Examining the Association Between Moral Injury and Suicidal Behavior in Military Populations: A Systematic Review.
Military
Moral injury
Suicide
Suicide behavior
Veteran
Journal
Journal of religion and health
ISSN: 1573-6571
Titre abrégé: J Relig Health
Pays: United States
ID NLM: 2985199R
Informations de publication
Date de publication:
Dec 2023
Dec 2023
Historique:
accepted:
25
07
2023
medline:
29
11
2023
pubmed:
18
8
2023
entrez:
17
8
2023
Statut:
ppublish
Résumé
The increasing number of suicides among military populations cannot be fully accounted for by conventional risk factors like Post-Traumatic Stress Disorder (PTSD). As a result, researchers and theorists propose that delving into the concept of Moral Injury could offer a more comprehensive understanding of the phenomenon of suicide. Moral Injury is not currently a recognized mental health disorder but can be associated with PTSD. Moral Injury is a multi-dimensional issue that profoundly affects emotional, psychological, behavioral, social, and spiritual well-being. The objective of this systematic review is to examine the association between Moral Injury and suicidal behavior (suicide ideation, plans and or suicide attempt) within military populations. The review will specifically concentrate on identifying and analyzing studies that have investigated the connection between these variables, with a specific focus on the context of military personnel both serving and former serving members. Of the 2214 articles identified as part of this review, 12 studies satisfied the research criteria with a total participant sample having an average age of 40.7 years. The male population accounted for 78.6% of the overall sample. Two studies were identified as high-quality, while the remaining ten were rated as moderate. The analysis of these twelve studies consistently affirms a connection between Moral Injury and suicidal behavior; most obviously, that exposure to morally injurious events substantially amplify the risk of suicide, with higher levels of potential exposure being linked to increased Moral Injury and heightened levels of suicidal behavior. Our review uncovered noteworthy findings regarding the association between Moral Injury and suicidal behavior, marking a pioneering effort in exploring this association and offering valuable insights into this emerging issue. Several limitations are noted regarding this review and recommendations are made concerning the need to prioritize, expand and employ longitudinal research designs that include non-military populations such as first responders (e.g., police, paramedics, firefighters) and medical, nursing, or allied health professionals-all disciplines known to be impacted by Moral Injury.
Identifiants
pubmed: 37592186
doi: 10.1007/s10943-023-01885-6
pii: 10.1007/s10943-023-01885-6
doi:
Types de publication
Systematic Review
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
3904-3925Informations de copyright
© 2023. Crown.
Références
Ames, D., Erickson, Z., Youssef, N. A., Arnold, I., Adamson, C. S., Sones, A. C., Yin, J., Haynes, K., Volk, F., & Teng, E. J. (2019). Moral injury, religiosity, and suicide risk in US veterans and active duty military with PTSD symptoms. Military Medicine, 184(3–4), e271–e278. https://doi.org/10.1093/milmed/usy148
doi: 10.1093/milmed/usy148
pubmed: 29912418
Australian Insitute of Health and Welfare. (2022). Serving and ex-serving Australian Defence Force members who have served since 1985: Suicide monitoring 1997 to 2020. Retrieved from https://www.aihw.gov.au/reports/veterans/serving-and-ex-serving-adf-suicide-monitoring-2022/contents/analysis/suicides-by-sex-and-service-status-group
