The provision of services in the UK for UK armed forces veterans with PTSD: a rapid evidence synthesis

Definitions of ‘veteran’

In the recent NHS England stakeholder engagement survey questionnaire, a veteran is referred to as follows:

We use ‘veteran’ to mean anyone who has been a serving member of the British armed forces for a day or more. It means the same as ‘ex-service personnel’ . . . when we say ‘veteran’ or when we talk about armed forces’ experiences, this includes reservists as well as regulars.

p. 2 of the questionnaire7

Other definitions exist. For example, in the USA, a veteran is ‘a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonourable’ (Title 38 of the Code of Federal Regulations). 8

In our research we aimed to capture definitions of ‘veteran’ in the international research literature and adopt a consistent approach to reporting.

Post-traumatic stress disorder and ‘complex post-traumatic stress disorder’

Post-traumatic stress disorder is an anxiety disorder following very stressful, frightening or distressing events. People with PTSD can experience nightmares and flashbacks; they can feel isolated, irritable and guilty. Various sequelae, such as insomnia and poor concentration, can have a significant impact on day-to-day living. NHS standard treatments for PTSD currently include watchful waiting, psychotherapy, trauma-focused cognitive–behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), group therapy and counselling, and medication (antidepressants). 9

Post-traumatic stress disorder is not a static condition. Many people leave the armed forces with undiagnosed PTSD, and the condition often manifests after they have left the service. Expert opinion suggests that veterans will commonly (around 50% of the time) suffer from ‘complex PTSD’ (or complex presentations of PTSD). There is currently no agreed diagnostic code for this condition, and ‘complex PTSD’ is not a universally agreed term in the research literature.

‘Complex PTSD’ is described by field experts as PTSD compounded by comorbidities such as substance misuse and depression. It is linked to multiple (as opposed to single) traumatic events, although it does not always arise from active military service; for example, the condition may result from repeated trauma/sexual abuse in childhood. 10,11 ‘Complex PTSD’ is interpreted by some medical professionals as PTSD with additional syndromes, such as pathological disassociation, emotional dysregulation, somatisation and altered core schemes about the self, relationships and sustaining beliefs. 12 The US Department of Veterans Affairs National Center for PTSD describes ‘complex PTSD’ as a condition arising from repeated trauma over a number of months or years, manifesting as a cluster of symptoms that may require special treatment consideration. 13

Despite the absence of a clear definition and a diagnostic mechanism for ‘complex PTSD’, it appears to be distinguished from PTSD by its link with exposure to multiple traumatic events. Therefore, for the purposes of our work we assumed that PTSD in the veteran population was synonymous with ‘complex PTSD’.

It is thought that the context, severity and complexity of PTSD in armed forces veterans may require different approaches13 (i.e. treatments or models of care) from those offered to the general population; these are, as yet, not fully understood. Veterans appear to have higher levels of adverse childhood events before they join, seem to drink more alcohol than the general population and are more likely to have been exposed to multiple traumatic events that may produce different challenges for treatment when compared with treatment for single events or occasions of sexual/domestic abuse and rape. It is also thought that veterans are more willing to admit to combat-related PTSD as a less-stigmatised form of mental illness. 10

Post-protocol decisions relating to stage 2

Our working definition of ‘models of care’ (see Chapter 1, Objectives) was helpful in shaping initial parameters for stage 2. However, during screening and selection of studies it became clear that the term ‘model of care’ could be interpreted in more than one way. For example, we found studies that described a specific method or mechanism by which an intervention was delivered (e.g. telehealth, smartphone applications, group support) and others that adopted a broader organisational or systems perspective (e.g. integrated care, community outreach). This important distinction turned our thoughts to what might be the most helpful perspective for readers of our rapid evidence synthesis. Given the ongoing UK policy focus to achieve sustainable new models of care (i.e. how services can be optimally organised and structured), we decided to focus on the broader ‘systems’ interpretation. Based on this interpretation, we developed a coding list (see Appendix 3) to help organise the evidence and to shape the data extraction and synthesis going forward. Two reviewers independently assigned codes to individual studies. Disagreements were resolved by consensus or through discussion with a third reviewer.

The number of included studies was much larger than expected. Given the short time frame and resources, we had to make pragmatic decisions at the data extraction stage to ensure that there was sufficient time to adequately synthesise the studies. We therefore chose to data extract in full and critically appraise more robust study designs, conventionally considered to be systematic reviews, randomised controlled trials (RCTs) and controlled trials. We also chose to extract data in full qualitative studies that provide insight from a service user perspective. The remaining studies were predominantly single-group designs, which are typically considered less methodologically robust. These studies had more limited data extraction (e.g. study design, sample size, code and description of model of care, list of outcomes and a summary of authors’ conclusions and recommendations). Although these single-group studies were not formally assessed for methodological quality, we considered the adequacy and clarity of reporting on context, methods and impact.

North of England (four service providers)

Midlands (three service providers)

South of England (five service providers)

Scotland

Wales

Northern Ireland

UK-wide third-sector organisations

Other service providers

Two other organisations in the north of England were contacted on the basis that they did not appear to fit with either the NHS or third-sector delivery models. The St Johns and Red Cross Defence Medical Welfare Service is available across Greater Manchester hospitals. It does not provide treatment but instead provides support and signposting for veterans across the referral pathway. The service is specifically for veterans aged ≥ 65 years.

Liverpool Veterans appears to be an independent organisation developed by Breckfield and North Everton Neighbourhood Council in conjunction with the Foundation for Art and Creative Technology (FACT). It provides links to services, research and fundraising events for veterans and their families in the Liverpool area. Of particular note is that the organisation signposts individuals with PTSD to Tom Harrison House (a specialist facility for addiction recovery). 32

Funding and resources

Inadequate funding to meet current demand was frequently cited, particularly for trauma services. Availability of appropriate clinicians and venues was also seen to be problematic. Lack of resources was reported to result in lengthy waiting lists for services and treatment in some areas. In Northern Ireland, restriction of eligibility to those only with previous service in the UDR or R IRISH (home service) or a veteran discharged via the Personnel Recovery Unit was seen as a limitation.

Wider system challenges

Perhaps as a consequence of inadequate funding and resources, further challenges to implementation were difficulties in negotiating appropriate longer-term treatments (such as psychotherapy) within the NHS. Service providers also mentioned that NHS IAPT can be slow to provide definitive treatment. As veterans often present in crisis because of pressure from partners, employers or the criminal justice system, such delay is at odds with the pressing needs and expectations that require prompt attention in this population group.

Poor co-ordination of care between agencies was also cited as a hindrance to successful implementation of services and treatments. For example, veterans with comorbid substance misuse were described by one service provider as ‘. . . a football between services’. The difficulty, in their view, appears to be about where to place the veterans’ needs on the continuum of care. Indeed, veterans are often viewed as too risky for well-being services but not unwell enough for secondary psychological services.

Research and development: knowledge base

Inadequate research and treatment development was cited by one service provider as being at odds with the increased drive to deliver evidence-based interventions with appropriate assurances in place. A concern expressed by another service provider was that a particular delivery model delivered by them was not understood sufficiently by commissioners, resulting in the inability to achieve full implementation of the intervention.

Complexities of the client group

Successful implementation of services and treatments for veterans with PTSD is affected, generally, by the fact that this is a highly challenging client group. They are described by service providers as unstable, unreliable and generally hard to engage because of inherent difficulties they tend to experience with help seeking. On referral, clients often arrive with testing social, financial and premorbid disposition. They can also feel let down because of problems already mentioned in relation to long waiting lists, unsatisfactory previous treatment and wider system challenges.

Integrated care, partnership working, networks and co-located services

These types of care models were the most frequently reported (Table 6 presents details of the models). Two before-and-after studies conducted in the US VA setting reported on benefits for PTSD and pain. 62,63 Of these, Plagge et al. 63 suggested that involving primary care in the delivery of behavioural activation therapy was feasible and potentially effective in treating PTSD and comorbid pain in veterans. Benefits for pain and PTSD were also indicated following the integration of CPT and CBT in Otis et al. 62 Returning to primary care involvement, a VA-based evaluation by Bohnert et al. 52 suggested that same-day integrated mental health services (i.e. delivering services on the same day as initial need is detected) in collaboration with primary care increased the likelihood of PTSD diagnosis and treatment initiation after a positive screen when compared with mental health service delivery in other settings. An observational study by Brawer et al. 51 also drew links to the success of integrating primary care and mental health services on increasing rates of consultation in the VA setting.

