Trajectories of functioning in a population-based sample of veterans: contributions of moral injury, PTSD, and depression

Properties of the modified self-forgiveness dual-process scale in populations at risk for moral injury

Despite theory suggesting that self-forgiveness facilitates recovery from moral injury, no measure of self-forgiveness has been validated with individuals exposed to potentially morally injurious events (PMIEs). Military veterans, healthcare workers, and first responders who reported PMIE exposure (n = 924) completed the Self-Forgiveness Dual-Process Scale, which assesses two dimensions of the self-forgiveness process. The first dimension, value affirmation, refers to appraising personal responsibility and being willing to make amends for one's involvement in a PMIE. The second dimension, esteem restoration, refers to accepting oneself as valuable and capable of growth despite one's failures and imperfections. Exploratory and Confirmatory Factor Analyses replicated the original scale's two-factor structure in 10 items modified to apply to the diverse contexts in which PMIEs occur. Next, we found that the factor structure, item loadings, and item intercepts were fully or partially invariant across professions, genders, races, ages, and religious affiliations in a series of Multi-Group Confirmatory Factor Analyses. Finally, diverging patterns of associations between value affirmation and esteem restoration with moral distress, posttraumatic stress, depression, insomnia, functional impairment, and posttraumatic growth provide evidence of convergent and discriminant validity between the subscales. The modified self-forgiveness dual process scale is the first measure of self-forgiveness to be validated with individuals exposed to a PMIE. Researchers and clinicians can use the scale to examine how self-forgiveness (or difficulties with forgiving oneself) relates to moral injury.

How do you see me? The impact of perceived societal recognition on PTSD symptoms amongst Norwegian peacekeepers

Background: The peacekeeper role is different to that of traditional combat, however, peacekeepers, like combat soldiers, may also be exposed to high levels of dangerous and/or potentially morally injurious events (PMIEs).Objective: It was hypothesized that given the centrality of societal approval for the peacekeeping mission, in addition to the known relevance of perceived social support, perceived societal recognition would influence PTSD symptoms (PTSS) and depression. It was hypothesized that perceived societal recognition would moderate the effect of exposure to potentially traumatic events and PMIEs on psychological outcomes.Method: 8341, predominantly male, former UNIFIL peacekeepers, almost three decades following deployment, answered a survey to determine the impact of perceived social support and perceived societal recognition, on PTSS and depression symptoms. Hierarchical regression analyses were performed for PTSS and depression separately and moderation analysis was performed for perceived societal recognition.Results: Exposure to potentially traumatic events showed the greatest predictive value for PTSS and exposure to PMIEs and potentially traumatic events were equally predictive of depression symptoms. While perceived social support presented the strongest buffer for PTSS and depression symptoms following UNIFIL deployment, perceived societal recognition also significantly contributed to the prediction of both PTSS and depression symptoms. There was a weak moderation effect of perceived societal recognition on trauma type in the development of PTSS.Conclusions: Even decades following peacekeeping deployment, military experiences have a significant impact on psychological functioning. This impact is both from the types of events experienced and from the perception of social and societal support upon return home.

Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury

Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury and Distress Scale (MIDS). Participants who endorsed PMIE exposure (N = 645) were drawn from a population-based sample of military veterans, health care workers, and first responders. Using signal detection methods, we identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma-related guilt, and functional impairment. The most efficient cut scores across outcomes converged between 24 and 27. We recommend a cut score of 27 given that roughly 70% of participants who screened positive on the MIDS at this threshold reported clinically significant mental health symptoms, and approximately 50% reported severe trauma-related guilt and/or functional impairment. Overall, 10.2% of respondents exposed to a PMIE screened positive for moral injury at this threshold, particularly those who identified as a member of a minoritized racial or ethnic group (17.9%) relative to those who identified as White, non-Hispanic (8.0%), aOR = 2.52, 95% CI [1.45, 4.42]. This is the first known study to establish a cut score indicative of clinically meaningful and impairing moral injury. Such scores may enhance clinicians' abilities to conduct measurement-based moral injury care by enabling them to identify individuals at risk of negative outcomes and better understand risk and protective factors for moral injury.

