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. 2023 Jul 24;36(5):555–566. doi: 10.1080/08995605.2023.2235256

War trauma impacts in Ukrainian combat and civilian populations: Moral injury and associated mental health symptoms

Larysa Zasiekina a,b,✉, Tamara Duchyminska c, Antonia Bifulco d, Giacomo Bignardi b
PMCID: PMC11407378  PMID: 37486615

ABSTRACT

This is the first study to compare active-duty soldiers and student civilian samples during the first three months of the Ukrainian-Russian war in relation to moral injury and its association with PTSD, anxiety and depression. A total of 350 participants, including 191 active-duty soldiers of the Ukrainian Armed Force (UAF), who were on the frontline during the full-scale invasion of Russian troops in February 2022, and 159 students from different HEIs in Volyn oblast, were recruited into the study through their attendance at the Ukrainian Psychotrauma Center. Prior to the in-person group-intervention program of psychosocial support for military and civil populations at the Ukrainian Psychotrauma Center, moral injury, PTSD, depression, and anxiety were assessed. Results showed significantly higher moral injury, PTSD, depression, and anxiety scores in civilian students, with a two-way ANOVA indicating a significant impact of female gender in civilians only. A hierarchical regression indicated that moral injury is a predictor of PTSD symptoms in both active-duty and civilian student groups. However, previous family trauma of genocide is associated with PTSD symptoms in active soldiers only. The findings of the current study could contribute insights for clinical practice for combatants and civilians during the current war.

KEYWORDS: Moral injury, PTSD, mental health symptoms, active-duty soldiers, civilians

What is the public significance of this article?—This article confirms the association between moral injury and PTSD, together with anxiety and depression in an ongoing war setting. Moral injury is defined as an emotional response to personal actions or witnessing others’ actions that go against moral values and moral beliefs. Violation of moral values and moral beliefs leads to emotions of shame, guilt, anger and disgust and damage of core beliefs aligned with self-blame, disappointment of authority, loss of religious faith and trust in others. It is usually studied in war combatants or veterans only but has more recently been extended to civilians (Eikenaar, 2022; Molendijk, 2022). This study examined moral injury in active combatants (191 service members of the Ukrainian Armed Force (UAF), who were on the front line during the 2022 full-scale invasion of Russian troops), and 159 civilians, students from different HEIs in Volyn oblast. All were recruited into the study by the Ukrainian Psychotrauma Center (UPC), where they were assessed by questionnaire prior to voluntary participation in an intervention program of psychosocial support following emotional distress. The participants of the program attend the UPC on a voluntary basis during March-May, 2022.

This is the first study to compare active-duty soldiers and civilian samples during the first three months of the Ukrainian-Russian war in relation to moral injury and its association with PTSD, anxiety, and depression. The study highlighted the increased risk of moral injury, PTSD symptoms, depression, and anxiety for civilians, especially females. The results also indicated that moral injury is a robust predictor of PTSD symptoms in both active-duty military and civilian groups with previous family trauma of genocide additionally predicting PTSD symptoms in active-duty combatants only. The findings of this study have implications for future psychological practice indicating that moral injury is a potential consequence of war trauma not only in combatants but also civilians exposed to atrocities, and that family history of genocide is a critical element of PTSD in combatants. Thus, both moral injury and family genocide history need to be examined in relation to in tailored trauma-focused therapies.

Introduction

Military conflict, warfare and persecution involve trauma exposure, which leads to significant psychological disorder both in combatants and civilians in war zones. Among the psychological consequences of war, increase in rates of PTSD, anxiety and depression are the most significant (Murthy & Lakshminarayana, 2006; Musisi & Kinyanda, 2020). Previous research has established that the prevalence of PTSD and associated emotional disorder is around 12% in combat soldiers and 10% in civilians, with another 10% having problems with physical and social functioning during the war and postwar period (Hines et al., 2014; World Health Organization [WHO], 2003). Recent findings on the psychological effects of the war on emotional distress pay particular attention to gender differences, namely higher anxiety in women compared to men and higher alexithymia levels in men compared to women in the military population in Ukraine (Chaban et al., 2018); different symptoms of PTSD, including more distress from traumatic triggers in female combatants and nightmares, emotional numbing, and hypervigilance in male combatants (King et al., 2013). Evidence consistently shows that higher rates of PTSD in civilian females compared to civilian males may be aligned with social gender roles, gender norms and women-specific traumas, including sexual traumas (Ainamani et al., 2020; Kellezi & Reicher, 2014). Additionally, children and adolescents, the elderly and the disabled have high rates of emotional distress amongst civilians (Betancourt et al., 2020; Bürgin et al., 2022; Murthy & Lakshminarayana, 2006).

