Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2020 Mar 1.
Published in final edited form as: Psychol Trauma. 2018 Sep 20;11(3):337–344. doi: 10.1037/tra0000407

Sex Differences in Mental Health Symptoms and Substance Use and their Association with Moral Injury in Veterans

Michelle L Kelley 1,2,*, Abby L Braitman 1, Tyler D White 3, Sarah Ehlke 1
PMCID: PMC6389381  NIHMSID: NIHMS990251  PMID: 30234322

Abstract

Objective:

This study examines potential sex differences in three types of experiences (i.e., Atrocities of war, Cognitive/emotional changes from combat, and Leadership failure/betrayal) that may result in moral injury (i.e., guilt, shame, inability to forgive one’s self, inability to forgive others, and withdrawn behavior associated with these three types of experiences). In addition, we examine whether moral injury results in different associations with mental health and substance use outcomes for female versus male veterans. We expected more symptoms of depression and anxiety for women and more symptoms of hazardous alcohol use and drug abuse for men. Also, we examined sex as a moderator between moral injury and outcomes, expecting stronger relationships between moral injury and symptoms of depression and anxiety among women, and stronger associations between moral injury and alcohol use and drug abuse symptoms for men.

Method

Participants (n = 256; 60.9% [n = 156] males) were a community sample of recent-era military personnel who completed a measure of MIEs and associated moral injury.

Results:

After correcting for Type I error rate, sex was not associated with mental health or substance use. Further, no sex by moral injury interactions were present; however, moral injury significantly positively predicted all negative mental health symptoms (depression, anxiety, suicidality, and PTSD), and hazardous alcohol use, but not drug abuse symptoms.

Conclusions:

Results reveal the need for improved screening and treatment of moral injury and integrated treatments that may assess moral injury and associated disorders.

Keywords: moral injury, gender, combat, mental health, substance use

Combat situations put military members at risk for physical and psychological harm (Godfrey et al., 2015; Hoge & Castro, 2006). Combat also places military members at risk for another type of trauma known as moral injury. Morally injurious experiences (MIEs) are events that violate one’s personal beliefs (Litz et al., 2009). While many veterans are resilient to their wartime experiences and do not develop moral injury, other veterans are believed to develop moral injury from exposure to MIEs. For veterans who develop moral injury, it is an internal reaction (guilt, shame, etc.) from external circumstances (i.e., MIEs). In this paper, we explore whether MIEs have differential risk for moral injury for female versus male veterans, and whether moral injury results in different associations with mental health and substance use outcomes for female versus male veterans.

Although moral injury has been recognized for many years (Shay, 1994), since the drawdown of recent wars, moral injury has gained considerable attention. The attention given to moral injury may in part reflect that the nature of recent wars, which have been marked by increases in unconventional warfare, such as unmarked combatants, civilian threats, and extensive use of improvised explosive devices (IEDs; Bird & Fairweather, 2007). These tactics may increase the likelihood that veterans experienced MIEs.

The most cited model of moral injury is that proposed by Litz et al. (2009). Litz and colleagues contend that moral injury is the result of traumatic events (i.e., MIEs) that do not necessarily result in fear or impending threat to one’s physical safety. MIEs include events such as engagement in or observation of betrayals (e.g., leadership failure), within-rank violence (e.g., sexual assault, friendly fire), inability to prevent injury or death to others, war-related destruction or the death of civilians or children (Drescher et al., 2011; Farnsworth, Drescher, Nieuwsma, Walser, & Currier, 2014; Litz et al., 2009). Even when sanctioned and part of one’s military mission, events during combat or combat operations may lead to moral injury. For instance, a military member may have the general belief that killing is wrong but engage in sanctioned killing during combat. Thus, sanctioned or non-sanctioned MIEs may create cognitive dissonance, that is, conflict between what the military member has witnessed or engaged in and one’s belief system. When veterans are unable to integrate these MIEs or their part in them into their belief system, they may develop moral injury.

Although there is no consensus regarding what constitutes moral injury, most investigators contend that guilt and shame are core symptoms of moral injury (Bryan et al., 2016; Farnsworth et al., 2014; Frankfurt & Frazier, 2016; Jinkerson, 2016; Litz et al., 2009). Other components of moral injury include difficulty with forgiveness, anger/contempt, grief/sorrow, and spiritual/existential distress (Currier, Holland, Drescher, & Foy, 2015; Frankfurt & Frazier, 2016; Jinkerson, 2016; Litz et al., 2009). When moral beliefs are breached and the veteran is not able to make meaning from these events, moral injury may develop. Over time, secondary symptoms, such as depression, PTSD, and substance use problems (Author, in press; Currier, Holland, & Malott, 2015; Held, Klassen, Brennan, & Zalta, 2018; Jinkerson, 2016; Litz et al., 2009; Maguen & Litz, 2012) may emerge from moral injury.