The independent and combined impact of moral injury and moral distress on post-traumatic stress disorder symptoms among healthcare workers during the COVID-19 pandemic

Background: Healthcare workers (HCWs) across the globe have reported symptoms of Post-Traumatic Stress Disorder (PTSD) during the COVID-19 pandemic. Moral Injury (MI) has been associated with PTSD in military populations, but is not well studied in healthcare contexts. Moral Distress (MD), a related concept, may enhance understandings of MI and its relation to PTSD among HCWs. This study examined the independent and combined impact of MI and MD on PTSD symptoms in Canadian HCWs during the pandemic.Methods: HCWs participated in an online survey between February and December 2021, with questions regarding sociodemographics, mental health and trauma history (e.g. MI, MD, PTSD, dissociation, depression, anxiety, stress, childhood adversity). Structural equation modelling was used to analyze the independent and combined impact of MI and MD on PTSD symptoms (including dissociation) among the sample when controlling for sex, age, depression, anxiety, stress, and childhood adversity.Results: A structural equation model independently regressing both MI and MD onto PTSD accounted for 74.4% of the variance in PTSD symptoms. Here, MI was strongly and significantly associated with PTSD symptoms (β = .412, p < .0001) to a higher degree than MD (β = .187, p < .0001), after controlling for age, sex, depression, anxiety, stress and childhood adversity. A model regressing a combined MD and MI construct onto PTSD predicted approximately 87% of the variance in PTSD symptoms (r2 = .87, p < .0001), with MD/MI strongly and significantly associated with PTSD (β = .813, p < .0001), after controlling for age, sex, depression, anxiety, stress, and childhood adversity.Conclusion: Our results support a relation between MI and PTSD among HCWs and suggest that a combined MD and MI construct is most strongly associated with PTSD symptoms. Further research is needed better understand the mechanisms through which MD/MI are associated with PTSD.

The impact of stress and well-being during the COVID-19 pandemic on mental health in U.S. veterans

The COVID-19 pandemic disrupted life around the globe and negatively impacted mental health (MH), including among military veterans. Building on previous research with U.S. veterans, the present study examined the association between a broad array of pandemic stressors and well-being on MH outcomes. A total of 372 veterans (51.3% women) from all service eras completed measures of posttraumatic stress disorder and depression during early (timepoint 1 [T1]) and peri-pandemic (timepoint 2 [T2]) periods. Pandemic-related stressors and well-being (satisfaction in life domains) were assessed at the peri-pandemic timepoint (T2). Logistic regression analyses were used to investigate associations between stressors and well-being with the likelihood of a probable MH diagnosis at T2 controlling for T1 MH status. More negative physical and MH impacts of the pandemic in addition to fewer positive consequences and lower satisfaction with paid work, finances, health, romantic relationships, and social life were associated with a higher likelihood of a probable T2 MH diagnosis. COVID infection was associated with lower odds of a probable T2 MH diagnosis. There were significant indirect effects, such that physical and MH impacts of the pandemic were associated with T2 MH via well-being. Overall, these findings highlight the role of stress and well-being on MH during a global pandemic. Interventions to address well-being may be important to address veteran MH during other periods of stress. Future research should examine the generalizability of study findings and further investigate factors that contribute to veterans' MH resilience during stressful life experiences.

The Middle-Out Approach to reconceptualizing, assessing, and analyzing traumatic stress reactions

Alternative models of traumatic stress and broader psychopathology have been proposed to address issues of heterogeneity, comorbidity, clinical utility, and equitable representation. However, systematic and practical methods and guidelines to organize and apply these models remain scarce. The Middle-Out Approach is a novel, integrative, contextually informed framework for organizing and applying existing empirical methods to evaluate current and alternative traumatic stress reactions. Rather than beginning to identify traumatic stress reactions from the top-down (i.e., disorder-first approach) or bottom-up (i.e., symptom-first approach), constructs are evaluated from the middle out (i.e., presentation-first approach), unconstrained by higher-order disorders or lower-order diagnostic symptoms. This approach provides innovation over previous methods at multiple levels, including the conceptualization of traumatic stress reactions as well as the type of assessments and data sources used and how they are used in statistical analyses. Conceptualizations prioritize the identification of middle-order phenotypes, representing person-centered clinical presentations, which are informed by the integration of multidimensional, transdiagnostic, and multimodal (e.g., psychosocial, physiological) assessments and/or data sources. Integrated data are then analyzed concurrently using person-centered statistical models to identify precise, discrete, and representative health outcomes within broader heterogeneous samples. Subsequent variable-centered analyses are then used to identify culturally sensitive and contextually informed correlates of phenotypes, their clinical utility, and the differential composition within and between broader traumatic stress reactions. Examples from the moral injury literature are used to illustrate practical applications that may increase clinical utility and the accurate representation of health outcomes for diverse individuals and communities.