Russia’s full-scale invasion of Ukraine, which started in February 2022, has created continuous traumatic stress, threat, and uncertainty in Ukraine and globally at an alarming pace. This invasion is considered the largest attack by one state against another in Europe since World War II and confirms the worst fears of the West for war escalation. The invasion of Ukraine has had detrimental psychological impacts of war exposure not only on the combat population, but also on civilians, disrupting most domains of daily life and threatening the survival of the self, close others and the community (Shevlin et al., 2022). The rapid deployment of many civilians into their new combat roles with little or no training makes them increasingly vulnerable to military trauma and serves as a risk factor for developing mental health symptoms in active-duty soldiers (Bryant et al., 2022). The civilian population has also endured repeated displacements since Russia’s first invasion of Ukraine in 2014 with bombing and continuous rocket sirens over all of Ukraine resulting in elevated trauma exposure and risk for PTSD and associated symptoms. Recent findings based on parents’ reports in Ukraine indicate that 18.5% of pre-schoolers and 14.2% of school-age children met DSM-5 criteria for PTSD. Among the main risk factors for PTSD in these age groups are parents’ employment in the emergency services or the army, neurodevelopmental delay in a child or parental negative mental health (Martsenkovskyi et al., 2022).

This war has seen exposure to traumatic events involving moral pain due to high civilian casualties and indiscriminate bombing of residential areas, schools, and hospitals. The psychological effects indicate a negative impact on moral sentiments, with emotions of anger, shame, guilt, and disgust in both military and civilian populations (Cricenti et al., 2022). These emotions are aligned with the moral suffering of Ukrainians, involving self-blame, disappointment in authority, loss of religious faith and loss of trust in others (Zasiekina et al., 2022). The emotional distress arising from the discrepancy between high moral beliefs held and forced low moral behavior is defined as moral injury, which has become one of the key constructs in assessment and treatment of PTSD related to military trauma (Koenig et al., 2020; Litz et al., 2009).

In the context of Ukrainian history, a number of studies have connected the moral emotions of shame, guilt, anger and disgust to the transgenerational transmission of family trauma of genocide, namely the Holodomor (1932–1933) and the Holocaust atrocities which occurred in the territory of the Soviet Ukraine (Gorbunova & Klymchuk, 2020; Kis, 2020; Zasiekina et al., 2021). Data from several studies indicate increased rates of anger and disgust in Holodomor and Holocaust survivors’ offspring. Additionally, they show a predisposition to PTSD in Holodomor and Holocaust survivors’ direct descendants in the face of continuous traumatic stress exposure (Bar-On et al., 1998; Braga et al., 2012). Therefore, collective trauma impacts of genocide may serve as a risk factor for moral injury and associated mental health symptoms during war.

In recent years, there has been an increasing interest from researchers, mental health professionals and policymakers in the concept of moral injury. Ames et al. (2019) define it as a complex phenomenon characterized by spiritual, psychological and moral distress in relation to morally repugnant events. The existing body of research on moral injury highlights its association with emotional distress among military personnel with negative impact on mental health and well-being (Farnsworth et al., 2014; Terpou et al., 2022). Recently, investigators have also examined the effects of moral injury on mental health in frontline workers including service members, police officers, healthcare workers and humanitarian aid professionals (Eikenaar, 2022; Molendijk, 2022). However, the specifics of moral injury and its impact on civilians compared to active-duty soldiers during wartime is understudied. Pilot data reveals that moral injury is associated with trauma exposure, suicide behaviors, PTSD and depression in civilians (Fani et al., 2021). These findings indicate a need to understand further the various mechanisms of developing moral injury and associated mental health symptoms in active-duty soldiers compared to civilians during the current war.

Therefore, this study aims to extend our understanding of moral injury and associated mental health symptoms in civilian and combat population during the current war in Ukraine.