In other studies, a before-and-after survey conducted by Baringer et al. 50 revealed improvements in a range of patient-identified psychosocial problem areas following a short-term pilot inpatient PTSD stabilisation unit co-located with existing VA treatment provision. A service evaluation in the UK by Burdett and Greenberg35 revealed improvements in veterans’ mental health following human givens therapy31 delivered by a countrywide network of 200 therapists when compared with the UK IAPT programme.

The remaining studies were descriptive. From Australia there was a critical analysis of PTSD group treatment programmes,44 and from the USA there was a thesis on collaborative care depression treatment in the VA setting53 and an editorial describing an integrated community-based primary care strategy (the Community-Based Wounded Warrior Sustainability Initiative). 49

Settings-based models of care

Two quasi-experimental studies compared care delivery across different settings (Table 7). 46,56 In Australia, Creamer et al. 46 indicated that delivery in a less expensive (and less restrictive) day hospital may be equally effective for veterans with PTSD as inpatient or outpatient programmes on a range of psychological and social variables. A similar trend was reported by Fontana and Rosenheck56 in the USA VA setting, favouring less intensive programmes to achieve clinical, satisfaction and cost outcomes. Delivery of care in a local setting matched to the severity of clinical symptoms appeared to be favoured in Australia by Forbes et al. 45 Cognitive reprocessing therapy resulted in greater PTSD symptom relief when delivered to veterans as outpatients compared to those in residential care in the VA-based study by Walter et al,65 although the reliability of this finding may be limited by baseline group differences in PTSD symptom severity. The observational study (using a large administrative data set) in the USA VA system by Randall et al. 64 illustrated that lower rates of hospitalisation and lower demand for specialist care could be achieved by enhancing access to primary care through Primary Aligned Care Teams (PACT). In the UK, Murphy et al. 36,47 used observational data to demonstrate the success of a 6-week residential programme (underpinned by TFCBT), offered by Combat Stress, in terms of long-term benefits on PTSD symptoms and functional assessment.

Peer support

In rural California, an observational study (reported in three articles) by Jain et al. 58–60 suggested that positive perceptions of peer support delivered in residential- and community-based settings in the VA system can favourably influence attitudes to recovery in veterans with PTSD. Peer support delivered by telephone outreach in the VA setting was also described in a written communication by Joseph et al. 61 (Table 8).

Multicomponent programmes

A promising multicomponent theory-based VA programme (‘Transcend’: a combination of cognitive–behavioural skills training, substance abuse relapse and peer support) was reported for PTSD and addiction severity outcomes by Donovan et al. (two articles). 54,55 Another VA-based study by Forman and Havas57 described a multicomponent hospital-based treatment and rehabilitation programme covering a wide range of activity (Table 9).

Family systems model

The ‘Home Base’ three-generational family systems health-care model, codeveloped by a third-sector organisation and a general hospital in the USA, was described by Ohye et al. 48 The application of this clinical model, designed to address three interdependent aspects of family life affected by PTSD (i.e. relationship attachments, impaired family role of the veteran and multiple pathways to treatment) was illustrated by case studies (Table 10).

In summary, a range of evidence from less robust study designs spanned five different types of care model. The reliability of this evidence is unclear; however, these studies were reviewed principally to enrich the descriptive evidence map. The emphasis of activity appears to lie in integrated care, partnership working, networks and co-located services. This is followed by other services delivered with a settings-based approach. Indications from the VA system are that integrating mental health services in primary care, and the combination of CPT and CBT, may be promising models of care to improve pain and PTSD-related outcomes in veterans. Co-located stabilisation services may also successfully complement VA provision in reducing psychosocial problems. In the UK, a specialist network delivering theory-based treatment may be helpful in improving veterans’ mental health. With the exception of one study in the UK,36,47 which endorsed the value of treatment in the residential setting, all studies (from the USA and Australia) indicated that less expensive, less intensive and locally delivered services (including the provision of day hospitals, patient-centred primary care teams and outpatient cognitive reprocessing therapy) could lead to favourable PTSD-related outcomes, patient satisfaction and reduced hospitalisation. Evidence for multicomponent models and peer support was supported by one study each in the VA system, indicating, respectively, potentially positive outcomes for PTSD and on perceptions influencing veterans’ attitudes to recovery.

Psychosocial interventions

Five reviews (six articles) reported solely on psychosocial interventions (Table 11). 66–70,73 Goodson et al. 69 reported interventions conducted in a VA setting, including exposure-based interventions featuring EMDR, PE and implosive therapy. Exposure-based treatment demonstrated large effect sizes for reducing PTSD symptoms (12 studies). Inpatient interventions, described as multicomponent multidisciplinary treatment programmes, reported a small effect size for reduction in PTSD symptoms (seven studies). Cognitive–behavioural interventions comprised CPT and trauma management and showed reductions in PTSD symptoms with a large effect size favouring treatment (seven studies), but the sample size was unknown. Authors also reported single-study data for miscellaneous interventions. Conclusions suggested that across intervention types, about half of treated individuals would show improvement and, therefore, evidence-based exposure treatments were likely to be effective for combat-related trauma. No assessment of the quality of the studies was carried out and there was a lack of reporting of methods of meta-analysis, which may limit interpretation of the analysis. The conclusions were supported by the evidence analysed. However, as these interventions were conducted within the VA system they may not be generalisable to UK and NHS practice.

A review by Kitchiner et al. 70 also investigated trauma-focused interventions. These included EMDR, CPT and implosive flooding, and were compared with usual care or waiting list. The results showed a small but significant decrease in self-reported PTSD symptoms following treatment (four studies, 128 participants). The findings were based on a small number of studies with moderate statistical heterogeneity. The authors concluded that there is some evidence of effectiveness for trauma-based interventions and call for more research into combined therapy as well as tolerability. Of note is the fact that, although half the included studies could not be quantitatively synthesised, they were also not included in the narrative, which, the authors acknowledge, is a limitation. Most of the studies were conducted before 1990, potentially limiting their relevance to current practice. The authors also reported concerns about the methodological quality of the studies.

The veteran studies within the review by Tran et al. 73 focused on comparing CPT with waiting list, usual care or another intervention. When compared with waiting list, CPT significantly reduced clinician-rated PTSD symptom severity (two RCTs, 119 participants) and, to a smaller extent, self-rated symptoms (two observational studies, 213 participants). There was also a reduction in depression symptoms treatment (two RCTs, 119 participants). Comparisons between CPT versus EMDR with concurrent CPT, and CPT versus PE, were based on single observational studies that found mixed effects between CPT and comparisons for PTSD, depression and anxiety symptoms. Authors reported very low to low methodological quality of evidence for these outcomes and sample sizes were generally small. No separate veteran characteristics were reported, making generalisability to other veteran populations uncertain. The authors’ conclusion suggests that CPT may be effective in vulnerable groups, but the quality of evidence is low. The authors’ tentative conclusion seems reliable and is consistent with results from the limited data presented for military veterans. Future research aims included incorporating quality-of-life outcomes as well as investigating combinations of therapy.

A review by Bisson et al. 66 provided single-study data for EMDR and TFCBT in comparison with waiting list. EMDR was reported to significantly reduce PTSD symptoms as rated by a clinician (one RCT, 25 participants), while TFCBT showed no significant difference compared with waiting list (one RCT, 24 participants). Both findings were based on small samples of male Vietnam veterans in their mid-thirties to early forties and should be considered with caution because of the nature of single-study data. The conclusions indicated that, although TFCBT and EMDR appeared effective generally, they were less so for veterans. Future research should focus on more direct comparisons between treatments. The authors did not report the results of the quality assessment of primary studies, making it difficult to assess the reliability of the conclusions.

Goetter et al. 67,68 included psychosocial interventions featuring PE, CPT and exposure therapy in outpatient settings. Within the included studies, there were few females; there was some representation of ethnic minority groups and participant age ranged from mid-twenties to early forties. Veterans had served in different conflicts including OEF (Operation Enduring Freedom), OIF and Operation New Dawn, and 18.3% of participants were still on active service. Dropout varied between research setting (clinical care and clinical trials), with trials experiencing less attrition, although the difference was not statistically significant. When comparing treatment format, a greater likelihood of dropout was found in group therapy settings rather than in individual therapy settings. Although there was a high level of statistical heterogeneity and clinical heterogeneity (particularly in clinical care) in these studies, it suggests that clinical care showed greater dropout than clinical trials, which the authors suggested was because clinical trials provided free treatment, support staff were motivated to retain participants and participants were motivated for treatment, having completed pre-screening. Conclusions suggest that use of individual therapy may encourage treatment completion. Overall, the cautious conclusions are within the limitations of the study. Inconsistencies in figures presented, as well as the lack of quality assessment and high degree of heterogeneity, give rise to concerns about bias and lack of reliability. It is also reported that 15% of participants were at the subclinical threshold for PTSD, which may limit generalisability to other veteran populations.