Australian Institute of Health and Welfare (2019). National suicide monitoring of serving and ex-serving Australian Defence Force personnel: 2019 update. https://www.aihw.gov.au/reports/veterans/national-veteran-suicide-monitoring/contents/summary
Barnes, H. A., Hurley, R. A., & Taber, K. H. (2019). Moral injury and PTSD: Often co-occurring yet mechanistically different. The Journal of Neuropsychiatry and Clinical Neurosciences, 31(2), A4-103. https://doi.org/10.1176/appi.neuropsych.19020036
doi: 10.1176/appi.neuropsych.19020036
pubmed: 31012825
Beck, A. T. , Kovacs, M. , & Weissman, A. (1979). Assessment of suicidal intention: The scale for suicide ideation. Journal of Consulting and Clinical Psychology, 47(2), 343–352. https://doi.org/10.1037/0022-006X.47.2.343
doi: 10.1002/jclp.22598
Boudreau, T. (2011). The morally injured. The Massachusetts Review, 52(3/4), 746–754. https://www.jstor.org/stable/23210143
Boyle, M. H. (1998). Guidelines for evaluating prevalence studies. BMJ Mental Health, 1(2), 37–39. https://www.jstor.org/stable/23210143
Brock, R. N., Keizer, H., & Lettini, G. (2012). Moral injury: The crucial missing piece in understanding soldier suicides. Huffington Post, New York. Jul 23, 2012, 11:19 AM Sep 22, 2012 https://www.huffpost.com/entry/moral-injury-the-crucial-missing-piece-in-understanding-soldier-suicides_b_1686674
Bryan, A. O., Bryan, C. J., Morrow, C. E., Etienne, N., & Ray-Sannerud, B. (2014). Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology, 20(3), 154–160. https://doi.org/10.1037/h009985
doi: 10.1037/h009985
Bryan, C. J., Bryan, A. O., Anestis, M. D., Anestis, J. C., Green, B. A., Etienne, N., Morrow, C. E., & Ray-Sannerud, B. (2016). Measuring moral injury: Psychometric properties of the moral injury events scale in two military samples. Assessment, 23(5), 557–570. https://doi.org/10.1177/1073191115590855
doi: 10.1177/1073191115590855
pubmed: 26092043
Bryan, C. J., Bryan, A. O., Roberge, E., Leifker, F. R., & Rozek, D. C. (2018). Moral injury, posttraumatic stress disorder, and suicidal behavior among National Guard personnel. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), 36–45. https://doi.org/10.1037/tra0000290
doi: 10.1037/tra0000290
pubmed: 28581315
Cameron, A. Y., Eaton, E., Brake, C. A., & Capone, C. (2021). Moral injury as a unique predictor of suicidal ideation in a veteran sample with a substance use disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 13(8), 856–860. https://doi.org/10.1037/tra0000988
doi: 10.1037/tra0000988
pubmed: 33370139
Carey, L. B., & Hodgson, T. J. (2018). Chaplaincy, spiritual care and moral injury: Considerations regarding screening and treatment. Frontiers in Psychiatry, 9(619), 1–10. https://doi.org/10.3389/fpsyt.2018.00619
Corona, C. D., Van Orden, K. A., Wisco, B. E., & Pietrzak, R. H. (2019). Meaning in life moderates the association between morally injurious experiences and suicide ideation among U.S. combat veterans: Results from the National Health and Resilience in Veterans Study. Psychological Trauma: Theory, Research, Practice and Policy 11(6), 614–620. https://doi.org/10.1037/tra0000475
Currier, J. M., Holland, J. M., Drescher, K., & Foy, D. (2015). Initial psychometric evaluation of the moral Injury Questionnaire--Military version. Clinical Psychology & Psychotherapy, 22(1), 54–63. https://doi.org/10.1002/cpp.1866
doi: 10.1002/jclp.22598
Department of Defence. (2016). Senate standing committee on foreign affairs, defence and trade inquiry into suicide by veterans and ex-service personnel: Written submission. Submission 124. Australina Government Foreign Affairs Defence and Trade. Retrieved from http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Foreign_Affairs_Defence_and_Trade/VeteranSuicide/Submissions .