This study was initiated as part of the project “Moral Injury and Healing of Combatants: Neuropsychological Correlates and Psychological Interventions,” supported by the Ukrainian Ministry of Education and Sciences during March-May, 2022. Health services are being provided to military and civilian populations by the Ukrainian Psychotrauma Center (UPC) in Lutsk, Ukraine, which gave clinicians and researchers in Ukraine the opportunity to gain an in-depth understanding of moral injury and associated mental health symptoms during military conflict to develop approaches to help mitigate negative psychological consequences of the war.

Method

Sample

In total, 379 participants expressed interest in participating in the research. Of these, 17 did not continue beyond the consent form. A further 12 did not respond to the background variable items. As a result, 350 participants, including 191 service members of the Ukrainian Armed Force (UAF), who were on the frontline during full-scale invasion by Russian troops, and 159 students from different HEIs in Volyn oblast were recruited into the study by the UPC. Participants had all voluntarily enrolled in an in-person group-intervention program of psychosocial support for military and civilian populations due to emotional distress experienced. The program of psychosocial support was based on Spiritually Oriented Cognitive Processing Therapy for moral injury, outlined by Koenig et al. (2017).

The program of psychosocial support covered eight topics related to moral injury (Introduction to Moral Injury; Meaning of the Event; Values and Meaningful Life; Forgiveness and Trust; Compassion, Fatigue and Satisfaction; Trauma and Resilience; Self-worthiness and Significant Others; Post-Traumatic Growth), and included psychoeducation, open discussions, and group exercises. The programs of psychosocial support for the service members and students were slightly different, in the session “Trauma and Resilience” specific war-related paradoxical ethical situations (political ideas vs actual experience, professional roles vs organizational procedure, myth of war vs reality of war, religious belief vs military values, order vs chaos, dead vs alive) have been discussed. The same session with students included only some of these situations, namely political ideas vs actual experience, professional roles vs organizational procedure, order vs chaos.

The programme was made available on a voluntary basis to both service personnel of the UAF and to civilians, (all of whom were students), who had reported emotional distress and moral suffering due to war-related trauma. These groups were targeted by the service because of having specific psychological risk in relation to the ongoing military conflict. Service personnel because of their direct contact with the fighting, high exposure to trauma events and those potentially morally injurious. Civilian students because first, as young adults with less life experience they were estimated to have fewer personal and coping resources on which to draw and second because disorder in early life is more likely to repeat so the intervention could have lifetime positive impact. Both groups participated in the weekly program that took place every Wednesday for students and every Saturday for service members of the UAF during April–May 2022. The participation of the service members of the UAF was promoted by the Commander’s Support Staff of the military units. The participation of the students was promoted by the Student Psychological and Counseling Services Unions at the HEIs.

Participant demographic data is presented in Table 1. It can be seen that the civilians were younger (average age 23.4 vs 34.5 years), more likely to be female (67.9% vs 15.7%), less likely to have children (19.5% vs 64.9%) and more likely to have a family history of genocide (20% vs 12.6%) compared to combatants. Of the 159 civilian students, 11.3% (N = 18) were refugees during the first month of the war and then returned in Ukraine, of whom 55.6% (N = 10) were displaced to Poland, 27.8% (N = 5) to Germany and 16.6% (N = 3) were internally displaced persons from the Eastern part of Ukraine. The remainder had not left Ukraine (N = 141) during the conflict. In terms of trauma exposure, of the civilians most, 69.2% (N = 110), witnessed trauma to others, 17.0% (N = 27) were exposed to direct trauma and 13.8% (N = 22) experienced the demolition of property. Among the service personnel, 41.9% (N = 80) of the participants were from the Air Force, 47.6% (N = 91) were from the Army National Guard and 10.5% (N = 20) were from mechanized infantry. All military participants had been active-duty combatants since the first days of the invasion of Ukraine, and all had direct combat exposure.

Table 1.

Demographic data for the active-duty soldiers (n = 191), and civilian (n = 159) groups.

