Moral Injury Exposure Classes Differentially Predict Mental Health Severity Among Veterans

Background and Purpose:

Many American veterans of the wars in Iraq and Afghanistan report exposure to events that violate deeply held moral beliefs, such as killing others, witnessing disproportionate violence, or experiencing betrayal. The resulting psychological distress, known as moral injury, is associated with mental health problems such as depression and posttraumatic stress disorder (PTSD). However, the study of the psychological impact of moral injury is relatively nascent, particularly with respect to differentiating between the effect of different types or combinations of morally injurious events. Thus, the objective of the present study is to explore among a sample of veterans whether there are classes of moral injury event exposure, and to examine the relationship between exposure classes and mental health disorders.

Methods:

Veterans age 18-40 (N=1,001) were recruited from social media websites. Morally injurious events were measured using the Moral Injury Events Scale. Depression was measured using the Patient Health Questionnaire (PHQ-9). PTSD was measured using the PTSD Checklist for DSM 5 (PCL-5). Generalized anxiety disorder was measured using the Generalized Anxiety Disorder scale (GAD-7). A latent profile analysis identified emergent classes of morally injurious event exposure classes. Multiple regression analyses controlling for combat exposure and sociodemographic covariates were used to test associations between exposure class membership and mental health disorder severity.

Results:

We identified 6 emergent morally injurious event exposure classes: no exposure, ambivalent about endorsing exposure, troubled by personal failure to act, witnessed transgressions, witnessed transgressions and experienced betrayal, and high all. Classes were differentially associated with mental health severity, for example, relative to those with no exposure, all other classes endorsed more symptoms of depression and PTSD, and nearly all endorsed more symptoms of anxiety. Symptoms were generally higher for veterans in classes with multiple exposure types, although those who were ambivalent about endorsing exposure also had relatively high symptomology.

Conclusions and Implications:

The results of our latent profile analysis with a large community sample of veterans suggest there are classes of morally injurious event exposures, and these are differentially associated with mental health disorder symptoms. Clinicians working with combat exposed veterans should be knowledgeable about the different types of events that might precipitate moral injury and its psychological impact. Researchers should seek to further elucidate the differential impact of morally injurious event types and the mechanisms linking them to psychological outcomes. The relationship between ambivalence about endorsing exposure and high mental health symptomology also warrants particular attention.