It is important to recognize the distinction between PTSD and moral injury. Although PTSD and moral injury are highly correlated (Battles et al., 2018), they stem from different forms of risk. Moral injury is a reaction to exposure to moral danger (i.e., challenges to one’s ethical code), whereas PTSD is generally, but not always, a reaction to mortal danger (i.e., risk of physical harm; Nieuwsma et al., 2015). Of note, MIEs typically do not meet diagnostic criteria for PTSD suggesting that moral injury may be a distinct syndrome that should be examined separately from PTSD (Drescher et al., 2011). However, it is important to realize that due to the nature of combat, one may be exposed to physical danger in the same event in which morals are challenged (e.g., killing an enemy combatant to protect oneself). In addition, consequences of both types of trauma (i.e., both moral and mortal) are often similar and may result in similar outcomes (e.g., reexperiencing, avoidance or numbing, loss of trust; Shay, 2014). Moreover, in a recent study, both moral injury and PTSD were significantly positively associated with depression, anxiety, suicidality, hazardous alcohol use, and drug abuse symptoms (Battles et al., 2018). However, when both moral injury and PTSD were included as simultaneous mediators between MIEs and these mental health symptoms, PTSD emerged as a unique mediator above and beyond moral injury, demonstrating some unique prediction despite their strong correlations.

In support of the Litz et al. model (2009), events that constitute betrayal, such as following an order that one perceives violates rules of engagement may lead to guilt and shame (Drescher et al., 2011). Similarly, witnessing or engaging in cruelty or violence toward civilians may lead to feeling one has been betrayed or betrayed their own values and result in guilt or shame. Correspondingly, guilt served to mediate the association between MIEs and depression and anxiety (Jinkerson, 2017). Further, guilt and shame were associated with more severe PTSD among Vietnam veterans (Currier, Holland, Drescher, & Foy, 2015) and more severe suicidal ideation among recent-era veterans (Bryan, Bryan, Morrow, Etienne, & Ray-Sannerud, 2014). Therefore, MIEs may be an important contributor to PTSD due to feelings of shame and guilt that stem from experiences during combat. Additionally, perceptions of the ‘wrongness’ of events contributes to anger, PTSD, depression, guilt, and shame above combat exposure alone (Lancaster & Erbes, 2017). McLean and colleagues (2017) found that among post-9/11 veterans, PTSD symptom severity was indirectly associated with suicidal ideation via negative cognitions regarding warzone traumas. Taken together, findings support the notion that PTSD and moral injury may be separate disorders, and that MIEs as well as moral injury may be associated with mental health outcomes.

Whether MIEs confer greater risk for female veterans, however, is not known. Alcohol abuse rates are higher among male veterans (Hoggatt et al., 2015), whereas combat has stronger associations with depression for female veterans (Luxton, Skopp, & Maguen, 2010). Further, a large sample of first-time users of the VA healthcare system who served in Iraq and Afghanistan found that male veterans were over twice as likely to be diagnosed with an alcohol and/or drug use disorder (Seal et al., 2011). However, female veterans are more likely than males to report being diagnosed with depression or anxiety (Blosnich, Brenner, & Bossarte, 2016). Results of previous studies are inconclusive as to whether combat experiences pose greater risk for the development of PTSD for female veterans. Namely, Luxton et al. (2010) found combat exposure results in greater risk for PTSD among female veterans; however, other studies reported no sex differences in the development of PTSD among combat veterans (e.g., Jacobson, Donoho, Crum-Cianflone, & Maguen, 2015; Vogt et al., 2011). Nevertheless, sex differences exist in mental health diagnoses and substance use in the larger population (Substance Abuse and Mental Health Services Administration, 2014). Further, it is possible that women and men may discern and/or may respond to MIEs differently, which may yield different mental health and substance use outcomes.

Between September 2001 and February 2013, 299,548 women were deployed (National Center for Veterans Analysis and Statistics, 2017). Thus, we examined whether MIEs, reactions of moral injury (guilt, shame, inability to forgive one’s self or others, and withdrawn behavior), mental health symptoms (i.e., depression, anxiety, suicidality, and PTSD) and substance use (hazardous alcohol use, drug abuse symptoms) differed for male versus female veterans. We hypothesized that women would report higher depression and anxiety, whereas men would report more alcohol and drug abuse symptoms. Also, we expected moderation such that moral injury would have stronger associations with depression and anxiety among women, and stronger associations with hazardous alcohol use and drug abuse symptoms among men. Findings from previous studies are mixed as to whether combat confers greater risk for PTSD for female as compared to male veterans. For this reason, we included PTSD in the models; however, we did not make a specific directional hypothesis for PTSD.