Pharmacotherapy interventions

Puetz et al. 71 reviewed pharmacotherapy interventions including selective serotonin reuptake inhibitors (SSRIs) (such as fluoxetine and sertraline), antidepressants (such as nefazodone and amitriptyline), antipsychotics (risperidone) and anticonvulsants (such as divalproex) (Table 12). All drug groups were found to reduce PTSD, anxiety and depression symptom severity with moderate effect size. The results were based on 18 studies (773 participants) that included predominantly male participants from Vietnam, Europe and other conflicts, with an average age of 47 years. The authors suggested that this supports the use of pharmacotherapy [in particular SSRIs and tricyclic antidepressants (TCAs)], which showed the largest effect size in reduction of PTSD symptoms. The reliability of the review is affected by moderate to substantial statistical heterogeneity; in addition, the meta-analysis methodology was not clearly reported and may have involved undue weighting of trials with multiple outcomes. Although study quality was assessed, the authors did not apply this to the synthesis, making it difficult to judge the reliability of the evidence.

Psychosocial and pharmacological interventions

Stewart and Wrobel72 investigated both psychosocial and pharmacotherapy interventions (Table 13). Most of the participants in the review were veterans of Vietnam, and the remainder were veterans of Croatia and Gulf Wars; no further participant details were reported. The psychosocial interventions studied included CPT, stress management and trauma-focused interventions. The results showed a small decrease in PTSD immediately post treatment (based on nine studies, 1134 participants). A small decrease in depression symptoms was reported immediately post treatment (number of studies and participants was unclear).

This review also found evidence in favour of pharmacotherapy. The studies in the review most commonly featured TCAs and antipsychotics (drugs included risperidone, fluoxetine and imipramine) and found a small decrease in both PTSD (based on 11 studies, 286 participants) and, to a lesser extent, depression symptoms immediately post treatment (number of studies and participants was unclear). The authors’ conclusions suggested pharmacotherapy to be an effective treatment for PTSD symptom reduction.

The authors also performed an indirect comparison of the psychotherapy and pharmacotherapy results. The comparison found a statistically significantly greater reduction in PTSD symptoms among pharmacotherapy studies. Further to this, the rate of change in PTSD symptoms over time was seen to be significantly different, with pharmacotherapy studies having an expected symptom change lower than psychotherapy studies at 1 month. Pharmacotherapy studies also produced a greater decrease in depression symptoms than psychotherapy studies over the same period of time, but this difference was not statistically significant.

The authors conclude that pharmacotherapy and psychological interventions independently reduce PTSD and depression symptoms in veterans with PTSD. They also conclude that there is a need for more research into the effectiveness of combined therapies that are generalisable to veterans in Iraq and Afghanistan. Potential biases in the conduct of the review, the uncertain quality and design of the included studies and the fact that the comparison of pharmacotherapy and psychotherapy interventions was indirect suggest that the authors’ conclusions should be treated with caution. Recommendations for further research seem appropriate.

NHS England stakeholder engagement survey: summary of findings relating to veterans

NHS England survey respondents were largely white male veterans aged between 41 and 65 years, and who had previous service in the army. Almost two-thirds of respondents had experienced a mental health problem and some had clearly suffered PTSD, although exact numbers were unclear.

The findings of surveys of veterans who had not yet begun treatment revealed a general lack of awareness (on the part of both patients and GPs) about the availability of the 12 specialist services. Despite this, veterans noted a reluctance to seek help, often because of fear of their condition being misunderstood. They also anticipated problems with being pushed around a poorly co-ordinated system. Difficulties with access (waiting lists and obtaining appointments), continuity of care (including transfer of medical records) and lack of funding were also cited. Early intervention before leaving the armed forces, including advertising of services and adequate health screening prior to discharge, was seen as a way to improve transition to civilian life. Veterans already receiving treatment apparently did so using a combination of NHS and specialist services (though not always one of the 12 providers under review), including those provided by the third sector. In general, patients perceived greater benefits from specialist services than those provided in NHS mainstream settings. Although the above matters were raised only in the context of services provided in England, many of the issues mirrored those raised in the needs assessments of veterans and their families carried out in Scotland and Wales. 24,25 This indicates a consistent pattern of veterans’ mental health-care needs across the UK, with the exception of Northern Ireland, where data are (as yet) unavailable. Veterans’ views about services in England were also reflected in factors affecting service implementation communicated to us by some current UK service providers (e.g. lack of knowledge in primary care about the complex needs of veterans, and the challenges of poorly co-ordinated care).

Views from a veteran and service user

We were fortunate to obtain the views and comments of a veteran and service user on the first draft of our report. Lieutenant Colonel (retired) John Skipper, an army veteran with 35 years’ military service, provided advice and input into the interpretation of our research findings. We drew on John’s account of deployments in worldwide conflicts (including the Falklands, Northern Ireland and Bosnia) and from reflections on his engagement with UK health services following a diagnosis of PTSD. 75,76

He considered our work to be a timely and relevant contribution to current research and practice in the topic area. Indeed, many of his observations resonate with our background research and interpretation of the evidence presented at stages 1, 2 and 3 of this rapid evidence synthesis.

Our reflections on complexities of the veteran population chimed with John’s. The influence of stigma (particularly relevant for veterans living in deprived communities, in his view), reticence to seek help and associations with complex presentations of PTSD compounded by comorbidities (such as substance misuse and criminal activity) were significant. John drew our attention to personal experience of time lapse between his trauma and presentation of PTSD, supporting the case for pre-emptive intervention early in the transition from military to civilian life.

Peer support had featured prominently in John’s military career, and its identification as an area of focus early in our research was welcomed by him. He also considered the intervention to be temporally relevant, especially given the present economic challenges in providing more resource-intensive therapies. John reminded us of the changing nature of conflict and how much additional learning might be gained from conflicts of higher intensity such as the Falklands, Iraq, Afghanistan, Bosnia, Northern Ireland and Sierra Leone, and from the continued effects of world-wide terrorism. We had already gleaned from stages 2 and 3 a clear need for more research in other conflicts and settings.

John tabled a possibility that the inconsistent national picture of service provision we found in stage 1 may (in part) be a consequence of devolved health care and consequent variations in practice. The extensive services provided by third-sector organisations are, in his view, a vital complement to those from the NHS; however, lack of evaluation and the need for proper regulation would be critical to assure future best practice. He expressed particular concern about the potential danger of non-evidence-based treatments, especially in undiagnosed patients. We gathered from John’s feedback that a mental health service provided uniquely for veterans may not be paramount. Furthermore, with appropriate training of clinicians and proper signposting, all accredited mental services should have the capacity to treat veterans, and important learning from this may ultimately also benefit civilians who experience trauma. This view is, to some degree, at odds with feedback from the NHS England engagement survey,18 in which some veterans favoured specialist services over mainstream NHS provision.

Our approach to appraising the evidence on models of care in stage 2 (i.e. summarising, rather than labouring over the less methodologically sound study designs) was viewed as refreshing and distinct from other research reports John had reviewed. He was encouraged by some of the best evidence presented, namely the identification of peer support as a potentially effective adjunct to treatment, the essential multidisciplinary approach to address PTSD, and indications that low-intensity interventions closer to home may represent the most promising help.

In relation to treatments, John stressed the importance of delivering complementary treatment plans to patients, stating that pharmacological solutions alone are too often applied in practice without proper attention to the complexities of PTSD and full understanding of the veteran patient. This feedback supported our research implications in stage 3 for the future evaluation of combined psychological/pharmacological interventions. His comments also supported research indications for future direct treatment comparisons (such as CBT and EMDR). In terms of future developments, John alerted us to an ongoing RCT focusing on 3MDR (Military Motion-Assisted Memory Desensitisation and Reprocessing) – a new psychosocial therapy for PTSD funded by the Forces In Mind Trust, the University of Cardiff and Veterans NHS Wales.

Our implications for practice were viewed as appropriate and timely. In John’s view, our findings signify the need for a consistent, properly resourced, well-signposted, multidisciplinary UK-wide approach based on best practice complicit with the Armed Forces Covenant.

General

• More research relevant to the UK setting.

• Routine and continuous evaluation of how interventions work in practice.

For models of care

• More robust research on models of care, with longer follow-up.

• Explore a wider range of outcomes, including process outcomes (intervention uptake), clinical, patient satisfaction, social functioning, quality of life, disparities in age-related treatment effectiveness; improving access to services by minority populations; and cost-effectiveness.

