Moral injury and suicidal behavior among US combat veterans: Results from the 2019–2020 National Health and Resilience in Veterans Study

Abstract

Background: Recent research suggests that exposure to potentially morally injurious experiences (PMIEs) may be associated with increased risk for suicidal behavior among US combat veterans, but population-based data on these associations are scarce. This study examined the association between PMIEs with current suicidal ideation (SI), lifetime suicide plans (SP), and suicide attempts (SA) in a contemporary, nationally representative sample of combat veterans. Methods: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US combat veterans (n = 1321). PMIEs were assessed using the Moral Injury Events Scale (MIES). Multivariable logistic regression analyses were conducted to examine associations between MIES total scores and specific types of PMIEs with suicidal behavior.Results: Thirty-six point three percent of veterans reported at least one PMIE.Perceived transgressions by self, others, and betrayal were associated with SI, SP, and SA (odds ratios [ORs] = 1.21-1.27, all p s < .05), after adjusting for sociodemographic, trauma, and psychiatric characteristics. MIES total scores were significantly, albeit weakly, associated with SP (OR = 1.03, p < .01), but not SI/SA. Depression, posttraumatic stress disorder (PTSD), and age emerged as the strongest correlates of SI/SP/SA (14.9%-38.1% of explained variance), while PMIEs accounted for a comparatively modest amount of variance (3.3%-8.9%).Conclusions: Reports of potentially morally injurious experiences are prevalent among US combat veterans, and associated with increased risk for suicidal behavior, above and beyond severity of combat exposure, PTSD, and depression. Implications for clinical practice and future research are discussed, including the need for methodological advancements in the measurement of moral injury.

Moral Injury and Suicide Ideation Among Combat Veterans

“…Our findings indicated that veterans reporting higher PMIE-Self and PMIE-Betrayal levels also reported significantly higher levels of SI and depression. These results align with several studies (e.g., Nichter et al, 2021;Zerach & Levi-Belz, 2021) and the MI theoretical model (Litz et al, 2009), demonstrating the deleterious effects of PMIE exposure among veterans. Moreover, self-disclosure was found to contribute negatively to current SI among veterans, beyond the contribution of PMIEs and depression.…”

Moral injury and substance use disorders among US combat veterans: results from the 2019–2020 National Health and Resilience in Veterans Study

“…First, we computed descriptive statistics for the sample to summarize sociodemographic, military, clinical, and MIES characteristics. Second, we examined the association between exposure to three types of PMIEs (perpetration, witnessing, and betrayal subscales of the MIES) with lifetime and past-year AUD, DUD, and SUD in a series of multivariable logistic regression analyses; consistent with prior work (Nichter et al, 2021;Wisco et al, 2017), models adjusted for sociodemographic characteristics, combat exposure severity, lifetime trauma exposure, and lifetime PTSD and MDD. Prior to regression analyses, we conducted independentsamples t tests to compare MIES subscale scores in each of the dependent variable groups (i.e.…”

“…exposure to PMIEs is associated with greater severity of PTSD and MDD symptoms, as well as heightened risk for suicidal thoughts and behaviors (Griffin et al, 2019;Maguen et al, 2020a, b;Nichter, Norman, Maguen, & Pietrzak, 2021;Wisco et al, 2017). Although researchers have speculated that moral injury may be linked to a greater likelihood of substance use disorders (SUDs; e.g.…”

The Costs and Health Benefits of Expanded Access to MDMA-assisted Therapy for Chronic and Severe PTSD in the USA: A Modeling Study

“…Post-traumatic stress disorder (PTSD) is a highly debilitating psychiatric condition that adversely affects mood, cognition, physical and emotional health, and can lead to suicidal ideation and behavior [1][2][3][4]. In any given year, 3.5-4.7% of US adults or about 7.3-9.8 million individuals experience PTSD.…”