  Active-duty soldiers
 Civilians
  Mean (SD) Range Mean (SD) Range
Age (mean/SD) 34.53 (9.05)   23.47 (8.49)  
Age range 18–56   17–50  
Gender (female/male) 30/161 15.7/84.3% 108/51 67.9/32.1%
Marital status        
 Single 63 45.6 91 57.2
 Married 128 54.4 68 42.8
Children        
 With children 124 64.9 31 19.5
 Without children 67 35.1 125 78.6
Oblast of military service        
 Rivne 86 45.0 5 3.1
 Volyn 100 52.4 145 91.2
 Lviv 4 2.1 9 2.5
 Khmelnytskyi 1 0.5 0 21.6
Occupational field        
Air Force 80 41.9 - -
Mechanized infantry 20 10.5 - -
The Army National 91 47.6 - -
Guard        
Previous family psychotrauma        
 Yes 24 12.6 32 20.1
 No 167 87.4 127 79.9
Displaced     18 11.3
Yes - - 141 88.7
No - -    
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The study was reviewed and approved by the Research Ethics Committee (#03-24/04/1070) at Lesya Ukrainka Volyn National University.

The following set of research questions were formulated:

(RQ1) Are there significant differences in moral injury, PTSD, depression and anxiety symptoms between active-duty soldiers and civilian student groups?

(RQ2) Are there gender effects in the two groups (active-soldiers and civilian students) in relation to moral injury and associated mental health symptoms?

(RQ3) Is a family history of genocide associated with moral injury, PTSD, depression and anxiety?_

(RQ4) Is moral injury a predictor of PTSD in both groups?

Procedure

The research aims were explained to participants who were provided with information sheets and signed informed consent. Participants were asked to complete the set of questionnaires described below. These survey instruments were part of their assessment and screening during the intervention program of psychosocial support for civilian and military population at the UPC during war time. (To date only student civilians had participated).

The Moral Injury Symptoms Scale (MISS-M-SF) assesses betrayal, guilt, shame, moral concerns, loss of trust, loss of meaning, difficulty forgiving, self-condemnation, religious struggle, and loss of religious/spiritual faith. Cronbach’s alpha is 0.73 (95% CI 0.69–0.76), and test–retest reliability is 0.87 (Koenig et al., 2018). The Ukrainian version of the MISS-M-SF scale was culturally adapted by Zasiekina and Kozihora (2022) and demonstrates sound psychometric properties. The procedure for adapting this version of MISS-M-SF, for both military and civilian populations was similar to the procedure for designing the civilian version of MIES as advised by Fani et al. (2021). The following change in MISS-M-SF was applied to the original items: From item 7: I have forgiven myself for what happened to me or others during combat to item 7: I have forgiven myself for what happened to me or others in war. Reliability was assessed through internal consistency using Cronbach’s α = .70 (n = 111), and the test–retest reliability after 8 days, r = .67, p ≤ .01 (n = 32). The study assessed the discriminant validity of MISS-M-SF first through its association with PCL-5, which is r = .36 p ≤ .05 and second through its association with GAD-7, which is r = .37, p ≤ .05. Convergent validity is indicated by the correlation of MISS-M-SF and other measures of emotional distress, namely PQH (r = .53 p ≤ .01; Zasiekina & Kozihora, 2022).

The PTSD Checklist for DSM‐5 (PCL‐5) is a 20‐item self‐report measure to assess PTSD symptoms experienced during the last month in accordance with DSM‐5 criteria. The active-duty soldiers and civilians use the military and civilian forms of PCL-5, respectively. Participants were instructed to complete the PCL‐5 considering the most stressful life event in their military/war experience. Items were rated on a 5‐point scale, ranging from 0 = Not at all to 4 = Extremely, and summed for a total symptom severity score. Internal consistency of PCL‐5 is α = .97. The Ukrainian version of the PCL-5 questionnaire conducted on a large sample (n = 2203) of internally displaced Ukrainians in 2016 showed very high reliability of the total scale (α = 0.96) and subscales (Shevlin et al., 2018).

The 9-item Patient Health Questionnaire (PHQ-9) and 7-item Generalized Anxiety Disorder (GAD-7) were used to measure depression and anxiety symptoms, respectively. These two instruments are short screening measures often utilized to assess comorbidities of MI. Each item on these measures is rated on 4-point Likert scale (from 0 to 3) indicating how often each symptom has occurred within the past 2 weeks. Total scores range from 0 to 54 for PHQ-9 and 0–42 for GAD-7, with higher scores indicating more severe symptoms. PHQ-9 demonstrates strong internal consistency using Cronbach’s α = .70 and test–retest reliability is 0.83 (Kroenke et al., 2001). The internal consistency of the GAD is 0.92.