• More research on the format and structure of group peer support.

• More research on peer support using telephone outreach.

For treatments

• Use of direct treatment comparisons.

• Investigate the effectiveness of combined therapies (e.g. pharmacological and psychosocial).

• Explore outcomes such as tolerability (including reasons for dropout), adverse events, quality of life and cost-effectiveness.

• More evaluation of treatments in veterans from a wide range of conflicts and settings.

• Improve the methodological rigour of systematic reviews (including primary study quality assessment).

• Report clinically meaningful data.

Search strategy

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73. (web-based or internet-based).ti,ab. (26,638)

74. ((web or online or on line or internet or computer or digital or e-mail or e-mail or phone or electronic) adj3 (therap$or treatment$or intervention$or program$or platform$)).ti,ab. (29,416)

75. (mobile health or mhealth or e-mental health or mobile technolog$).ti,ab. (2645)

76. or/62–75 (193,044)

77. 25 and 76 (299)

78. self care/ (27,976)

79. self administration/ (10,235)

80. self medication/ (4350)

81. Self-Assessment/ (11,254)

82. (selfcare or self care).ti,ab. (13,145)

83. (selfmanag$or self manag$).ti,ab. (12,880)

84. (selfmonitor$or self monitor$).ti,ab. (5983)

85. (selfhelp or self help).ti,ab. (5419)

86. (selftreat$or self treat$).ti,ab. (1407)

87. (selfmedicat$or self medicat$).ti,ab. (3394)

88. (selfdiagnos$or self diagnos$).ti,ab. (570)

89. (selfadminist$or self administ$).ti,ab. (35,495)

90. (selfassess$or self assess$).ti,ab. (11,970)

91. Self-Help Groups/ (8362)

92. or/78–91 (123,524)

93. 25 and 92 (159)

94. exp Psychotherapy, Group/ (24,738)

95. (group$adj2 (therap$or psychotherap$or treatment$or intervention$or program$)).ti,ab. (149,929)

96. ((family or families) adj2 (therap$or psychotherap$or treatment$or intervention$or program$)).ti,ab. (15,774)

97. 94 or 95 or 96 (178,963)

98. 25 and 97 (310)

99. biopsychosocial.ti,ab. (4211)

100. (psychopharmacolog$or psychopharmacotherap$).ti,ab. (8052)

101. 99 or 100 (12,220)

102. 25 and 101 (34)

103. exp Mental Health Services/ (83,986)

104. Community Mental Health Centers/ (2801)

105. Community Psychiatry/ (1773)

106. (mental health adj2 (service$or clinic$or setting$or provider$or program$)).ti,ab. (20,910)

107. (community adj4 (service$or clinic$or setting$or provider$or program$)).ti,ab. (54,269)

108. (community-based adj4 (service$or clinic$or setting$or provider$or program$)).ti,ab. (12,066)

109. outreach.ti,ab. (10,169)

110. 103 or 104 or 105 or 106 or 107 or 108 or 109 (153,728)

111. 25 and 110 (704)

112. Organizations, Nonprofit/ (3024)

113. Voluntary Health Agencies/ (4073)

114. Charities/ (3551)

115. third sector.ti,ab. (131)

116. (nonprofit or non profit or not-for-profit).ti,ab. (6859)

117. (voluntary adj2 (agenc$or organi?ation$or sector$)).ti,ab. (1531)

118. (charity or charities or charitable).ti,ab. (4705)

119. or/112–118 (20,768)

120. 25 and 119 (17)

121. social support/ (59,357)

122. peer group/ (16,566)

123. (support adj2 (group$or network$or peer$or social)).ti,ab. (40,743)

124. (peer$adj2 (intervention$or service$or program$or visit$)).ti,ab. (2102)

125. or/121–124 (97,101)

126. 25 and 125 (412)

127. 61 or 77 or 93 or 98 or 102 or 111 or 120 or 126 (2304)

128. (letter or editorial or comment).pt. (1,539,706)

129. 127 not 128 (2227)

Search strategy

(SU.EXACT(“Veterans”) OR SU.EXACT(“Air Force Personnel” OR “Army Personnel” OR “Child Soldiers” OR “Coast Guard Personnel” OR “Commissioned Officers” OR “Enlisted Personnel” OR “Marine Personnel” OR “Military Personnel” OR “Military Police Personnel” OR “Missing in Action” OR “National Guard Personnel” OR “Navy Personnel” OR “Noncommissioned Officers” OR “Peacekeeping Personnel” OR “Reserve Personnel” OR “Resistance Fighters” OR “Special Forces Personnel”) OR TI,AB(veteran* OR military) OR TI,AB((armed NEAR/1 force*) OR (armed NEAR/1 service*) OR (armed NEAR/1 personnel)) OR TI,AB(army OR soldier* OR troop OR troops) OR TI,AB(serviceman OR servicemen OR service-man OR service-men) OR TI,AB(servicewoman OR servicewomen OR service-woman OR service-women) OR TI,AB(ex-service*) OR TI,AB(ex-force*) OR TI,AB(ex-military) OR TI,AB(reservist* OR National Guard OR (reserve* NEAR/2 territorial*) OR (reserve NEAR/2 force*) OR (reserve NEAR/2 volunteer*) OR (reserve NEAR/2 home))) AND ((SU.EXACT(“Integrated Treatment”) OR SU.EXACT(“Client Centered Psychotherapy”) OR SU.EXACT(“Case Management”) OR (SU.EXACT(“Veterans Centers”) OR SU.EXACT(“Veterans Hospitals”)) OR SU.EXACT(“Veterans Organizations”)) OR (TI,AB(deliver* NEAR/3 (care OR healthcare OR service*)) OR (TI,AB((system OR systems) NEAR/3 (care OR healthcare OR service*)) OR TI,AB((organis* OR organis*) NEAR/3 (care OR healthcare OR service*))) OR (TI,AB((model OR models) NEAR/2 (care OR healthcare OR service* OR treatment* OR intervention* OR therap*)) OR TI,AB(integrat* NEAR/2 (care OR healthcare OR service* OR program* OR approach*))) OR (TI,AB(collaborat* NEAR/3 (care OR manag* OR healthcare OR service* OR program* OR approach* OR working)) OR TI,AB(patient-centred OR patient-centered)) OR (TI,AB(“medical home” OR PCMH) OR TI,AB(“shared care”)) OR (TI,AB(continu* NEAR/2 care) OR TI,AB((coordinat* OR co-ordinat*) NEAR/2 (care OR healthcare OR service* OR program* OR approach*))) OR (TI,AB(team* NEAR/2 (care OR treatment* OR assessment* OR consultation* OR healthcare OR service* OR program* OR approach*)) OR TI,AB(multidisciplinary OR interprofessional OR multispecialty OR interdisciplinary OR multimodal OR multi-disciplinary OR inter-professional OR multi-specialty OR inter-disciplinary OR multi-modal))) OR (TI,AB(interorgani?ation* or multiprofessional or multiagenc* or interagenc* or inter-organi?ation* or multi-professional or multi-agenc* or inter-agenc*) OR (TI,AB(specialty NEAR/2 (care OR healthcare OR clinic* OR service* OR program* OR approach* OR treatment* OR therap* OR intervention*)) OR TI,AB((case OR care) NEAR/1 management)) OR (TI,AB(comanag* OR co-manag*) OR TI,AB(“stepped care”)) OR TI,AB(holistic)) OR ((SU.EXACT(“Telemedicine”) OR SU.EXACT(“Computer Assisted Psychotherapy”) OR SU.EXACT(“Videotherapy”)) OR TI,AB(telemedicine OR telehealth OR telehealthcare OR telecare OR telemental OR telemanagement OR telerehabilitation OR telepsychology OR teletherapy OR tele-medicine OR tele-health OR tele-healthcare OR tele-care OR tele-management OR tele-mental OR tele-rehabilitation OR tele-psychology OR tele-therapy) OR TI,AB(telephone* OR “cell phone” OR “cell phones” OR cellphone OR “mobile phone” OR “mobile phones” OR smartphone* OR “smart phone” OR “smart phones” OR (mobile NEAR/1 app*) OR “mobile device” OR “mobile devices”) OR TI,AB(text messag* OR SMS OR short messag* service* or texting or messaging) OR TI,AB(teleconferenc* OR videoconferenc* OR tele-conferenc* OR video-conferenc*) OR TI,AB(web-based OR internet-based) OR TI,AB((web OR online OR on-line OR internet OR computer OR digital OR e-mail OR e-mail OR phone OR electronic) NEAR/3 (therap* OR treatment* OR intervention* OR program* OR platform*)) OR TI,AB(“mobile health” OR mhealth OR “e-mental health” OR mobile technolog*)) OR (SU.EXACT(“Self Help Techniques”) OR TI,AB(selfcare OR self-care OR selfmanag* OR self-manag* OR selfmonitor* OR self-monitor* OR selfhelp OR self help OR selftreat* OR self-treat* OR selfmedicat* OR self-medicat* OR selfdiagnos* OR self-diagnos* OR selfadminist* OR self-administ* OR selfassess* OR self- assess*)) OR (SU.EXACT(“Encounter Group Therapy” OR “Group Psychotherapy” OR “Marathon Group Therapy” OR “Psychodrama” OR “Therapeutic Community” OR “Trauma Focused Group Psychotherapy”) OR SU.EXACT(“Behavioral Couples Therapy” OR “Conjoint Therapy” OR “Family Therapy”) OR TI,AB(group* NEAR/2 (therap* OR psychotherap* OR treatment* OR intervention* OR program*)) OR TI,AB((family OR families) NEAR/2 (therap* OR psychotherap* OR treatment* OR intervention* OR program*))) OR (SU.EXACT(“Psychopharmacology”) OR TI,AB(biopsychosocial OR psychopharmacolog* OR psychopharmacotherap*)) OR (SU.EXACT(“Community Mental Health Centers”) OR TI,AB(“mental health” NEAR/2 (service* OR clinic* OR setting* OR provider* OR program*)) OR TI,AB(community NEAR/4 (service* OR clinic* OR setting* OR provider* OR program*)) OR TI,AB(community-based NEAR/4 (service* OR clinic* OR setting* OR provider* OR program*)) OR SU.EXACT(“Outreach Programs”) OR TI,AB(outreach)) OR ((SU.EXACT(“Nongovernmental Organizations”) OR SU.EXACT(“Voluntary Organizations”)) OR (TI,AB(“third sector”) OR TI,AB(nonprofit or “non profit” or “not-for-profit”)) OR (TI,AB(voluntary NEAR/2 (agenc* OR organi?ation* OR sector*)) OR TI,AB(charity OR charities OR charitable))) OR ((SU.EXACT(“Support Groups”) OR SU.EXACT(“Social Support Networks”) OR SU.EXACT(“Peer Counseling”)) OR (TI,AB(support NEAR/2 (group* OR network* OR peer* OR social)) OR TI,AB(peer* NEAR/2 (intervention* OR service* OR program* OR visit*)))))

