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

Abstract

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.

Morally Distressing Experiences, Moral Injury, and Burnout in Florida Healthcare Providers during the COVID-19 Pandemic

“…As hypothesized and similar to previous findings [ 21 ], we found that MI was related to burnout. We also found that MI was associated with higher levels of psychiatric symptoms including depression, anxiety, and PTSD, a finding that is consistent with prior research focused on HCPs [ 3 , 15 ] and military samples [ 42 ]. In our sample, providers who reported Others MI were almost three times more likely to score above the clinical cutoff for depression, while those reporting Self MI were over two times more likely to score above the clinical cutoff for depression, over four times more likely to score above the clinical cutoff for anxiety, and over 6 times more likely to score above the clinical cutoff for PTSD.…”

The Moral Injury, PTSD, and Suicidal Behaviors in Health Professionals 1 Year After the COVID-19 Pandemic Peak in China

“…This study found that over one-third of the health professionals reported suffering signi cant MI symptoms. Studies have found that MI has been associated with several adverse mental health outcomes and lower quality of health care (including increased medical errors) [32]. The prevalence in the study post-pandemic is lower than in a study conducted during the early stage of the pandemic when healthcare resources were extremely limited and the number of positive cases increasing rapidly [33].…”

Substantial Impact of COVID-19 on Self-Reported Mental Health of Healthcare Professionals in the Netherlands

“…This result shows the need for institutional meddling to prevent emotions such as overwhelm, fear, frustration and feelings of hopelessness, and helplessness. Since these emotions and feelings are associated with significant mental health challenges such as mental illnesses, behavioral issues (e.g., substance misuse), physical health challenges (e.g., sleep disturbances), and occupational impairment (e.g., burn-out and work absenteeism) ( 30 ).…”