We applied a cross-sectional, between-subjects design utilizing a univariate two-way ANOVA to establish whether there is an interaction between independent group variables (active-soldiers and civilian student groups) and gender on the dependent variables (moral injury, PTSD, anxiety and depression). Hierarchical multiple regression analysis is used to specify the effects of gender and family trauma of genocide (the first step), and moral injury (the second step) as certain predictors of PTSD symptoms in the two groups. The PROCESS macro for SPSS examines potential differences between the two groups in the strengths of the associations between each of the predictors and PTSD symptoms as an interaction effect.

Results

Research question 1

Univariate two-way ANOVAs (one for each of the four dependent variables) were applied to determine whether the effect of group (civilian student vs miliary) on moral injury, PTSD symptoms, depression, and anxiety influenced by gender. For PTSD symptoms (F = 45.4, df = 1, p < .001, ηp2 = .116) and depression (F = 58.3, df = 1, p < .001, ηp2 = .144), there was a medium to large effect size of group. While still significant, anxiety (F = 17.9, df = 1, p < .001, ηp2 = .04) and moral injury (F = 16.08, df = 1, p < .001, ηp2 = .044) showed smaller effects. Thus, the prevalence of moral injury, PTSD, anxiety, and depression was significantly higher in the civilian student group after controlling for the effect of gender.

Research question 2

For PTSD, there was a significant interaction between group and gender (F = 10.5, df = 1, p = .001, ηp2 = .029) (see Figure 1). The effect of group (civilian student vs military) was larger in females (Mean difference = 17.16, 95% CI [11.82, 22.50]) than males (Mean difference = 6.01, 95% CI [1.86, 10.17]) (see Table 2). For depression, there was a significant interaction between group and gender (F = 9.08, df = 1, p = .003, ηp2 = .026) (see Figure 2). The effect of group (civilian student vs military) was larger in females (Mean difference = 6.49, 95% CI [4.60, 8.38]) than males (Mean difference = 2.82, 95% CI [1.35, 4.29]) (see Table 3). For anxiety, there was a significant interaction between group and gender (F = 4.17, df = 1, p = .042, ηp2 = .012) (see Figure 3). The effect of group (civilian student vs military) was larger in females (Mean difference = 3.01, 95% CI [1.52, 4.50]) than males (Mean difference = 1.05, 95% CI [−.11, 2.21]) (see Table 4). For moral injury, there was no significant interaction between group and gender (F = .234, df = 1, p = .63, ηp2 = .001) (see Figure 4). The effect of group (civilian student vs military) was similar in females (Mean difference = 5.84, 95% CI [.699, 10.97]) and males (Mean difference = 7.44, 95% CI [3.44, 11.44]) (see Table 5).

Figure 1.

Figure 1.

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The effect of group (civilian vs military) on PTSD symptoms in males and females.

Table 2.

Descriptive statistics for variable PCL-5.

Group Gender Mean Std Deviation N
Military Males 11.38 1.04 161
  Female 13.27 2.40 30
Civilians Males 17.39 1.84 51
  Females 30.43 1.27 108
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PCL-5 = PTSD symptoms.

Figure 2.

Figure 2.

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The effect of group (civilian vs military) on depression in males and females.

Table 3.

Descriptive statistics for variable PHQ-9.

Group Gender Mean Std Deviation N
Military Males 3.16 3.90 161
  Female 3.67 4.21 30
Civilians Males 5.98 4.33 51
  Females 10.15 5.82 108
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PHQ-9 = Depression.

Figure 3.

Figure 3.

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The effect of group (civilian vs military) military experience on anxiety in males and females.

Note. Error bars show the 95% confidence interval.

Table 4.

Descriptive statistics for variable GAD-7.

Group Gender Mean Std Deviation N
Military Males 3.85 3.18 161
  Female 5.00 1.00 30
Civilians Males 4.90 3.56 51
  Females 8.01 4.73 108
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GAD-7 = Anxiety.

Figure 4.

Figure 4.

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The effect of group (civilian vs military) on moral injury in males and females.

Table 5.

Descriptive statistics for variable MISS-M-SF.

Group Gender Mean Std Deviation N
Military Males 34.70 12.06 161
  Female 27.10 10.19 30
Civilians Males 42.14 12.72 51
  Females 32.94 14.02 108
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MISS-M-SF = Moral injury.

