How Do Moral Injury, PTSD, and Depression Affect Veterans' Daily Functioning Over Time?

What you need to know

• Most veterans maintain good functioning in relationships, health, and work after military service
• Depression and moral injury from causing harm to others are the strongest predictors of declining function over time
• Veterans who experience moral injury may need specialized treatment focused on processing these experiences, beyond standard PTSD care

Understanding Moral Injury

Moral injury occurs when someone experiences events that violate their deeply held moral beliefs and expectations. For veterans, this can happen in three main ways:

1. Witnessing others commit morally questionable acts
2. Directly participating in actions that go against one’s values (perpetration)
3. Experiencing betrayal by leaders or others in positions of trust

Unlike PTSD, which is primarily a fear-based response to trauma, moral injury involves complex feelings of guilt, shame, and spiritual/existential struggles. This research examined how different types of moral injury, along with PTSD and depression, affect veterans’ ability to function in daily life over time.

The Research Approach

The researchers followed over 7,000 post-9/11 veterans for about 27 months after they left military service. They measured:

• Relationship functioning (emotional support, communication with partner)
• Health functioning (following medical recommendations, self-care)
• Work functioning (completing tasks, meeting expectations)
• Symptoms of PTSD, depression, and moral injury

Key Findings

Relationship Functioning

Four main patterns emerged:

• High and stable (71.6% of veterans)
• Moderate and stable (23.8%)
• High but declining (2.7%)
• Moderate but improving (2%)

Veterans who reported moral injury from perpetration were more likely to show declining relationship function over time.

Health Functioning

Three patterns were identified:

• High and stable (95.3%)
• High but declining (3.3%)
• Moderate but improving (1.4%)

Both depression and moral injury from perpetration predicted worse health functioning trajectories.

Work Functioning

Three patterns emerged:

• High and stable (89.1%)
• High but declining (7.2%)
• Moderate but improving (3.7%)

Again, depression and moral injury from perpetration were the strongest predictors of declining work function.

Clinical Implications

The study highlights several important points for healthcare providers:

1. Regular screening for moral injury should be part of veteran care, as it affects functioning independently of PTSD and depression

2. Different types of moral injury may require different treatment approaches:

   • Perpetration-based moral injury may need specialized interventions focused on processing guilt and shame
   • Betrayal-based moral injury might benefit from approaches that address trust and relationship issues

3. Treatment plans should consider both immediate and long-term effects on daily functioning

Conclusions

• While most veterans maintain good functioning after military service, a significant minority experience difficulties
• Moral injury from perpetrating harmful acts is particularly damaging to long-term functioning
• Current veteran mental health care may need to expand to better address moral injury
• More research is needed on how moral injury develops and changes over time