How Do Morally Injurious Events Affect Suicide Risk in Veterans?

What you need to know

• Exposure to potentially morally injurious events (PMIEs) during military service increases risk of suicide attempts in veterans
• The effects of PMIEs on suicide risk differ between men and women veterans
• For men, perpetrating PMIEs was most strongly linked to increased suicide risk during and after service
• For women, experiencing betrayal was most strongly linked to increased suicide risk during and after service
• Assessing for moral injury is important for comprehensive suicide risk evaluation in veterans

Understanding moral injury in veterans

Moral injury is a concept that has gained attention in recent years as researchers and clinicians seek to understand the psychological impact of military service. Moral injury occurs when a person experiences, witnesses, or learns about events that violate their deeply held moral beliefs and expectations. For veterans, this might include:

• Being involved in the death of civilians
• Failing to prevent the death or injury of fellow service members
• Following orders that violate personal ethics
• Witnessing atrocities or extreme human suffering
• Experiencing betrayal by leaders or fellow service members

These experiences can lead to profound feelings of guilt, shame, anger, and loss of trust. While related to post-traumatic stress disorder (PTSD), moral injury is considered a distinct phenomenon that can occur with or without PTSD.

How moral injury impacts suicide risk

This study examined how exposure to potentially morally injurious events (PMIEs) during military service affects the risk of suicide attempts in veterans, both during their service and after leaving the military. The researchers looked at three types of PMIEs:

1. Witnessing immoral acts by others
2. Perpetrating acts that violate one’s moral code
3. Experiencing betrayal by leaders or others

The study found that exposure to these events does increase suicide risk, even when accounting for other factors like PTSD, depression, and pre-military mental health issues. However, the impacts differed between men and women veterans.

Gender differences in moral injury and suicide risk

For men veterans:

• Perpetrating morally injurious acts was most strongly linked to increased suicide risk, both during and after military service
• Men who reported perpetrating PMIEs were 50% more likely to attempt suicide during service and twice as likely after leaving the military
• Experiencing betrayal increased suicide risk during service, but this effect weakened after leaving the military

For women veterans:

• Experiencing betrayal was most strongly linked to increased suicide risk, both during and after military service
• Women who reported betrayal were over 50% more likely to attempt suicide during and after service
• Perpetrating PMIEs did not significantly predict suicide attempts for women when accounting for other risk factors

These findings highlight the importance of considering gender when assessing moral injury and suicide risk in veterans.

Other factors affecting veteran suicide risk

The study also identified several other factors that increased suicide risk in veterans:

• Pre-existing mental health issues, especially previous suicidal thoughts or attempts
• Symptoms of depression and PTSD
• For women, experiencing military sexual trauma

Importantly, the effects of moral injury on suicide risk remained significant even when accounting for these other risk factors. This suggests that moral injury represents a unique contributor to suicide risk in veterans that should be specifically assessed.

Implications for veteran mental health care

The findings of this study have several important implications for how we approach mental health care and suicide prevention for veterans:

1. Comprehensive assessment: Evaluations of suicide risk in veterans should include screening for exposure to morally injurious events, not just traditional mental health symptoms.

2. Gender-specific approaches: The differing impacts of moral injury on men and women suggest that gender-specific assessment and treatment approaches may be beneficial.

3. Targeted interventions: Developing and implementing interventions that specifically address moral injury may help reduce suicide risk in veterans. Some promising approaches include:

   • Impact of Killing (IOK) treatment
   • Adaptive Disclosure therapy
   • Trauma-Informed Guilt Reduction Therapy
   • Acceptance and Commitment Therapy for Moral Injury

4. Addressing betrayal: Given the strong link between experiencing betrayal and suicide risk, especially for women veterans, interventions that help restore trust and address feelings of betrayal may be particularly important.

5. Timing of interventions: The study found that some effects of moral injury on suicide risk persisted or even strengthened after leaving military service. This highlights the need for ongoing assessment and support for veterans, not just during active duty.

Conclusions

• Moral injury from military service significantly increases suicide risk in veterans
• The effects of moral injury on suicide risk differ between men and women veterans
• Assessing for moral injury is crucial for comprehensive suicide risk evaluation
• Developing targeted interventions for moral injury may help reduce suicide risk in veterans
• Ongoing support is needed to address the long-term impacts of moral injury on veteran mental health

This research underscores the complex relationship between military experiences, moral injury, and suicide risk in veterans. By better understanding these connections, we can work towards more effective prevention and treatment strategies to support the mental health and well-being of those who have served.