Research question 3

There was no significant difference in rates of moral injury in the groups with or without previous family genocide trauma. However, those with previous family genocide trauma demonstrated significantly higher rates of PTSD, depression, and anxiety (see Table 6).

Table 6.

The independent samples two-tailed t-test results comparing moral injury, PTSD, and associated mental health symptoms in participants with (n = 56) and without (n = 294) family history of genocide.

  With family trauma of genocide
 Without family trauma of genocide
      
  M SD M SD t-test p df
PCL-5 24.95 15.43 17.16 15.31 −1.121 <.001 348
PHQ-9 7.50 5.62 5.45 5.49 −3.156 .007 348
GAD-7 6.50 4.53 5.17 3.95 −2.489 .022 348
MISS-M-SF 36.39 13.24 34.24 12.59 −2.247 .125 348
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MISS-M-SF = Moral injury, PCL-5 = PTSD symptoms, PHQ-9 = Depression, GAD-7 = Anxiety.

Research question 4

The results of hierarchical multiple regression for each group (see Table 7) showed some differences in predicting PTSD. Previous family history of genocide was significantly associated with PTSD in the military group only (β = .27, p  < .01). In contrast, gender was a significant predictor of PTSD in the civilian student group only (β = .40, p  < .00). Moral injury was included in the second step and added a significant amount to the explained variance (16.5% and 7.2% among military and civilian students respectively). Moral injury was significantly and positively associated with PTSD in both groups: the greater moral injury score, the higher PTSD score (β = .44, p  < .001 and β = .29, p  < .001 for military and civilian student samples, respectively). The changes in R2 are 16.5% and 7.2.% among military and civilian students, respectively.

Table 7.

Hierarchical regression analyses for variables predicting PTSD among active-duty soldiers and civilians.

  Active-duty soldiers
 Civilians
Predictor B B 95% CI [LL, UPL] β B B 95% CI [LL, UPL] β
Step1: demographics            
Gender 1.43 [−2.961, 5.811] .046 13.933 [8.601,
19.265]		 .404**
Age .12 [−.061, .291] .092 .166 [−.128,.460] .087
Previous family trauma 7.78 [2.975, 12.575] .227** 2.232 [−3.638,
8.102]		 .056
R2 .063       .153  
∆R2 .063       .153  
F 4.202**       9.303***  
Step 2: Moral Injury .414 [.284, .544] .440*** .329 [.157, .500] .290***
R2 .228   .225    
∆R2 .165   .072    
F 39.647***   14.287***    
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*p < .05, **p < .01, ***p < .001.

We tested to see if the effect of each predictor on PTSD differs between the military and civilian student groups. We ran a new model combining both groups, and using the PROCESS macro for SPSS, we tested interaction effects between each predictor and group membership (civilian student vs military; Hayes & Rockwood, 2017). Each potential interaction effect was tested separately, while all the other three variables were entered into the regressions analyses as covariates. The analyses revealed only two significant interaction effects (p  < .001), which explained .362 and .381 of PTSD variance over and above the main effects and the control variables. While moral injury was positively associated with PTSD in both the civilian student (B = 0.24, SE[B] = .07, p < .001) and military participants (B = .44, SE[B] = .08, p < .001), gender was significantly positively associated with PTSD (B = 16.59, SE[B] = 2.19, p < .001) only among the civilian student participants.

Discussion

The full-scale Russian invasion of Ukraine introduced trauma exposure to Ukrainian civilians and active-duty military service members on a large scale. Since there are specific war-related paradoxical ethical situations (political ideas vs actual experience, professional roles vs organizational procedure, myth of war vs reality of war, religious belief vs military values, order vs chaos, dead vs alive), behavior in these situations might cause violation of individual moral values and principles and lead to moral injury (Fleming, 2021). This study is a preliminary effort to examine moral injury and associated mental health symptoms in civilian student and active-duty combat population during the war in Ukraine. This study was unique given its activation during the ongoing military conflict where both civilians and active-duty soldiers are potentially exposed to traumatic events aligned with war trauma including atrocities.

