Greater prevalence of post‐traumatic stress disorder and depression in deployed Canadian Armed Forces personnel at risk for moral injury

Nazarov, Anthony; Fikretoglu, Deniz; Liu, A.; Thompson, Megan M.; Zamorski, Mark A.

doi:10.1111/acps.12866

Cited by 56 publications

(80 citation statements)

References 64 publications

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“…The methods used in this paper are partly based on previous work by our group which explored the prevalence and correlates of potentially morally injurious experiences (PMIEs) among personnel deployed to Afghanistan (Nazarov et al, 2018) and mental health service use among all Regular Force members irrespective of deployment status (Fikretoglu, Guay, Pedlar, & Brunet, 2008). As such, the sections below on participants, measures, and, to a lesser extent analytic methods, are partly drawn from those previous publications.…”

Section: Methodsmentioning

confidence: 99%

“…As such, the sections below on participants, measures, and, to a lesser extent analytic methods, are partly drawn from those previous publications. For brevity, these sections are abridged; further details can be found in our earlier publication (Nazarov et al, 2018).…”

Section: Methodsmentioning

confidence: 99%

“…2013 Canadian Forces Mental Health Survey (CFMHS)) . The details of the sampling frame can be found in Nazarov et al (2018). Considering that our primary objective was to understand the impact of potentially morally injurious deployment experiences on help-seeking patterns, our analysis was limited to Regular Force (RegF) and Primary Reserve Force personnel previously deployed in support of the mission in Afghanistan (unweighted sample size of 4854 representing 33,525 deployed personnel).…”

Section: Participantsmentioning

confidence: 99%

“…Respondents were provided with a list of eight stressful deployment experiences and were asked to identify any items that they have experienced while on deployment (aligning the CIDI trauma inventory process) (Kessler & Üstün, 2004). Using an approach that was previously applied in Nazarov et al (2018), the stressful deployment-related experiences that aligned well with the expanding theoretical framework Currier, Holland, Drescher, & Foy, 2015;Nash & Litz, 2013) on the types of events that may cause a moral injury were identified from the list of DEX items. Specifically, the items that were identified to increase the risk for moral injury and included in the analysis were: DEX-4, 'seen ill or injured women or children who you were unable to help'; DEX-6, 'ever felt responsible for the death of Canadian or ally personnel'; DEX-8, 'had difficulty distinguishing between combatants and non-combatants.'…”

Section: Potentially Morally Injurious Experiences (Pmies)mentioning

confidence: 99%

“…Events that involve perpetrating, observing, and/or failing to prevent acts that transgress deeply-held moral standards (e.g. feeling responsible for the death of an ally, being unable to help injured women and children) are prevalent in contemporary deployments (Nazarov, Fikretoglu, Liu, Thompson, & Zamorski, 2018), lead to psychological distress (Zerach & Levi-Belz, 2018), and increase risk for developing posttraumatic stress disorder (PTSD) (Nazarov et al, 2018), major depressive disorder (MDD) (Nazarov et al, 2018), and suicidal ideation (Ames et al, 2018;Bryan, Bryan, Morrow, Etienne, & Ray-Sannerud, 2014) (see Nazarov et al (2015) for review).…”

Section: Introductionmentioning

confidence: 99%

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Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury

Nazarov

Fikretoglu

Liu

et al. 2020

European Journal of Psychotraumatology

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Objective: Potentially morally injurious experiences (PMIE) (events that transgress an individual's subjective moral standards) have been associated with psychologically distressing moral emotions such as shame and guilt. Military leaders and clinicians have feared that those with PMIEs may be less likely to seek help due to the withdrawing nature of shame/ guilt; however, to date, help-seeking patterns of military personnel with PMIEs has not been explored. Our objective is to address this research gap. Method: Data from a nationally-representative mental health survey of active Canadian military personnel were analysed. To assess the association between exposure to three PMIEs and past-year help-seeking across different provider categories (i.e. professionals, para-professionals (those delegated with mental health advisory tasks but are not licenced to practice as medical professionals), non-professionals), a series of logistic regressions were conducted, controlling for exposure to other deployment and non-deployment-related psychological trauma, psychiatric variables, military factors, and sociodemographic variables. Analytical data frame included only personnel with a history of Afghanistan deployment (N = 4854). Results: Deployed members exposed to PMIEs were more likely to seek help from their family doctor/general practitioner (OR = 1.72; 95%CI = 1.25-2.36), paraprofessionals (OR = 1.72; 95% CI = 1.25-2.36), and non-professionals (OR = 1.44; 95%CI = 1.06-1.95) in comparison to members not exposed to PMIEs. Those exposed to PMIEs were also more likely to seek professional care from the civilian health care system (OR = 1.94; 95%CI = 1.27-2.96). Conclusion: Contrary to long-held, but untested, assumptions regarding the impact of PMIEs on help-seeking, we found those with PMIEs are more likely to seek help from gatekeeper professionals (i.e. general practitioners), para-professionals, and nonprofessionals rather than specialized mental health professionals (e.g. psychologists). Increased utilization of civilian professionals raises concerns that active military members may be avoiding military health services. Clinically, this highlights the need to increase awareness of moral injury to ensure that actively serving military members are provided with appropriate advice and treatment.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Participantsmentioning