Life meaning and mental health in post-9/11 veterans: the mediating role of perceived stress

BACKGROUND AND OBJECTIVES

Post-9/11 veterans frequently experience diminished mental health following military service. Life meaning is related to better mental health in veterans, yet its mechanism of action is unknown. A meaning-making model suggests that life meaning can reduce perceived stress, thus enhancing mental health. The present study tested this meaning-making model by predicting multiple dimensions of mental health (i.e., symptoms of posttraumatic stress disorder, anxiety, insomnia, and depression, and mental health quality of life) from life meaning as mediated by perceived stress.

DESIGN AND METHODS

The present study was a secondary analysis of a 12-month observational study of 367 post-9/11 veterans. Participants completed demographic and health surveys at baseline, 6-month, and 12-month follow-ups. A multivariate mediation model was created predicting changes in dimensions of mental health from 6 months to 12 months.

RESULTS

Higher life meaning at baseline predicted changes in all dimensions of mental health between 6 and 12 months, an effect mediated by changes in perceived stress between baseline and 6 months.

CONCLUSIONS

Across dimensions of mental health, the meaning-making model was supported. Understanding post-9/11 veteran mental health from this theoretical perspective may help better tailor healthcare efforts and enhance veteran health overall.

Contribution of risk and resilience factors to anxiety trajectories during the early stages of the COVID-19 pandemic: A longitudinal study

The COVID-19 pandemic, and the response of governments to mitigate the pandemic's spread, resulted in exceptional circumstances that comprised a major global stressor, with broad implications for mental health. We aimed to delineate anxiety trajectories over three time-points in the first 6 months of the pandemic and identify baseline risk and resilience factors that predicted anxiety trajectories. Within weeks of the pandemic onset, we established a website (covid19resilience.org), and enrolled 1362 participants (n = 1064 from US; n = 222 from Israel) who provided longitudinal data between April-September 2020. We used latent growth mixture modelling to identify anxiety trajectories and ran multivariate regression models to compare characteristics between trajectory classes. A four-class model best fit the data, including a resilient trajectory (stable low anxiety) the most common (n = 961, 75.08%), and chronic anxiety (n = 149, 11.64%), recovery (n = 96, 7.50%) and delayed anxiety (n = 74, 5.78%) trajectories. Resilient participants were older, not living alone, with higher income, more education, and reported fewer COVID-19 worries and better sleep quality. Higher resilience factors' scores, specifically greater emotion regulation and lower conflict relationships, also uniquely distinguished the resilient trajectory. Results are consistent with the pre-pandemic resilience literature suggesting that most individuals show stable mental health in the face of stressful events. Findings can inform preventative interventions for improved mental health.

Moral injury and substance use disorders among US combat veterans: results from the 2019-2020 National Health and Resilience in Veterans Study

BACKGROUND

Exposure to potentially morally injurious events (PMIEs) is associated with increased risk for substance use disorders (SUDs), although population-based studies remain limited. The goal of this study was to better understand the relationships between PMIE exposure and lifetime and past-year alcohol use disorder (AUD), drug use disorder (DUD), and SUD.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 1321 combat veterans. Multivariable analyses examined associations between three types of PMIE exposure (perpetration, witnessing, and betrayal), and lifetime and past-year AUD, DUD, and SUD, adjusting for sociodemographic variables, combat exposure severity, prior trauma, and lifetime posttraumatic stress disorder and major depressive disorder.

RESULTS

Perpetration was associated with increased odds of lifetime AUD (OR 1.15; 95% CI 1.01-1.31) and lifetime SUD (OR 1.18; 95% CI 1.03-1.35). Witnessing was associated with greater odds of past-year DUD (OR 1.20; 95% CI 1.04-1.38) and past-year SUD (OR 1.14; 95% CI 1.02-1.28). Betrayal was associated with past-year AUD (OR 1.20; 95% CI 1.03-1.39). A large proportion of the variance in past-year AUD was accounted for by betrayal (38.7%), while witnessing accounted for 25.8% of the variance in past-year DUD.

CONCLUSIONS

Exposure to PMIEs may be a stronger contributor to SUDs among veterans than previously known. These findings highlight the importance of targeted assessment and treatment of moral injury among veterans with SUDs, as well as attending to specific types of morally injurious experiences when conceptualizing and planning care.

