A Commotion in the Mind: Moral Injury, Stoicism, and Suicide Risk in US Military Veterans

Background:
Despite numerous public health interventions and resources, suicide rates among U.S. military veterans have continued to rise. Recent estimates of suicide deaths among veterans are as high as 17.6 deaths by suicide per day—double that of their civilian counterparts. This persistent crisis underscores the need to explore new psychological and philosophical frameworks that may serve contribute to veteran suicide prevention efforts. One emerging area of interest is the relationship between moral injury—a psychological consequence of transgressing deeply held moral values—and stoicism, a philosophical tradition emphasizing resilience, self-discipline, and acceptance. This study examines associations between moral injury, stoicism, and suicide risk among U.S. veterans.

Methods:
This study employed a cross-sectional survey design with a diverse sample of veterans (n=3,176), including both Veterans Health Administration (VHA) service users and non-users, a subgroup understudied in the veteran’s behavioral health literature. A latent variable modeling approach was employed to test associations between moral injury, stoicism, and suicide risk. First, confirmatory factor models established factor structure and factor loadings for latent variables. Second, a structural equation model (SEM) was fitted to examine direct effects for moral injury on stoicism and suicide risk, the direct effect for stoicism on suicide risk, and the indirect effect for moral injury on suicide risk through the stoicism pathway. Demographic covariates included age, gender, race/ethnicity, marital status, and educational attainment.

Results:
The SEM showed good model fit to the data (CFI = 0.91, TLI = 0.89, RMSEA = 0.06). As hypothesized, moral injury was negatively associated with stoicism (B= -0.32, SE=0.02, p<0.001) and positively associated with suicide risk (B = 0.26, SE = 0.03, p < .001). Stoicism was negatively associated with suicide risk (B = -0.26, SE = 0.03, p < .001). We also detected a significant indirect effect for moral injury on suicide risk through the stoicism pathway suggesting stoicism buffered the relationship between moral injury and suicide risk (B = 0.10, SE = 0.01, p < .001). Among demographic variables, younger age, lower education levels, and being unmarried were associated with higher suicide risk.

Conclusions and Implications:
This is the first study to examine stoicism as a potential buffering factor in the relationship between moral injury and suicide risk among veterans. While moral injury contributes to suicidality through mechanisms such as guilt, shame, and loss of meaning, stoicism may mitigate these effects by fostering emotion regulation, values-based action, and acceptance of uncontrollable circumstances. These findings suggest that stoicism could be a culturally and philosophically congruent construct informing suicide prevention efforts in veteran populations. Future work should seek to clarify the stoicism construct and examine its potential for modification in military-connected populations.