Moral Injury, Religiosity, and Suicide Risk in U.S. Veterans and Active Duty Military with PTSD Symptoms

MILITARY MEDICINE, 184, 3/4:e271, 2019 Moral Injury, Religiosity, and Suicide Risk in U.S. Veterans and Active Duty Military with PTSD Symptoms Donna Ames, MD*†‡; Zachary Erickson, CCRP*; Nagy A. Youssef, MD§; Irina Arnold, MD*; Chaplain Sam Adamson, MDiv*; Alexander C. Sones, BA*†; Justin Yin*†; Kerry Haynes, D.Min., BCC║; Fred Volk, PhD¶; Ellen J. Teng, PhD**; Rev. John P. Oliver, D.Min., BCC††; Harold G. Koenig, MD‡††‡‡§§ BACKGROUND Post-traumatic stress disorder (PTSD) is a common mental disorder among military personnel who have served in combat theaters,1 and is a known risk factor for suicide in Veterans and Active Duty Military (V/ADM).2–4 “Moral injury” (MI) is also common among V/ADM with PTSD symptoms.5–8 Litz and colleagues described MI as: “perpetrating, failing to *VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA 90073. †University of California – Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90024. ‡Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710. §Medical College of Georgia at Augusta University, and Charlie Norwood VA Medical Center, Augusta, Georgia. ║South Texas Veterans Healthcare System, San Antonio, TX. ¶Department of Counselor Education and Family Studies, School of Behavioral Sciences, Liberty University, Lynchburg, Virginia. **Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX. ††Durham Veterans Affairs Health Care System, Durham, NC. ‡‡King Abdulaziz University, Jeddah 21589, Saudi Arabia. §§Ningxia Medical University, 692 Shengli St, Xingqing Qu, Yinchuan Shi, Ningxia Huizuzizhiqu, 750000, China. The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Department of Veterans Affairs, U.S. Army, U.S. Navy, U.S. Air Force, the U.S. Department of Defense, or the U.S. Government. doi: 10.1093/milmed/usy148 © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: . MILITARY MEDICINE, Vol. 184, March/April 2019 prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs.”9 Brock and Lettini note that MI is characterized by “feelings of shame grief, meaninglessness, and remorse from having violated core moral beliefs.”10 There may also be a spiritual component to MI that involves a loss of religious faith and/or the presence of religious/spiritual struggles resulting from morally troubling experiences during wartime.8,11 Veterans raised in a religious environment may be particularly vulnerable to moral conflicts that arise from the horrors of war and combat.12 Experiences such as killing in combat may give rise to moral dilemmas that increase the risk of suicide. In a study of 2,854 active duty U.S. soldiers returning from deployment to support Operation Iraqi Freedom (OIF), both depression and PTSD symptoms (in particular) mediated the association between killing in combat and suicidal thoughts.13 In a small study of 69 ADM personnel treated at a military outpatient clinic, C. Bryan and colleagues found that feelings of guilt and shame were significantly related to severity of current suicidal ideation, independent of symptoms of depression and PTSD.14 Similarly, in another study of 151 ADM, A. Bryan and colleagues15 reported associations between MI assessed by the Moral Injury Events Scale5 and both PTSD symptoms and suicidal ideation (particularly transgressions against the self and feelings of betrayal). Furthermore, among those who reported past suicide attempts (n = 11), scores on both transgressions against self and others were significantly higher than in controls not making such attempts. e271 ABSTRACT Introduction: There is growing evidence that moral injury (MI) is related to greater suicide risk among Veterans and Active Duty Military (V/ADM). This study examines the relationship between MI and suicide risk and the moderating effect of religiosity on this relationship in V/ADM with post-traumatic stress disorder (PTSD) symptoms. Materials and Methods: This was a cross-sectional multi-site study involving 570 V/ADM from across the USA. Inclusion criteria were having served in a combat theater and the presence of PTSD symptoms. Multidimensional measures assessed MI, religiosity, PTSD symptoms, anxiety, and depression. In this secondary data analysis, a suicide risk index was created based on 10 known risk factors. Associations between MI and the suicide risk index were examined, controlling for demographic, religious, and military characteristics, and the moderating effects of religiosity were explored. Results: MI overall was correlated strongly with suicide risk (r = 0.54), as were MI subscales (ranging from r = 0.19 for loss of trust to 0.48 for self-condemnation). Controlling for other characteristics had little effect on this relationship (B = 0.016, SE = 0.001, p < 0.0001). Religiosity was unrelated to suicide risk and did not moderate the relationship between suicide risk and MI or any of its subscales. Conclusion: MI is strongly and independently associated with risk factors for suicide among V/ADM with PTSD symptoms, and religiosity does not mediate or moderate this relationship. Whether interventions that target MI reduce risk of suicide or suicidal ideation remains unknown and needs further study. Moral Injury, Religiosity, and Suicide Risk in U.S. Veterans METHODS This was a cross-sectional study of 570 V/ADM. Veterans (n = 467) completed in-person questionnaires following recruitment from outpatient Veterans Administration (VA) hospital clinics in Augusta, Georgia (n = 201, Charlie Norwood Veterans Administration Hospital), Los Angeles, CA, USA (n = 99, VA Greater Los Angeles Healthcare System; VAGLAHS), Durham, NC, USA (n = 84, Durham Veterans Affairs Health Care System), Houston, TX, USA (n = 47, Michael E. DeBakey VA Medical Center), and San Antonio, TX, USA (n = 35, South Texas Veterans Healthcare System). ADM (n = 103) completed online questionnaires following recruitment from students attending Liberty University (n = 54) and those identified through the Qualtrics online data collection platform (n = 49). Inclusion criteria were a history of deployment to a combat theater and the presence of PTSD symptoms. Participants received compensation in the form of a $25 gift card for completing the questionnaire. e272 All participants provided written informed consent, except at the VAGLAHS, where participants received a study information sheet and provided verbal informed consent prior to participation. Institutional review boards and Research & Development Committees of the above VA Health Systems, Duke University Medical Center, and Liberty University approved this research. The present study uses an expanded sample from a project originally designed to examine the psychometric properties of a novel scale designed to assess MI symptoms in V/ADM (n = 427).8 Questionnaire Demographics Demographic info (...truncated)