Moral injury and chronic pain in veterans

Posttraumatic stress disorder (PTSD) and chronic pain are highly prevalent and co-morbid among veterans. Moral injury (MI), which results from traumatic experiences that conflict with deeply held moral beliefs, is also associated with pain. However, relationships between different types of exposures to potentially morally injurious events (PMIEs) and pain have not yet been investigated. In the current study, we investigated these relationships between exposure to PMIEs (betrayal, witnessing, and perpetration) and different types of pain (joint pain, muscle pain, and overall pain intensity), while controlling for other relevant variables (including PTSD symptoms, combat exposure, adverse childhood experiences, age, gender, and race/ethnicity). We also examined gender differences in these associations. Participants were 11,871 veterans drawn from a nationwide, population-based survey who self-reported exposure to PMIEs, PTSD symptoms, frequency of adverse childhood experiences, combat exposure, sociodemographic information, past six-month joint pain, past six-month muscle pain, and past week overall pain intensity. Population weighted regression models demonstrated that PMIEs were not significantly associated with joint or muscle pain, but that betrayal was associated with past week overall pain intensity, even when controlling for all other variables. Models investigating men and women separately found that for women, betrayal was associated with joint pain and pain intensity, but for men, betrayal was not associated with any pain outcome. These findings suggest that it may be especially important to assess betrayal when treating patients with a history of trauma and chronic pain.

Research Gaps and Recommendations to Guide Research on Assessment, Prevention, and Treatment of Moral Injury Among Healthcare Workers

Healthcare workers face numerous occupational stressors, including some that may challenge personal and shared morals and values. This is particularly true during disasters and crises such as the COVID-19 pandemic, which require critical decisions to be made with little time and information often under personal distress and situational constraints. Consequently, healthcare workers are at risk for moral injuries characterized by stress-related and functional impacts. Although research on the evaluation and treatment of moral injury among military veterans burgeoned in the recent decade, addressing moral injury in healthcare workers and other civilians remains an important gap. In this perspective piece, we identify research gaps and make recommendations to advance future work on assessment, prevention, and treatment of moral injury in healthcare workers. We draw on empirical studies of moral injury in veterans, limited studies of moral injury in health professionals, and our clinical experiences with healthcare workers affected by moral injury.

Initial development of perpetrator confrontation using deepfake technology in victims with sexual violence-related PTSD and moral injury

BACKGROUND

Interventions aimed at easing negative moral (social) emotions and restoring social bonds - such as amend-making and forgiving-have a prominent role in the treatment of moral injury. As real-life contact between persons involved in prior morally injurious situations is not always possible or desirable, virtual reality may offer opportunities for such interventions in a safe and focused way.

OBJECTIVE

To explore the effects of the use of deepfake technology in the treatment of patients suffering from PTSD and moral injury as a result of being forced by persons in authority to undergo and commit sexual violence (so-called betrayal trauma).

METHODS

Two women who had experienced sexual violence underwent one session of confrontation with the perpetrator using deepfake technology. The women could talk via ZOOM with the perpetrator, whose picture was converted in moving images using deepfake technology. A therapist answered the questions of the women in the role of the perpetrator. Outcome measures were positive and negative emotions, dominance in relation to perpetrator, self-blame, self-forgiveness, and PTSD-symptom severity.

RESULTS

Both participants were positive about the intervention. Although they knew it was fake, the deepfaked perpetrator seemed very real to them. They both reported more positive and less negative emotions, dominance in relation to the perpetrator and self-forgiveness, and less self-blame and PTSD-symptoms after the intervention.

CONCLUSION

Victim-perpetrator confrontation using deepfake technology is a promising intervention to influence moral injury-related symptoms in victims of sexual violence. Deepfake technology may also show promise in simulating other interactions between persons involved in morally injurious events.

A longitudinal analysis of the role of potentially morally injurious events on COVID-19-related psychosocial functioning among healthcare providers

Medical leaders have warned of the potential public health burden of a "parallel pandemic" faced by healthcare workers during the COVID-19 pandemic. These individuals may have experienced scenarios in which their moral code was violated resulting in potentially morally injurious events (PMIEs). In the present study, hierarchical linear modeling was utilized to examine the role of PMIEs on COVID-19 pandemic-related difficulties in psychosocial functioning among 211 healthcare providers (83% female, 89% White, and an average of 11.30 years in their healthcare profession [9.31]) over a 10-month span (May 2020 -March 2021). Reported exposure to PMIEs was associated with statistically significant poorer self-reported psychosocial functioning at baseline and over the course of 10-months of data collection. Within exploratory examinations of PMIE type, perceptions of transgressions by self or others (e.g., "I acted in ways that violated my own moral code or values"), but not perceived betrayal (e.g., "I feel betrayed by leaders who I once trusted"), was associated with poorer COVID-19 related psychosocial functioning (e.g., feeling connected to others, relationship with spouse or partner). Findings from this study speak to the importance of investing in intervention and prevention efforts to mitigate the consequences of exposure to PMIEs among healthcare providers. Interventions for healthcare providers targeting psychosocial functioning in the context of moral injury is an important area for future research.