confidence: 99%

Section: Potentially Morally Injurious Experiences (Pmies)mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury

Nazarov

Fikretoglu

Liu

et al. 2020

European Journal of Psychotraumatology

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Moral injury, mental health and behavioural health outcomes: A systematic review of the literature

Hall

Everson

Billingsley

et al. 2021

Clin Psychology and Psychoth

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Despite a burgeoning of research on moral injury in the past decade, existing reviews have not explored the breadth of consequences and the multitude of pathways through which moral injury and potentially morally injurious experiences (PMIEs) influence mental and behavioural health outcomes. This study aimed to identify associations between moral injury on mental and behavioural health. Literature searches of psychological and medical databases were conducted through April 2020. Eligible studies measured moral injury or PMIEs, and health outcomes (e.g., depression, substance use and suicidality). Fifty-seven publications representing 49 separate samples were included. Studies examined the impact of moral injury on post-traumatic stress disorder (PTSD) (n = 43); depression (n = 32); anxiety (n = 15); suicide (n = 15); substance use (n = 14); and 'other'health outcomes, including pain, burnout, sleep disturbance and treatment-seeking behaviours (n = 11). The majority of studies found significant positive associations between moral injury-related constructs, mental health and behavioural health outcomes; however, the majority were also cross-sectional and focused on military samples. Proposed mediators included lack of social support, negative cognitions and meaning-making. Moderators included self-compassion, pre-deployment mental health education and mindfulness. Moral injury is associated with a variety of negative health outcomes. Research is needed to determine the mechanisms by which moral injury may influence these outcomes over time.

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Exposure to combat incidents within military and civilian populations as possible correlates of potentially morally injurious events and moral injury outcomes among Israeli combat veterans

Zerach

Levi‐Belz

2021

Clin Psychology and Psychoth

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Objectives: Exposure to potentially morally injurious events (PMIEs) is considered a necessary but insufficient determinant of moral injury (MI) outcomes. However, a question remains regarding possible acts and the necessary features of PMIEs that should be considered transgressive and might lead to MI psychopathological outcomes. We aim to examine the links between exposure to combat incidents within civilian Palestinian populations (CPPs), PMIEs and MI-related outcomes of posttraumatic stress disorder (PTSD) symptoms (PTSS), trauma-related guilt and shame. We also aim to explore the mediating roles of subjective perceptions of PMIEs in the relationship between exposure to combat incidents within CPP and MI-related outcomes among combat veterans. Method: A volunteer sample of 716 Israeli combat veterans responded to self-report questionnaires in a cross-sectional design study. Results: Exposure to combat incidents within CPP has been primarily associated with perpetration based PMIEs and MI-related guilt outcomes. Importantly, betrayal-based PMIEs mediated the association between reports of being the victim of verbal violence by militants and/or civilians and MI outcomes. Moreover, perpetration-based PMIEs mediated associations between reports of personal acts, or witnessing acts, of physical and verbal violence and degradation by militants and/or civilians, and MI outcomes. Conclusions: Military incidents within civilian populations are related to subjective perceptions of PMIEs and MI-related psychopathological outcomes. While betrayalbased experiences might serve as a mechanism to being a victim of verbal violence and MI outcomes, perpetration-based experiences might serve as mechanisms to physical, verbal and degradation incidents and MI outcomes.

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Greater prevalence of post‐traumatic stress disorder and depression in deployed Canadian Armed Forces personnel at risk for moral injury

Abstract: Exposure to PMIEs during deployments is common and represents an independent risk factor for past-year PTSD and MDD. Improved training that targets moral-ethical dilemmas and treatment interventions that address moral injury expressions is warranted.

Cited by 56 publications

References 64 publications

Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury

Help-seeking for mental health issues in deployed Canadian Armed Forces personnel at risk for moral injury

Moral injury, mental health and behavioural health outcomes: A systematic review of the literature

Exposure to combat incidents within military and civilian populations as possible correlates of potentially morally injurious events and moral injury outcomes among Israeli combat veterans

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