Drescher, K. D., Currier, J. M., Nieuwsma, J. A., McCormick, W., Carroll, T. D., Sims, B. M., & Cauterucio, C. (2018). A qualitative examination of VA chaplains’ understandings and interventions related to moral injury in military veterans. Journal of Religion and Health, 57(6), 2444–2460. https://doi.org/10.1007/s10943-018-0682-3
doi: 10.1007/s10943-018-0682-3
pubmed: 30094678
Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., & Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350–362. https://doi.org/10.1002/jts.22362
doi: 10.1002/jts.22362
pubmed: 30688367
Hall, N. A., Everson, A. T., Billingsley, M. R., & Miller, M. B. (2022). Moral injury, mental health and behavioural health outcomes: A systematic review of the literature. Clinical Psychology & Psychotherapy, 29(1), 92–110. https://doi.org/10.1002/cpp.2607
doi: 10.1002/cpp.2607
Hamrick, H. C., Kelley, M. L., & Bravo, A. J. (2020). Morally injurious events, moral injury, and suicidality among recent-era veterans: The moderating effects of rumination and mindfulness. Military Behavioral Health, 8(1), 109–120. https://doi.org/10.1080/21635781.2019.1669509
doi: 10.1080/21635781.2019.1669509
Hodgson, T. J., & Carey, L. B. (2017). Moral injury and definitional clarity: Betrayal, spirituality and the role of chaplains. Journal of Religion and Health, 56(4), 1212–1228. https://doi.org/10.1007/s10943-017-0407-z
doi: 10.1007/s10943-017-0407-z
pubmed: 28526912
Hodgson, T.J. & Carey, L.B. (2019). Moral Injury within the RAAF and the Role of Chaplains: Exploratory findings. Research conference presentation. Journal of Military and Veteran Health, 27(4), 58. https://jmvh.org/issue/volume-27-number-4/
Hodgson, T. J., Carey, L. B., & Koenig, H. G. (2022). Moral injury, betrayal and retribution: Australian veterans and the role of chaplains. Journal of Religion and Health, 61(2), 993–1021. https://doi.org/10.1007/s10943-022-01507-7
Jamieson, N., Usher, K., Maple, M., & Ratnarajah, D. (2020). Invisible Wounds and Suicide: Moral Injury and Veteran Mental Health. International Journal of Mental Health Nursing, 29(2), 105–109. https://doi.org/10.1111/inm.12704
doi: 10.1111/inm.12704
pubmed: 32162834
Jinkerson, J. D. (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22(2), 122–130. https://doi.org/10.1037/trm0000069
doi: 10.1037/trm0000069
Jones, K. A., Freijah, I., Carey, L.B., Carleton, R. N., Devenish-Meares, P., Dell, L., Rodrigues, S., Madden, K., Johnson, L., Hosseiny, F., & Phelps, A. J. (2022). Moral injury, chaplaincy and mental health provider approaches to treatment: A scoping review. Journal of Religion and Health, 61(2), 1051–1094. https://doi.org/10.1007/s10943-022-01534-4
Jordan, A. H., Eisen, E., Bolton, E., Nash, W. P., & Litz, B. T. (2017). Distinguishing war-related PTSD resulting from perpetration-and betrayal-based morally injurious events. Psychological Trauma: Theory, Research, Practice, and Policy, 9(6), 627–634. https://doi.org/10.1037/tra0000249
doi: 10.1037/tra0000249
pubmed: 28068142
Katz, I., Barry, C. N., Cooper, S. A., Kasprow, W. J., & Hoff, R. A. (2020). Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) in a large sample of Veterans receiving mental health services in the Veterans Health Administration. Suicide & Life-Threatening Behavior, 50(1), 111–121. https://doi.org/10.1111/sltb.12584
doi: 10.1002/jclp.22598
Kelley, M. L., Bravo, A. J., Davies, R. L., Hamrick, H. C., Vinci, C., & Redman, J. C. (2019). Moral injury and suicidality among combat-wounded veterans: The moderating effects of social connectedness and self-compassion. Psychological Trauma: Theory, Research, Practice, and Policy, 11(6), 621–629. https://doi.org/10.1037/tra0000447
doi: 10.1037/tra0000447
pubmed: 30896225
Koenig, H. G., & Al Zaben, F. (2021). Moral injury: An increasingly recognized and widespread syndrome. Journal of Religion and Health, 60, 2989–3011. https://doi.org/10.1007/s10943-021-01328-0
doi: 10.1007/s10943-021-01328-0
pubmed: 34245433
pmcid: 8270769
Koenig, H. G. (2018). Measuring symptoms of moral injury in veterans and active duty military with PTSD. Religions, 9(86), 1–14, https://www.mdpi.com/2077-1444/9/3/86
Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Volk, F., Teng, E. J., Haynes, K., Erickson, Z. K., Arnold, I., O’Garo, K., & Pearce, M. J. (2018). The moral injury symptom scale-military version. Journal of Religion & Health, 57(1), 249–265. https://doi.org/10.1007/s10943-017-0531-9
doi: 10.1007/s10943-017-0531-9
Koenig, H. G., Youssef, N. A., & Pearce, M. (2019). Assessment of moral injury in veterans and active duty military personnel with PTSD: A review. Frontiers in Psychiatry, 10(443), 1–15. https://doi.org/10.3389/fpsyt.2019.00443/full .
Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depression diagnostic and severity measure. In (Vol. 32, pp. 509–515): Slack Incorporated Thorofare, NJ.
Levi-Belz, Y., Dichter, N., & Zerach, G. (2022). Moral injury and suicide ideation among Israeli combat veterans: The contribution of self-forgiveness and perceived social support. Journal of Interpersonal Violence, 37(1–2). https://doi.org/10.1177/0886260520920865
Levi-Belz, Y., & Zerach, G. (2018). Moral injury, suicide ideation, and behavior among combat veterans: The mediating roles of entrapment and depression. Psychiatry Research, 269, 508–516. https://doi.org/10.1016/j.psychres.2018.08.105
doi: 10.1016/j.psychres.2018.08.105
pubmed: 30195745
Liberati, M., Tetzlaff, J., & Altman, D. (2009). Preferred reporting items for systematic reviews and meta analyses: THE PRISMA statement. Plos Medicine, 6(7), 1–6. https://doi.org/10.1016/j.ijsu.2010.02.007
doi: 10.1016/j.ijsu.2010.02.007
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695–706. https://doi.org/10.1016/j.cpr.2009.07.003
doi: 10.1016/j.cpr.2009.07.003
pubmed: 19683376
Loney, P. L., Chambers, L. W., Bennett, K. J., Roberts, J. G., & Stratford, P. W. (1998). Critical appraisal of the health research literature: Prevalence or incidence of a health problem. Chronic Diseases Canada, 19(4), 170–176. https://publications.gc.ca/site/eng/9.505086/publication.html
Maguen, S., Griffin, B. J., Vogt, D., Hoffmire, C. A., Blosnich, J. R., Bernhard, P. A., Akhtar, F. Z., Cypel, Y. S., & Schneiderman, A. I. (2022). Moral injury and peri-and post-military suicide attempts among post-9/11 veterans. Psychological Medicine, 53(7), 3200–3209. https://doi.org/10.1017/S0033291721005274
doi: 10.1017/S0033291721005274
pubmed: 35034682
pmcid: 10235653
Matchar, D. B. (2012). Chapter 1: Introduction to the methods guide for medical test reviews. Journal of General Internal Medicine, 27, 4–10. https://doi.org/10.1007/s11606-011-1798-2
McCarthy, M. M. (2016). An exploration of moral injury as experienced by combat veterans. https://aura.antioch.edu/etds/317/
Molendijk, T., Verkoren, W., Drogendijk, A., Elands, M., Kramer, E., Smit, A., & Verweij, D. (2022). Contextual dimensions of moral injury: An interdisciplinary review. Military Psychology. Military Psychology, 34(6), 742–753. https://doi.org/10.1080/08995605.2022.2035643
doi: 10.1080/08995605.2022.2035643
Nash, W. P., Marino Carper, T. L., Mills, M. A., Au, T., Goldsmith, A., & Litz, B. T. (2013). Psychometric evaluation of the Moral Injury Events Scale. Military Medicine, 178(6), 646–652. https://doi.org/10.7205/milmed-d-13-00017
doi: 10.7205/milmed-d-13-00017
pubmed: 23756071
Nichter, B., Norman, S. B., Maguen, S., & Pietrzak, R. H. (2021). Moral injury and suicidal behavior among US combat veterans: Results from the 2019–2020 National Health and Resilience in Veterans Study. Depression and Anxiety, 38(6), 606–614. https://doi.org/10.1002/da.23145
doi: 10.1002/da.23145
pubmed: 33666315
Nock, M. K., Holmberg, E. B., Photos, V. I., & Michel, B. D. (2007). Self-Injurious Thoughts and Behaviors Interview: development, reliability, and validity in an adolescent sample. Psychological Assessment, 19(3), 309–317. https://doi.org/10.1037/1040-3590.19.3.309