COVID-19 related moral injury: Associations with pandemic-related perceived threat and risky and protective behaviors

BACKGROUND

The coronavirus-2019 (COVID-19) pandemic is associated with increased potential for morally injurious events, during which individuals may experience, witness, or learn about situations that violate deeply held moral beliefs. However, it is unknown how pandemic risk and resilience factors are associated with COVID-related moral injury.

METHODS

Individuals residing in the U.S. (N = 839; M_age = 37.09, SD = 11.06; 78% women; 63% White; 33% PTSD) participating in an online survey reported on COVID-19 related moral injury (modified Moral Injury Events Scale), perceived current and future threat of pandemic on life domains (social, financial, health), and COVID-19 risky and protective behaviors. Multivariate linear regressions examined associations of perceived threat and risky and protective behaviors on type of COVID-19 related moral injury (betrayal, transgression by others, self).

RESULTS

Participants endorsed MI betrayal (57%, N = 482), transgression by other (59%, N = 497), and by self 17% (N = 145). Adjusting for sociodemographics, only future threat of COVID-19 to health was significantly associated with betrayal (B = 0.21, p = .001) and transgression by other (B = 0.16, p = .01), but not by self. In contrast, high frequency of risky behaviors was associated with transgressions by self (B = 0.23, p < .001). Sensitivity analyses showed PTSD did not moderate the observed effects.

CONCLUSIONS

Betrayal and transgression by others was associated with greater perceived future threat of COVID-19 to health, but not financial or social domains. Stronger endorsement of transgression by self was associated with more frequently engaging in risky behaviors for contracting COVID-19. These findings may suggest the need for individual, community, and system level interventions to address COVID-19 related moral injury.

Prevalence and Determinants of Immediate and Long-Term PTSD Consequences of Coronavirus-Related (CoV-1 and CoV-2) Pandemics among Healthcare Professionals: A Systematic Review and Meta-Analysis

Background: The COVID-19 pandemic continues to rise. In order to control the COVID-19 pandemic, healthcare professionals have been subjected to increased exposure to work stress. In this systematic review, we aimed at investigating the prevalence and determinants of immediate and long-term post-traumatic stress disorder (PTSD) effects on healthcare professionals by the COVID-19 (SARS CoV-2) and SARS-2003 (SARS CoV-1) pandemics. Methods: This systematic review was conducted according to the recommendations of the Protocols for Systemic Review and Meta-Analysis (PRISMA) statement. Only studies reporting the prevalence of PTSD (frequency, percentage) and related risk factors (adjusted odds ratio (OR)) in healthcare professionals (HCPs) during the SARS CoV-2 and SARS CoV-1 pandemics were included. The following databases were screened: Medline, Embase, PsychINFO, and Health Psychosocial Instrument (HaPI). Results: Six of eight studies reported PTSD symptoms among healthcare professionals during the COVID-19 pandemic in China (three), Singapore (one), India (one), and the United States of America (USA) (two), while two studies reported symptoms during the SARS-2003 pandemic in China (one) and Singapore (one). Sample sizes ranged from 263 to 5062 with a combined total of 10,074 participants. All of the studies self-reported the level of exposure to coronaviruses (CoV-1 and CoV-2) and severity of PTSD. Seven studies reported the prevalence of immediate PTSD and determinants, while one study reported delayed-onset PTSD (3 years after CoV-1 pandemic). Determinants of immediate PTSD were reported for the CoV-2 pandemic, while those for long-term PTSD were reported for the CoV-1 pandemic. Conclusions: A comprehensive understanding of the prevalence and determinants of immediate or long-term pandemic PTSD for healthcare workers can improve prevention, diagnosis, and management. Rigorous research measuring the prevalence of PTSD and its associated risk factors (adjusted OR) for the CoV-2 pandemic are envisaged. Although strategies to resolve immediate PTSD are key, long-term PTSD must not be overlooked.