{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T15:28:30Z","timestamp":1788967710732,"version":"build-2803163510"},"reference-count":30,"publisher":"American Medical Association (AMA)","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Psychiatry"],"abstract":"\n Importance<\/jats:title>\n Killing in war is associated with multiple adverse outcomes, including posttraumatic stress disorder (PTSD), moral injury (MI), and suicide. Impact of killing (IOK) is an individual psychotherapy developed to treat the mental health impact of killing in war.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To determine whether IOK improves veterans\u2019 mental health symptoms and functioning at posttreatment and 6-month follow-up.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This multisite, superiority, randomized clinical trial was conducted from August 2018 to November 2023. Participants were veterans randomized to IOK or present-centered therapy (PCT). Diagnostic assessments were administered at screening and posttreatment by blinded evaluators. Self-report measures were collected at baseline, midtreatment, posttreatment, and 6-month follow-up at 3 Veterans Affairs health care systems in California, New York, and North Carolina via in-person and remote appointments. Participants were a sample of veterans with PTSD who reported distress related to killing in war or feeling responsible for the death of others. Primary exclusion criteria were a psychotic disorder diagnosis, moderate or severe alcohol or substance use disorder, untreated mania, or recent suicidal or homicidal behavior.<\/jats:p>\n <\/jats:sec>\n \n Interventions<\/jats:title>\n IOK, an individual psychotherapy that focuses on killing cognitions, acceptance, self-forgiveness, and moral repair, and PCT, which addresses current functional issues due to moral distress with related problem-solving.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n The primary outcomes were psychosocial functioning assessed by the World Health Organization Quality of Life Scale\u2013Brief (WHOQOL-BREF) and the Sheehan Disability Scale (SDS). Secondary outcomes included PTSD and MI measures.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n A total of 100 individuals (98 male; mean [SD] age, 48.4 [13.7] years) were randomized. Linear mixed models revealed that psychosocial functioning improved for both groups at posttreatment (WHOQOL-BREF and SDS) and the IOK group had a significantly greater improvement than those in PCT on the SDS (\u22123.50;\n z<\/jats:italic>\n score, \u22122.42; Cohen\n d<\/jats:italic>\n , \u22120.51;\n P<\/jats:italic>\n \u2009=\u2009.02; 95% CI, \u22125.65 to \u22120.59). There was no significant difference between treatments on the WHOQOL-BREF at posttreatment. Compared to PCT participants, IOK participants also reported significantly greater improvement in PTSD and MI symptoms.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n Individuals in both treatments improved on measures of psychosocial functioning (WHOQOL-BREF and SDS). Those who received IOK evidenced greater improvements in work or school, social life, and home or family life (as measured by the SDS) compared to those in PCT at posttreatment. IOK participants also reported improved PTSD and MI symptoms. The findings suggest that IOK may improve several outcomes for those who experience distress due to killing in war.<\/jats:p>\n <\/jats:sec>\n \n Trial Registration<\/jats:title>\n \n ClinicalTrials.gov Identifier:\n NCT03764033<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamapsychiatry.2026.2307","type":"journal-article","created":{"date-parts":[[2026,8,5]],"date-time":"2026-08-05T15:00:40Z","timestamp":1785942040000},"source":"Crossref","is-referenced-by-count":1,"title":["Psychotherapy for Impact of Killing During War"],"prefix":"10.1001","author":[{"given":"Shira","family":"Maguen","sequence":"first","affiliation":[{"name":"Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California"},{"name":"Department of Psychiatry and Behavioral Sciences, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rebecca","family":"Gloria","sequence":"additional","affiliation":[{"name":"Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California"},{"name":"Department of Psychiatry and Behavioral Sciences, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy","family":"Lehrner","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, James J. Peters Veterans Affairs Medical Center, Bronx, New York, New York"},{"name":"Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jean C.","family":"Beckham","sequence":"additional","affiliation":[{"name":"Durham Veterans Affairs Health Care System, Durham, North Carolina"},{"name":"Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephanie Y.","family":"Wells","sequence":"additional","affiliation":[{"name":"Durham Veterans Affairs Health Care System, Durham, North Carolina"},{"name":"Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Pratchett","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, James J. Peters Veterans Affairs Medical Center, Bronx, New York, New York"},{"name":"Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jamil","family":"Davis","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, James J. Peters Veterans Affairs Medical Center, Bronx, New York, New York"},{"name":"Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Deborah E.","family":"Barnes","sequence":"additional","affiliation":[{"name":"Department of Psychiatry and Behavioral Sciences, University of California, San Francisco"},{"name":"Department of Epidemiology & Biostatistics, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristine","family":"Burkman","sequence":"additional","affiliation":[{"name":"Mental Health Service, San Francisco Veterans Affairs Health Care System, San Francisco, California"},{"name":"Department of Psychiatry and Behavioral Sciences, University of California, San Francisco"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2026,8,5]]},"reference":[{"issue":"5","key":"yoi260038r1","doi-asserted-by":"publisher","first-page":"435","DOI":"10.1002\/jts.20451","article-title":"The impact of killing in war on mental health symptoms and related functioning.","volume":"22","author":"Maguen","year":"2009","journal-title":"J Trauma Stress"},{"issue":"1","key":"yoi260038r2","doi-asserted-by":"publisher","first-page":"21","DOI":"10.1037\/a0019897","article-title":"The impact of killing on mental health symptoms in Gulf War veterans.","volume":"3","author":"Maguen","year":"2011","journal-title":"Psychol Trauma"},{"issue":"1","key":"yoi260038r3","doi-asserted-by":"publisher","first-page":"86","DOI":"10.1002\/jts.20434","article-title":"The impact of reported direct and indirect killing on mental health symptoms in Iraq war veterans.","volume":"23","author":"Maguen","year":"2010","journal-title":"J Trauma 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Takano M [D C 41. Text - H.R. 6411 - 117th Congress (2021-2022): STRONG Veterans Act of 2022. Published July 11, 2022. 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