Search strategy

1. military veterans/ (9952)

2. exp military personnel/ (14,544)

3. military duty status/ (466)

4. veteran$.ti,ab. (16,396)

5. military.ti,ab. (20,151)

6. (armed adj (force$or service$or personnel)).ti,ab. (1717)

7. (army or soldier$or troop or troops).ti,ab. (12,397)

8. (serviceman or servicemen or service-man or service-men).ti,ab. (444)

9. (servicewoman or servicewomen or service-woman or service-women).ti,ab. (78)

10. (ex-service$or ex-force$or ex-military).ti,ab. (109)

11. (reservist$or National Guard or (reserve$adj2 (territorial$or force$or volunteer$or home))).ti,ab. (685)

12. or/1–11 (46,364)

13. exp posttraumatic stress disorder/ (26,208)

14. PTSD.ti,ab. (24,525)

15. (stress$adj4 (post-trauma$or posttrauma$or trauma$)).ti,ab. (33,779)

16. 13 or 14 or 15 (38,912)

17. 12 and 16 (7945)

18. ((combat or battle or war) adj2 (disorder$or stress$)).ti,ab. (1275)

19. operational stress$.ti,ab. (118)

20. ((combat or battle or war) adj (neurosis or neuroses or fatigue)).ti,ab. (516)

21. (shell shock$or shellshock$).ti,ab. (207)

22. or/18–21 (1978)

23. 12 and 22 (1190)

24. 17 or 23 (8451)

25. health care delivery/ (18,876)

26. integrated services/ (2775)

27. client centered therapy/ (2870)

28. disease management/ (5365)

29. case management/ (2839)

30. “continuum of care”/ (1452)

31. interdisciplinary treatment approach/ (6544)

32. multimodal treatment approach/ (1708)

33. treatment planning/ (4672)

34. holistic health/ (1764)

35. (deliver$adj3 (care or healthcare or service$)).ti,ab. (22,836)

36. ((system or systems) adj3 (care or healthcare or service$)).ti,ab. (23,069)

37. ((organis$or organiz$) adj3 (care or healthcare or service$)).ti,ab. (10,782)

38. ((model or models) adj2 (care or healthcare or service$or treatment$or intervention$or therap$)).ti,ab. (197,32)

39. (integrat$adj2 (care or healthcare or service$or program$or approach$)).ti,ab. (13,619)

40. (collaborat$adj3 (care or manag$or healthcare or service$or program$or approach$or working)).ti,ab. (5305)

41. (patient-centred or patient-centered).ti,ab. (3997)

42. (medical home or PCMH).ti,ab. (667)

43. shared care.ti,ab. (293)

44. (continu$adj2 care).ti,ab. (4434)

45. ((coordinat$or co-ordinat$) adj2 (care or healthcare or service$or program$or approach$)).ti,ab. (3892)

46. (team$adj2 (care or treatment$or assessment$or consultation$or healthcare or service$or program$or approach$)).ti,ab. (8461)

47. (multidisciplinary or interprofessional or multispecialty or interdisciplinary or multimodal or multi-disciplinary or inter-professional or multi-specialty or inter-disciplinary or multi-modal).ti,ab. (46,265)

48. (interorgani?ation$or multiprofessional or multiagenc$or interagenc$or inter-organi?ation$or multi-professional or multi-agenc$or inter-agenc$).ti,ab. (4708)

49. (specialty adj2 (care or healthcare or clinic$or service$or program$or approach$or treatment$or therap$or intervention$)).ti,ab. (1881)

50. ((case or care) adj management).ti,ab. (5731)

51. (comanag$or co-manag$).ti,ab. (164)

52. stepped care.ti,ab. (582)

53. holistic.ti,ab. (14,723)

54. or/25–53 (183,056)

55. 24 and 54 (697)

56. telemedicine/ (3607)

57. exp telephone systems/ (4970)

58. telecommunications media/ (1315)

59. teleconferencing/ (799)

60. exp mobile devices/ (4195)

61. exp electronic communication/ (15,247)

62. computer assisted therapy/ (775)

63. online therapy/ (1981)

64. internet/ (25,981)

65. websites/ (3982)

66. (telemedicine or telehealth or telehealthcare or telecare or telemental or telemanagement or telerehabilitation or telepsychology or teletherapy or tele-medicine or tele-health or tele-healthcare or tele-care or tele-management or tele-mental or tele-rehabilitation or tele-psychology or tele-therapy).ti,ab. (2376)

67. (telephone$or cell phone$or cellphone or mobile phone$or smartphone$or smart phone$or mobile app$or mobile device$).ti,ab. (26,422)

68. (text messag$or SMS or short messag$service$or texting or messaging).ti,ab. (3833)

69. (teleconferenc$or videoconferenc$or tele-conferenc$or video-conferenc$).ti,ab. (1709)

70. (web-based or internet-based).ti,ab. (13,534)

71. ((web or online or on line or internet or computer or digital or e-mail or e-mail or phone or electronic) adj3 (therap$or treatment$or intervention$or program$or platform$)).ti,ab. (13,744)

72. (mobile health or mhealth or e-mental health or mobile technolog$).ti,ab. (1286)

73. or/56–72 (88,277)

74. 24 and 73 (258)

75. exp self management/ (55,00)

76. drug self administration/ (1799)

77. self medication/ (615)

78. self evaluation/ (8634)

79. self report/ (14,534)

80. self monitoring/ (2705)

81. (selfcare or self care).ti,ab. (7059)

82. (selfmanag$or self manag$).ti,ab. (7186)

83. (selfmonitor$or self monitor$).ti,ab. (5204)

84. (selfhelp or self help).ti,ab. (7348)

85. (selftreat$or self treat$).ti,ab. (361)

86. (selfmedicat$or self medicat$).ti,ab. (1437)

87. (selfdiagnos$or self diagnos$).ti,ab. (271)

88. (selfadminist$or self administ$).ti,ab. (15,229)

89. (selfassess$or self assess$).ti,ab. (6761)

90. self-help techniques/ (3779)

91. self-care skills/ (3811)

92. or/75–91 (75,444)

93. 24 and 92 (218)

94. exp group psychotherapy/ (21,025)

95. group intervention/ (1501)