The first research question was whether there were any differences in moral injury and associated mental health symptoms between civilian student and military combatants. Our findings showed that the prevalence of moral injury, PTSD, anxiety, and depression was higher in the civilian student group after controlling for the effect of gender. These findings are partially in line with recent study, which demonstrates that there is significantly higher prevalence of depression and anxiety in civilians compared to military troops but no significant difference between groups with respect to post-traumatic stress (Lim et al., 2022). The high prevalence of PTSD symptoms in civilian students in the current study can be interpreted in several ways. First, emotional distress of the COVID-19 pandemic 2020–2021 and the Russian-Ukrainian war in February 2022 created restrictions and continuous traumatic stress that affected the general population’s mental health in terms of continuous life threat (Pat‐Horenczyk et al., 2022). The young adults in Ukraine, who constitute the civilian sample in our research, experienced behavioral, emotional, and attentional difficulties during the forced social isolation which may have had greater impact than for the older combatant group. Another potential interpretation for the higher prevalence of PTSD among civilian students in our study is that, compared to military service members, they may have had lower formal psychological preparedness for the Russian invasion. Many Ukrainians have tight family and professional connections with Russia since both countries are post-Soviet states. Many military service members will have developed a sound sense of unit cohesion as military-serving personnel, which might be a protective factor for combatants (Bryant et al., 2022). Finally, many civilians now in the west of Ukraine, where the current research was conducted, are internally displaced people, first displaced during the first Russian invasion in 2014 and second displaced again during the full-scale invasion in 2022. Recent findings show that those internally displaced have a higher prevalence of PTSD compared to urban-dwelling people non-displaced in the east of Ukraine (Johnson et al., 2021). The unexpected result of our research is that there are higher rates of moral injury reported in civilian students compared to active-duty combatants. A possible explanation for this might be that specific war-related ethical situations for civilians, aligned with displacement, life threat, threats to religious faith, and distrust can evoke moral sufferings of a different quality from military personnel. Such interpretations need further investigation. A possible explanation is that the civilian students compared to military personnel experience feelings of guilt and shame for having a more passive role during the conflict and feelings of not contributing enough under continuous traumatic stress. Whilst exposed to trauma, the military personnel may develop a greater sense of mission and directed action to alleviate such emotions. Fani et al. (2021) argue that after traumatic events civilians might experience emotional distress, which is phenomenologically quite different from PTSD, namely loss of purpose/meaning, sense of betrayal, difficulties forgiving self or others. Interestingly, the majority of the civilian student participants in our study had indirect exposure to war-related traumas, which might have a bearing on such moral sufferings.

The second research question was whether there are gender effects in the two groups (civilian student vs military) in relation to moral injury and associated mental health symptoms. PTSD, anxiety and depression were higher in females compared to males, only in the civilian student group. Our findings are in line with other studies which investigate a wider range of civilian experience. Evidence consistently suggests that there is an increase in the incidence and prevalence of clinical disorder in civilian women compared to men during war (Murthy & Lakshminarayana, 2006). Additionally, there are specific war trauma exposures for women, namely sexual assault, and abandoning children or elderly parents, which might violate cultural norms around women-specific responsibility (Bifulco, 2021; Kis, 2020; Zasiekina et al., 2021). Kellezi and Reicher (2014) point out that men who were injured in fighting the enemy feel pride and support, whereas sexually assaulted women feel shame and rejection by the community. It may be that women combatants were relatively protected by feeling pride and support of their fighting role.

There was no significant difference between females and males in the active-duty military population studied. Our findings are in line with the results of Kelber et al. (2021) suggesting that combat females may be no more vulnerable to PTSD compared to combat males. Whereas there is a higher incidence and prevalence of PTSD in women combatants, the persistence of PTSD diagnosis is more pronounced in men. More to the point, Kelber et al. (2021) ague that a higher incidence and prevalence of PTSD in women is aligned with other types of trauma than with combat exposure per se. However, the study findings do not support previous research, which indicates a higher prevalence of anxiety in female active-duty combatants in Ukraine (Chaban et al., 2018). This inconsistency may be due to the stage and location of fighting – the aforementioned study was conducted in Donetsk and Lugansk regions of Ukraine in hospitals near the zone of active combat operations (ATO zone) during the first Russian invasion of Ukraine (2014–2018), whereas the current research was conducted much later, in March-May, 2022 in Western Ukraine. Therefore, it could be argued that by 2022 both female and male combatants were more professionally and psychologically prepared for war exposure than before. It may also relate to the wider world support provided for the current war following full-scale invasion, which may have had positive impact on both male and female combatants for participating in the war hostilities in this latest phase.

