold for probable common mental disorder. HCWs from White Other (Adjusted Odds Ratio (AOR) 0.79; 95% CI 0.64 to 0.99) and Asian ethnic groups (AOR 0.65; 95% CI 0.57 to 0.74) were less likely to feel supported by their colleagues than White British HCWs. Similarly, those born outside of the UK and European Union were less likely to feel supported by their colleagues than UK-born HCWs (AOR 0.70; 95% CI 0.52 to 0.94). No variations in support programme use or manager support were found across ethnicity or migration status.Conclusions The study suggests equitable formal support but identified critical disparities in perceived support from colleagues for HCWs during the COVID-19 pandemic. Improving workplace well-being should address the underlying social and structural factors that influence peer support and belonging.

OBJECTIVES:Twenty years since the start of UK Armed Forces participation in the Iraq and Afghanistan conflicts post-2001, the extent to which these deployments continue to impact mental health outcomes and alcohol misuse in UK military personnel is unknown. This is the reporting of the fourth phase, cross-sectional study of a longitudinal cohort study that has assessed the health and well-being of UK serving and ex-serving personnel since 2004. METHODS:Participants were eligible for the most recent phase (2022-2023) if they took part previously (2014-2016) and consented to recontact. Primary outcome measures included symptoms of common mental disorders (CMD), such as depression and anxiety, probable posttraumatic stress disorder (PTSD), complex PTSD (C-PTSD) and alcohol misuse. RESULTS:In the overall sample (n=4104, response rate=54.6%), CMD were the most prevalent outcome (27.8%), followed by probable PTSD (9.4%) and alcohol misuse (8.4%). The majority of PTSD experienced met the criteria for C-PTSD (72.7%). Ex-serving Regulars compared with serving Regulars reported a higher prevalence of PTSD (10.5% vs 7.4%, adjusted OR (AOR)=1.68, 95% CI 1.12 to 2.51) and C-PTSD (6.5% vs 3.9%, AOR=1.80, 95% CI (1.07 to 3.05); a higher prevalence of both disorders was also reported in serving/ex-serving Regulars whose last deployment to Iraq/Afghanistan was in a combat role. CONCLUSION:Although the majority of those who deployed to Iraq or Afghanistan remain well, there is an enduring impact of combat deployment on PTSD. Attention should continue to be directed towards the prevention, early detection and treatment needs of this cohort.