96. group counseling/ (4872)

97. (group$adj2 (therap$or psychotherap$or treatment$or intervention$or program$)).ti,ab. (54,312)

98. ((family or families) adj2 (therap$or psychotherap$or treatment$or intervention$or program$)).ti,ab. (28,035)

99. family intervention/ (2582)

100. exp family therapy/ (20,429)

101. or/94–100 (97,322)

102. 24 and 101 (430)

103. biopsychosocial approach/ (3261)

104. exp psychopharmacology/ (8635)

105. biopsychosocial.ti,ab. (5739)

106. (psychopharmacolog$or psychopharmacotherap$).ti,ab. (9986)

107. 103 or 104 or 105 or 106 (21,786)

108. 24 and 107 (57)

109. exp mental health services/ (37,137)

110. (mental health adj2 (service$or clinic$or setting$or provider$or program$)).ti,ab. (31,993)

111. (community adj4 (service$or clinic$or setting$or provider$or program$)).ti,ab. (34,242)

112. (community-based adj4 (service$or clinic$or setting$or provider$or program$)).ti,ab. (7412)

113. outreach programs/ (977)

114. outreach.ti,ab. (5977)

115. exp community services/ (29,021)

116. 109 or 110 or 111 or 112 or 113 or 114 or 115 (99,911)

117. 24 and 116 (614)

118. nonprofit organizations/ (1960)

119. ngos/ (993)

120. third sector.ti,ab. (176)

121. (nonprofit or non profit or not-for-profit).ti,ab. (5566)

122. (voluntary adj2 (agenc$or organi?ation$or sector$)).ti,ab. (1336)

123. (charity or charities or charitable).ti,ab. (2918)

124. 118 or 119 or 120 or 121 or 122 or 123 (10,784)

125. 24 and 124 (16)

126. social support/ (30,634)

127. support groups/ (3891)

128. peers/ (9862)

129. (support adj2 (group$or network$or peer$or social)).ti,ab. (51,505)

130. (peer$adj2 (intervention$or service$or program$or visit$)).ti,ab. (2364)

131. 126 or 127 or 128 or 129 or 130 (73,308)

132. 24 and 131 (420)

133. 55 or 74 or 93 or 102 or 108 or 117 or 125 or 132 (2161)

134. (editorial or letter or “review book” or “review media” or “review software other”).dt. (176,536)

135. 133 not 134 (2102)

Search strategy

(“post-traumatic stress” OR “posttraumatic stress” OR PTSD)

Search strategy

1. intitle:PTSD OR intags: PTSD OR inurl:PTSD

18 results browsed – seven relevant.

1. intitle:“post-traumatic stress” OR intags:“post-traumatic stress” OR inurl:“post-traumatic stress”

Six results browsed – five relevant.

1. intitle:“posttraumatic stress” OR intags:“posttraumatic stress” OR inurl:“posttraumatic stress”

One relevant result.

Relevant results from the three searches were deduplicated leaving 11 results in total.

Search strategy

#1 MeSH descriptor: [Veterans] this term only (655)

#2 MeSH descriptor: [Veterans Health] this term only (21)

#3 MeSH descriptor: [Military Personnel] this term only (730)

#4 veteran*:ti,ab,kw (2903)

#5 military:ti,ab,kw (1832)

#6 (armed next (force* or service* or personnel)):ti,ab,kw (104)

#7 (army or soldier* or troop or troops):ti,ab,kw (837)

#8 (serviceman or servicemen or service-man or service-men):ti,ab,kw (30)

#9 (servicewoman or servicewomen or service-woman or service-women):ti,ab,kw (6)

#10 (ex-service* or ex-force* or ex-military):ti,ab,kw (2)

#11 (reservist* or “National Guard”):ti,ab,kw (22)

#12 (reserve* near/2 (territorial* or force* or volunteer* or home)):ti,ab,kw (9)

#13 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 (4957)

#14 MeSH descriptor: [Stress Disorders, Post-Traumatic] this term only (1267)

#15 PTSD:ti,ab,kw (1701)

#16 (stress* near/4 (post-trauma* or posttrauma* or trauma*)):ti,ab,kw (2587)

#17 #14 or #15 or #16 (2919)

#18 #13 and #17 (535)

#19 MeSH descriptor: [Combat Disorders] this term only (94)

#20 ((combat or battle or war) near/2 (disorder* or stress*)):ti,ab,kw (118)

#21 operational next stress*:ti,ab,kw (9)

#22 ((combat or battle or war) next (neurosis or neuroses or fatigue)):ti,ab,kw (5)

#23 (shell next shock* or shellshock*):ti,ab,kw (3)

#24 #19 or #20 or #21 or #22 or #23 (134)

#25 #13 and #24 (97)

#26 #18 or #25 (544)

#27 #18 or #25 in Cochrane Reviews (Reviews and Protocols) (2)

Search strategy

1. MeSH DESCRIPTOR Veterans (38)

2. MeSH DESCRIPTOR Veterans health (6)

3. MeSH DESCRIPTOR Military Personnel (50)

4. (veteran*) OR (military) (621)

5. (armed NEAR1 (force* or service* or personnel)) (9)

6. (army or soldier* or troop or troops) (92)

7. (serviceman or servicemen or service-man or service-men) (1)

8. (servicewoman or servicewomen or service-woman or service-women) (1)

9. (ex-service* or ex-force* or ex-military) (0)

10. (reservist* or “National Guard”) (3)

11. (reserve* NEAR2 (territorial* or force* or volunteer* or home)) (0)

12. ((territorial* or force* or volunteer* or home) NEAR2 reserve*) (0)

13. #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 (685)

14. MeSH DESCRIPTOR Stress Disorders, Post-Traumatic (138)

15. (PTSD) (105)

16. (stress* NEAR4 (post-trauma* or posttrauma* or trauma*)) (155)

17. ((post-trauma* or posttrauma* or trauma*) NEAR4 stress*) (212)

18. #14 OR #15 OR #16 OR #17 (264)

19. #13 AND #18 (33)

20. MeSH DESCRIPTOR Combat Disorders (10)

21. ((combat or battle or war) NEAR2 (disorder* or stress*)) (11)

22. ((disorder* or stress*) NEAR2 (combat or battle or war)) (1)

23. (operational NEAR1 stress*) (0)

24. ((combat or battle or war) NEAR1 (neurosis or neuroses or fatigue)) (0)

25. (shell shock* or shellshock*) (1)

26. #20 OR #21 OR #22 OR #23 OR #24 OR #25 (11)

27. #13 AND #26 (8)

28. #19 OR #27 (33)

29. (*) IN DARE (45,418)

30. #28 AND #29 (23)

31. (*) IN NHS EED (17,613)

32. #28 AND #31 (6)

33. (*) IN HTA (16,640)

34. #28 AND #33 (4)

Search strategy

S48 S24 AND S47 Limiters – Publication Year: 2014–2016 (71)

S47 S45 NOT S46 (295,149)

S46 PT BOOK REVIEW (36,770)

S45 S25 or S26 or S27 or S28 or S29 or S30 or S31 or S32 or S33 or S34 or S35 or S36 or S37 or S38 or S39 or S42 or S43 or S44 (307,328)

S44 AB systematic* N10 overview* or AB methodologic* N10 overview* or AB quantitative* N10 overview* or AB research* N10 overview* or AB literature* N10 overview* or AB studies N10 overview* or AB trial* N10 overview* or AB effective* N10 overview* (4152)

S43 AB systematic* N10 review* or AB methodologic* N10 review* or AB quantitative* N10 review* or AB research* N10 review* or AB literature* N10 review* or AB studies N10 review* or AB trial* N10 review* or AB effective* N10 review* (98,661)

S42 S41 and S40 (59,677)

S41 AB systematic* or AB methodologic* or AB quantitative* or AB research* or AB literature* or AB studies or AB trial* or AB effective* (1,050,600)

S40 PT review (142,621)

S39 TX electronic* N2 database* or TX electronic* N2 data base* or TX bibliographic* N2 database* or TX bibliographic* N2 data base* (6634)

S38 (MH “Reference Databases+”) or (MH “Reference Databases, Health+”) (48,839)

S37 TX hand N2 search* or TX manual N2 search* or TX database* N2 search* or TX computer* N2 search* (18,143)

S36 TX pooled analy* or TX data N2 pool* (5809)

S35 TX medline or medlars or embase or scisearch or psycinfo or psychinfo or psychlit or psyclit (53,783)

S34 TX synthes* N3 literature* or TX synthes* N3 research or TX synthes* N3 studies or TX synthes* N3 data (6541)