The third research question was whether there were any differences in moral injury and associated mental health symptoms between individuals with and without family history of genocide (the Holodomor and the Holocaust). The results suggested there were no significant differences in the prevalence of moral injury in these groups, but the group with previous family history of genocide demonstrated significantly higher rates of PTSD, depression, and anxiety. This accords with other studies, which showed that Holocaust and the Holodomor survivors’ offspring show higher vulnerability to stress and higher predisposition to PTSD, especially in the situations of continuous threat (Dashorst et al., 2019; Gorbunova & Klymchuk, 2020; Kis, 2020; Zasiekina et al., 2021). The results showing moral injury in the groups with and without previous family history of genocide may also be in line with our earlier observations. They showed that, Holodomor offspring do not express emotions of guilt and shame; however, they do experience outrage toward perpetrators (Zasiekina et al., 2021). Since outrage is a moral emotion, (including moral feelings of anger and betrayal) not explicitly assessed by MISS-M-SF, it is outside the scope of this study. Therefore, further research is needed to explore the family history of genocide and its consequences in terms of moral injury during further trauma experience.

Results of the regression analysis emphasize the relationships between moral injury and PTSD. We found that, after controlling for background variables, moral injury is highly related to PTSD symptoms and explained a significant amount of its variance. Furthermore, these associations were similar in the two groups. Our findings are in accord with a large number of previous studies indicating that moral injury and PTSD often co-occur yet are different concepts (Currier et al., 2021; Levi-Belz et al., 2020; Nichter et al., 2021). Although moral injury is not represented in DSM-5, experience of morally injurious events is one of the most important factors that cause PTSD in military personnel (Koenig et al., 2020). One unanticipated finding of this analysis, however, was that while gender was associated with PTSD symptoms in the civilian student group, previous family history of genocide was associated with PTSD symptoms only in active-duty soldiers. This might be explained by the research finding that Holocaust survivor offspring show heightened vulnerability for stress, only in the face of actual danger (Dashorst et al., 2019). Considering the great number of traumatic situations on the frontline of the Ukrainian-Russian war, the active-duty solders might have been more engaged in war-related morally injurious events compared to civilians, including those of perpetration. This interpretation should be further studied with a specific focus on the experiences they were exposed to.

Study limitations and future directions

This study had several limitations that should be addressed. It relied on a cross-sectional survey and therefore cannot make any conclusions regarding causality. Second, it was conducted during the first three months of the Ukrainian-Russian war and therefore cannot evaluate potential long-term consequences. Additionally, there was no pre-war baseline data on moral injury and associated mental health symptoms. A longitudinal study could show whether moral injury and associated mental health symptoms fade or worsen over time. The sample comprised those undergoing emotional distress who volunteered for a community intervention and was not a representative group, thus limiting generalizability. Trauma exposure was not explicitly measured so dose effects with moral injury and associated mental health symptoms could not be ascertained. Also, the two groups studied were not demographically matched. Specifically, most of the civilian students were female and most of the combatants, male with small numbers therefore available for full gender comparisons. The civilian students were also younger, although age did not appear as a significant factor in the analysis.

Conclusion

The current study assessed active-duty and civilian student samples during the first three months of the Ukrainian-Russian war to compare mental health symptoms associated with moral injury. The study highlighted the increased rate of moral injury, PTSD symptoms, depression, and anxiety in civilian students, particularly in females. The study indicates that moral injury is a robust predictor of PTSD symptoms in both active-duty soldiers and civilian student groups. Additionally, previous family history of genocide impacts PTSD symptoms in active-duty soldiers only, those who may face more direct exposure to trauma. The findings of this study have a number of important implications for future practice and indicate that greater attention should be paid to the previous family trauma in treating PTSD symptoms in military populations. It is recommended that moral injury is highlighted as emotional suffering closely connected with PTSD, and this should be targeted in trauma-focused therapies. It is also important to consider how trauma-focused programs are suitable for moral injury in civilian populations in the face of the war atrocities against civilians and how to adjust trauma-focused interventions for both civilian and military populations.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are openly available in Mendeley Data https://doi.org/10.17632/j22dpy8ty2.1 and https://doi.org/10.17632/3mfp77gdxk.1

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are openly available in Mendeley Data https://doi.org/10.17632/j22dpy8ty2.1 and https://doi.org/10.17632/3mfp77gdxk.1

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