doi: 10.1037/1040-3590.19.3.309
pubmed: 17845122
Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, B. A., & Barrios, F. X. (2001). The Suicidal Behaviors Questionnaire-Revised (SBQ-R): Validation with clinical and nonclinical samples. Assessment, 8(4), 443–454. https://doi.org/10.1177/107319110100800409
doi: 10.1177/107319110100800409
pubmed: 11785588
Pompili, M., Sher, L., Serafini, G., Forte, A., Innamorati, M., Dominici, G., Lester, D., Amore, M., & Girardi, P. (2013). Posttraumatic stress disorder and suicide risk among veterans: A literature review. The Journal of Nervous and Mental Disease., 201(9), 802–812. https://doi.org/10.1097/NMD.0b013e3182a21458
doi: 10.1097/NMD.0b013e3182a21458
pubmed: 23995037
Ribeiro, J. D., Pease, J. L., Gutierrez, P. M., Silva, C., Bernert, R. A., Rudd, M. D., & Joiner, T. E., Jr. (2012). Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. Journal of Affective Disorders, 136(3), 743–750. https://doi.org/10.1016/j.jad.2011.09.049
doi: 10.1016/j.jad.2011.09.049
pubmed: 22032872
Schwartz, G., Halperin, E., & Levi-Belz, Y. (2022). Moral injury and suicide ideation among combat veterans: The role of trauma-related shame and collective hatred. Journal of Interpersonal Violence, 37(15–16), https://doi.org/10.1177/08862605211007932
Shay, J. (1994). Achilles in Vietnam: Combat Trauma and the Undoing of Character. Scribner.
Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi.org/10.1037/a0036090
doi: 10.1037/a0036090
Tripp, J. C., McDevitt-Murphy, M. E., & Henschel, A. V. (2016). Firing a weapon and killing in combat are associated with suicidal ideation in OEF/OIF veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 8(5), 626–633. https://doi.org/10.1037/tra0000085
doi: 10.1037/tra0000085
pubmed: 26460495
Veterans Affairs. (2022). National Veteran Suicide Prevention Annual Report. Retrieved from https://www.mentalhealth.va.gov/suicide_prevention/data.asp
Volk, F., & Koenig, H. G. (2019). Moral injury and religiosity in active duty US Military with PTSD symptoms. Military Behavioral Health, 7(1), 64–72. https://doi.org/10.1080/21635781.2018.1436102
doi: 10.1080/21635781.2018.1436102
Watson, D., O’Hara, M.W., Simms, L.J., Kotov, R., Chmielewski, M., McDade-Montez, E.A., Gamez, W., Stuart, S. (2007). Development and validation of the Inventory of Depression and Anxiety Symptoms (IDAS). Psychological Assessment, 19(3):253–268. https://doi.org/10.1037/1040-3590.19.3.253
doi: 10.1037/1040-3590.19.3.253
pubmed: 17845118
Westphal, R., & Convoy, S. (2015). Military culture implications for mental health and nursing care. The Online Journal of Issues in Nursing, 20(1), 47–54. PDF: https://doi.org/10.3912/OJIN.Vol20No01Man04
Wisco, B. E., Marx, B. P., May, C. L., Martini, B., Krystal, J. H., Southwick, S. M., & Pietrzak, R. H. (2017). Moral injury in US combat veterans: Results from the national health and resilience in veterans study. Depression and Anxiety, 34(4), 340–347. https://doi.org/10.1002/da.22614
doi: 10.1002/da.22614
Zerach, G., & Levi-Belz, Y. (2018). Moral injury process and its psychological consequences among Israeli combat veterans. Journal of Clinical Psychology, 74(9), 1526–1544. https://doi.org/10.1002/jclp.22598
doi: 10.1002/jclp.22598
pubmed: 29528102