S33 (MH “Literature Searching+”) or (MH “Computerized Literature Searching+”) (7177)

S32 (MH “Literature Review+”) (42,113)

S31 TI review* or TI overview* (146,228)

S30 PT systematic review (52,177)

S29 PT nursing interventions (1483)

S28 AB cochrane or TI cochrane (17,132)

S27 TI meta-analy* or AB meta-analy* (31,524)

S26 TI metaanaly* or AB metaanaly* (585)

S25 (MH “Meta Analysis”) (25,410)

S24 S17 OR S23 (4073)

S23 S12 AND S22 (330)

S22 S18 OR S19 OR S20 OR S21 (547)

S21 TI ((shell N1 shock$) or shellshock*) OR AB ((shell N1 shock$) or shellshock*) (30)

S20 TI ((combat or battle or war) N1 (neurosis or neuroses or fatigue)) OR AB ((combat or battle or war) N1 (neurosis or neuroses or fatigue)) (53)

S19 TI operational N1 stress* OR AB operational N1 stress* (44)

S18 TI ((combat or battle or war) N2 (disorder* or stress*)) OR AB ((combat or battle or war) N2 (disorder* or stress*)) (446)

S17 S12 AND S16 (3983)

S16 S13 OR S14 OR S15 (17,946)

S15 TI (stress* N4 (post-trauma* or posttrauma* or trauma*)) OR AB (stress* N4 (post-trauma* or posttrauma* or trauma*)) (9338)

S14 TI PTSD OR AB PTSD (5505)

S13 (MH “Stress Disorders, Post-Traumatic”) (14,849)

S12 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 (34,395)

S11 TI (reserve* N2 (territorial* or force* or volunteer* or home)) OR AB (reserve* N2 (territorial* or force* or volunteer* or home)) (50)

S10 TI (reservist* or “National Guard”) OR AB (reservist* or “National Guard”) (404)

S9 TI (ex-service* or ex-force* or ex-military) OR AB (ex-service* or ex-force* or ex-military) (51)

S8 TI (servicewoman or servicewomen or service-woman or service-women) OR AB (servicewoman or servicewomen or service-woman or service-women) (130)

S7 TI (serviceman or servicemen or service-man or service-men) OR AB (serviceman or servicemen or service-man or service-men) (140)

S6 TI (army or soldier* or troop or troops) OR AB (army or soldier* or troop or troops) (5602)

S5 TI ((armed N1 (force* or service* or personnel)) OR AB ((armed N1 (force* or service* or personnel)) (729)

S4 TI military OR AB military (10,664)

S3 TI veteran* OR AB veteran* (12,146)

S2 (MH “Military Personnel+”) (11,574)

S1 (MH “Veterans+”) (10,554)

Search strategy

1. veteran/ (22,605)

2. veterans health / (2230)

3. army/ (21,878)

4. soldier/ (28,570)

5. veteran$.ti,ab. (33,235)

6. military.ti,ab. (41,917)

7. (armed adj (force$or service$or personnel)).ti,ab. (4635)

8. (army or soldier$or troop or troops).ti,ab. (21,419)

9. (serviceman or servicemen or service-man or service-men).ti,ab. (1325)

10. (servicewoman or servicewomen or service-woman or service-women).ti,ab. (167)

11. (ex-service$or ex-force$or ex-military).ti,ab. (120)

12. (reservist$or National Guard or (reserve$adj2 (territorial$or force$or volunteer$or home))).ti,ab. (919)

13. or/1–12 (102,894)

14. posttraumatic stress disorder/ (45,906)

15. PTSD.ti,ab. (21,535)

16. (stress$adj4 (post-trauma$or posttrauma$or trauma$)).ti,ab. (32,413)

17. 14 or 15 or 16 (51,213)

18. 13 and 17 (9016)

19. ((combat or battle or war) adj2 (disorder$or stress$)).ti,ab. (1350)

20. operational stress$.ti,ab. (118)

21. ((combat or battle or war) adj (neurosis or neuroses or fatigue)).ti,ab. (216)

22. (shell shock$or shellshock$).ti,ab. (113)

23. 19 or 20 or 21 or 22 (1734)

24. 13 and 23 (850)

25. 18 or 24 (9211)

26. systematic$review$.ti,ab. (117,217)

27. systematic$literature review$.ti,ab. (8478)

28. “systematic review”/ (143,688)

29. “systematic review (topic)”/ (26,161)

30. meta analysis/ (151,314)

31. “meta analysis (topic)”/ (35,770)

32. meta-analytic$.ti,ab. (5747)

33. meta-analysis.ti,ab. (112,370)

34. meta-analysis.ti,ab. (381)

35. metaanalysis.ti,ab. (5356)

36. meta analysis.ti,ab. (112,370)

37. meta-synthesis.ti,ab. (434)

38. metasynthesis.ti,ab. (205)

39. meta synthesis.ti,ab. (434)

40. meta-regression.ti,ab. (5203)

41. metaregression.ti,ab. (687)

42. meta regression.ti,ab. (5203)

43. (synthes$adj3 literature).ti,ab. (2365)

44. (synthes$adj3 evidence).ti,ab. (6731)

45. (synthes$adj2 qualitative).ti,ab. (1218)

46. integrative review.ti,ab. (1272)

47. data synthesis.ti,ab. (10,781)

48. (research synthesis or narrative synthesis).ti,ab. (1410)

49. (systematic study or systematic studies).ti,ab. (10,249)

50. (systematic comparison$or systematic overview$).ti,ab. (2688)

51. (systematic adj2 search$).ti,ab. (18,122)

52. systematic$literature research$.ti,ab. (202)

53. (review adj3 scientific literature).ti,ab. (1322)

54. (literature review adj2 side effect$).ti,ab. (12)

55. (literature review adj2 adverse effect$).ti,ab. (2)

56. (literature review adj2 adverse event$).ti,ab. (12)

57. (evidence-based adj2 review).ti,ab. (2890)

58. comprehensive review.ti,ab. (11,342)

59. critical review.ti,ab. (14,108)

60. critical analysis.ti,ab. (7074)

61. quantitative review.ti,ab. (633)

62. structured review.ti,ab. (792)

63. realist review.ti,ab. (131)

64. realist synthesis.ti,ab. (83)

65. (pooled adj2 analysis).ti,ab. (12,942)

66. (pooled data adj6 (studies or trials)).ti,ab. (2044)

67. (medline and (inclusion adj3 criteria)).ti,ab. (16,488)

68. (search adj (strateg$or term$)).ti,ab. (26,187)

69. or/26–68 (371,133)

70. medline.ab. (95,491)

71. pubmed.ab. (75,334)

72. cochrane.ab. (60,420)

73. embase.ab. (61,687)

74. cinahl.ab. (17,654)

75. psyc?lit.ab. (967)

76. psyc?info.ab. (14,345)

77. lilacs.ab. (4913)

78. (literature adj3 search$).ab. (48,103)

79. (database$adj3 search$).ab. (45,204)

80. (bibliographic adj3 search$).ab. (1961)

81. (electronic adj3 search$).ab. (16,059)

82. (electronic adj3 database$).ab. (22,560)

83. (computeri?ed adj3 search$).ab. (3583)

84. (internet adj3 search$).ab. (3066)

85. included studies.ab. (15,272)

86. (inclusion adj3 studies).ab. (12,104)

87. inclusion criteria.ab. (88,306)

88. selection criteria.ab. (26,431)

89. predefined criteria.ab. (1925)

90. predetermined criteria.ab. (1060)

91. (assess$adj3 (quality or validity)).ab. (71,096)

92. (select$adj3 (study or studies)).ab. (62,732)

93. (data adj3 extract$).ab. (53,541)

94. extracted data.ab. (11,673)

95. (data adj2 abstracted).ab. (6337)

96. (data adj3 abstraction).ab. (1654)

97. published intervention$.ab. (159)

98. ((study or studies) adj2 evaluat$).ab. (189,108)

99. (intervention$adj2 evaluat$).ab. (10,713)

100. confidence interval$.ab. (347,680)

101. heterogeneity.ab. (146,768)

102. pooled.ab. (83,220)

103. pooling.ab. (12,028)

104. odds ratio$.ab. (239,358)

105. (Jadad or coding).ab. (165,503)

106. evidence-based.ti,ab. (99,142)

107. or/70–106 (1,408,000)

108. review.pt. (2,202,348)

109. 107 and 108 (171,657)

110. review.ti. (385,550)

111. 107 and 110 (97,090)

112. (review$adj10 (papers or trials or trial data or studies or evidence or intervention$or evaluation$or outcome$or findings)).ti,ab. (392,491)

113. (retriev$adj10 (papers or trials or studies or evidence or intervention$or evaluation$or outcome$or findings)).ti,ab. (20,124)

114. 69 or 109 or 111 or 112 or 113 (734,880)

115. letter.pt. (960,245)

116. editorial.pt. (521,200)

117. 115 or 116 (1,481,445)

118. 114 not 117 (720,757)

119. (animal/or nonhuman/) not exp human/ (4,996,453)

120. 118 not 119 (696,240)

121. 25 and 120 (423)

122. limit 121 to yr=“2014 -Current” (149)

Search strategy

1. Veterans/ (12,568)

2. Veterans Health/ (719)

3. Military Personnel/ (34,456)

4. veteran$.ti,ab. (27,569)

5. military.ti,ab. (36,759)

6. (armed adj (force$or service$or personnel)).ti,ab. (4278)

7. (army or soldier$or troop or troops).ti,ab. (21,270)

8. (serviceman or servicemen or service-man or service-men).ti,ab. (1225)

9. (servicewoman or servicewomen or service-woman or service-women).ti,ab. (159)

10. (ex-service$or ex-force$or ex-military).ti,ab. (115)

11. (reservist$or National Guard or (reserve$adj2 (territorial$or force$or volunteer$or home))).ti,ab. (893)

12. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 (95,591)

13. Stress Disorders, Post-Traumatic/ (25,510)

14. PTSD.ti,ab. (17,118)

15. (stress$adj4 (post-trauma$or posttrauma$or trauma$)).ti,ab. (26,896)

16. 13 or 14 or 15 (36,828)

17. 12 and 16 (7041)

18. Combat Disorders / (2847)

19. ((combat or battle or war) adj2 (disorder$or stress$)).ti,ab. (1130)

20. operational stress$.ti,ab. (103)

21. ((combat or battle or war) adj (neurosis or neuroses or fatigue)).ti,ab. (220)

22. (shell shock$or shellshock$).ti,ab. (118)

23. 18 or 19 or 20 or 21 or 22 (3898)

24. 12 and 23 (2540)

25. 17 or 24 (7665)

26. systematic$review$.ti,ab. (96,659)

27. meta-analysis as topic/ (15,527)

28. meta-analytic$.ti,ab. (5101)

29. meta-analysis.ti,ab,pt. (112,016)

30. meta-analysis.ti,ab. (154)

31. metaanalysis.ti,ab. (1343)

32. meta analysis.ti,ab. (89,076)

33. meta-synthesis.ti,ab. (448)

34. metasynthesis.ti,ab. (203)

35. meta synthesis.ti,ab. (448)

36. meta-regression.ti,ab. (4285)

37. metaregression.ti,ab. (437)

38. meta regression.ti,ab. (4285)

39. (synthes$adj3 literature).ti,ab. (2067)

40. (synthes$adj3 evidence).ti,ab. (6112)

41. integrative review.ti,ab. (1541)

42. data synthesis.ti,ab. (8840)

43. (research synthesis or narrative synthesis).ti,ab. (1451)

44. (systematic study or systematic studies).ti,ab. (9500)

45. (systematic comparison$or systematic overview$).ti,ab. (2506)

46. evidence based review.ti,ab. (1663)

47. comprehensive review.ti,ab. (9872)

48. critical review.ti,ab. (13,037)

49. quantitative review.ti,ab. (574)

50. structured review.ti,ab. (632)

51. realist review.ti,ab. (146)

52. realist synthesis.ti,ab. (109)

53. or/26–52 (228,219)

54. review.pt. (2,210,291)

55. medline.ab. (82,238)

56. pubmed.ab. (60,165)

57. cochrane.ab. (51,665)

58. embase.ab. (52,752)

59. cinahl.ab. (17,105)

60. psyc?lit.ab. (907)

61. psyc?info.ab. (15,280)

62. (literature adj3 search$).ab. (38,960)

63. (database$adj3 search$).ab. (37,818)

64. (bibliographic adj3 search$).ab. (1749)

65. (electronic adj3 search$).ab. (14,328)

66. (electronic adj3 database$).ab. (17,712)

67. (computeri?ed adj3 search$).ab. (3128)

68. (internet adj3 search$).ab. (2372)

69. included studies.ab. (13,532)

70. (inclusion adj3 studies).ab. (10,602)

71. inclusion criteria.ab. (54,859)

72. selection criteria.ab. (27,829)

73. predefined criteria.ab. (1476)

74. predetermined criteria.ab. (875)

75. (assess$adj3 (quality or validity)).ab. (56,562)

76. (select$adj3 (study or studies)).ab. (49,846)

77. (data adj3 extract$).ab. (43,459)

78. extracted data.ab. (11,150)

79. (data adj2 abstracted).ab. (4198)

80. (data adj3 abstraction).ab. (1208)

81. published intervention$.ab. (142)

82. ((study or studies) adj2 evaluat$).ab. (138,715)

83. (intervention$adj2 evaluat$).ab. (8231)

84. confidence interval$.ab. (304,749)

85. heterogeneity.ab. (121,995)

86. pooled.ab. (62,890)

87. pooling.ab. (9616)

88. odds ratio$.ab. (200,376)

89. (Jadad or coding).ab. (146,871)

90. or/55–89 (1,064,827)

91. 54 and 90 (171,903)

92. review.ti. (340,666)

93. 92 and 90 (79,487)

94. (review$adj4 (papers or trials or studies or evidence or intervention$or evaluation$)).ti,ab. (138,414)

95. 53 or 91 or 93 or 94 (400,694)

96. letter.pt. (945,544)

97. editorial.pt. (422,191)

98. comment.pt. (687,401)

99. 96 or 97 or 98 (1,539,706)

100. 95 not 99 (390,874)

101. exp animals/not humans/ (4,333,932)

102. 100 not 101 (379,938)

103. 25 and 102 (235)

104. limit 103 to yr=“2014 -Current” (100)

Search strategy

1. military veterans/ (9925)

2. exp military personnel/ (14,525)

3. military duty status/ (463)

4. veteran$.ti,ab. (16,365)

5. military.ti,ab. (20,113)

6. (armed adj (force$or service$or personnel)).ti,ab. (1714)

7. (army or soldier$or troop or troops).ti,ab. (12,388)

8. (serviceman or servicemen or service-man or service-men).ti,ab. (443)

9. (servicewoman or servicewomen or service-woman or service-women).ti,ab. (77)

10. (ex-service$or ex-force$or ex-military).ti,ab. (109)

11. (reservist$or National Guard or (reserve$adj2 (territorial$or force$or volunteer$or home))).ti,ab. (682)

12. or/1–11 (46,300)

13. exp posttraumatic stress disorder/ (26,162)

14. PTSD.ti,ab. (24,474)

15. (stress$adj4 (post-trauma$or posttrauma$or trauma$)).ti,ab. (33,716)

16. 13 or 14 or 15 (38,840)

17. 12 and 16 (7923)

18. ((combat or battle or war) adj2 (disorder$or stress$)).ti,ab. (1273)

19. operational stress$.ti,ab. (118)

20. ((combat or battle or war) adj (neurosis or neuroses or fatigue)).ti,ab. (516)

21. (shell shock$or shellshock$).ti,ab. (207)

22. or/18–21 (1976)

23. 12 and 22 (1188)

24. 17 or 23 (8429)

25. metaanaly*.ti,sh. (70)

26. meta-analy*.ti,sh. (14,782)

27. cochrane*.ti. (166)

28. (review or overview).ti. (139,627)

29. meta analysis/ (3906)

30. meta analysis.md. (15,491)

31. (review adj2 literature).ti. (3827)

32. “literature review”.md. (123,386)

33. “systematic review”.md. (14,982)

34. (synthes* adj3 (literature* or research or studies or data)).ti. (699)

35. pooled analys*.ti,ab. (576)

36. ((data adj2 pool*) and studies).ti,ab. (826)

37. ((hand or manual* or database* or computer* or electronic*) adj2 search*).ti,ab. (7356)

38. ((electronic* or bibliographic*) adj2 (database* or data base*)).ti,ab. (3471)

39. or/25–38 (244,855)

40. (“review software other” or “review media” or editorial or letter or “review book”).dt. (176,419)

41. (electronic collection or encyclopedia).pt. (44,525)

42. (rat or rats or mouse or mice or hamster or hamsters or animal or animals or dog or dogs or cat or cats or bovine or sheep).ti,ab,sh. (300,843)

43. 40 or 41 or 42 (477,299)

44. 39 not 43 (154,382)

45. 24 and 44 (343)

46. limit 45 to yr=“2014 -Current” (85)