Method

Participants

The sample (N = 256) consisted of veterans (n = 186, 72.7%), National Guard/Reservists (n = 51, 19.9%) and active duty members (n = 19, 7.4%). Participants must have served after September 11, 2001 and have deployed to Operation Iraqi Freedom (M OIF deployments = 3.31, SD = 1.23) or Operation Enduring Freedom (M OEF deployments = 3.42, SD = 1.26). To confirm participants’ service in recent era operations, participants were asked to describe their occupation while serving in the military. An experienced researcher that was a recent-era veteran examined participants’ descriptions of their military occupation to confirm participants’ service in the military. In total, participants who did not describe their position or participants with positions that could not be verified by the researcher (i.e., vague responses or fictitious titles) were excluded from the study. Participants were recruited from Facebook (n = 80, 31.3%), listserves (n = 48, 18.8%), student veteran organizations (n = 38, 14.8%), a Psychology Research pool (n = 30, 11.7%), and other sources (e.g., Craigslist, flyers, word of mouth; n = 60, 23.4%). See Author (in press) for more details. Participants were mostly early 30s (M = 32.69, SD = 6.97), married (n = 192; 75.0%), White (n = 173, 67.6%), had attended college (n = 237, 92.6%), employed full-time (n = 179, 69.9%), and Army members (n = 133, 52.0%). There were no significant differences between men and women demographically. In the larger post 9/11 veteran population, the average age is 35 and 34 for male and females, respectively, 57% of men and 49.2% of women are married, 76.8% and 85.7% have attended college, and 67.5% and 55.0% are White (U.S. Department of Veterans Affairs, 2018). Thus, in comparison to the larger 9/11 veteran population, our sample was comparable in terms of racial diversity, but approximately 2 years younger, and more likely to be female, married, and have attended college. After providing consent, participants completed an online survey. Non-students received a $10 Amazon gift card; students received research credit or were entered into twenty $20 raffles.

Materials

Morally injurious experiences.

The Moral Injury Questionnaire – Military version (MIQ-M; Currier, Holland, Drescher et al., 2015) was adapted to assess both MIEs and the reaction/core symptoms of moral injury (Author, in press). First, participants rated the frequency with which they had experienced MIEs using a 4-point scale where 1 = Never and 4 = Often. Author (in press) identified three domains of MIEs: Atrocities of war (“I saw the death[s] of children”, 13 items; α = .95), Cognitive/emotional changes from combat (“I survived when others didn’t”, 6 items; α = .85), and Leadership failure/betrayal (“Things I saw in the war left me feeling betrayed or let-down by military/political leaders”, 3 items; α = .78), for a total of 22 MIE items. Scores were calculated to represent the mean for the items that assessed each of the MIE factors. All MIE factors had good internal consistency; MIE factors were correlated (.31 to .54) with depression, anxiety, and PTSD.

Moral injury.

Reaction to MIEs (moral injury symptomology) was also assessed using the modified MIQ-M (Currier, Holland, Drescher et al., 2015; Author, in press). To assess reaction/core symptoms of moral injury, respondents answered five follow-up questions about each MIE item: how much each MIE item caused them to: 1) “feel guilt”, 2) “feel shame”, 3) “have difficulties with forgiving myself”, 4) “have difficulties forgiving others”, and 5) “to become withdrawn”, using the same 4-point scale where 1 = Never and 4 = Often. A single moral injury score represented reaction/core symptomology across all three factors, given the strong correlations among symptomology items regardless of MIE factor (Author, in press). Up to 110 items were used for the moral injury score (i.e., 5 follow-up questions after each of 22 MIE items). However, MIEs that the participants indicated they did not experience (by endorsing Never) were excluded from this calculation (i.e., if a participant reported never experiencing a particular MIE, then those follow-up questions regarding guilt, shame, etc., were not included in moral injury score calculations). Thus, the moral injury score may represent a smaller number of items for each individual. Moral injury had excellent internal consistency (α = .98); moral injury was correlated (.53 to .67) with depression, anxiety, and PTSD.

Respondents also completed assessments of PTSD, depressive symptoms, anxiety, suicidality, hazardous alcohol use, and drug abuse symptoms.

Posttraumatic stress disorder.

The 20-item PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) assessed DSM-5 (American Psychiatric Association, 2013) symptoms of PTSD. Respondents rated past month symptom severity on a 5-point scale from 0 (Not at all) to 4 (Extremely), with a total possible score of 80 (α = .96). A recent psychometric analysis of the PCL-5 revealed an optimal cut score of 33 with regards to DSM-5 criteria for PTSD (Wortmann et al., 2016). In the present sample, 57.7% (n = 90) of men and 54.0% (n = 54) of women, for a total of 56.3% (n = 144) participants scored at or above the cut-off of 33.

Depressive symptoms.

Depressive symptoms were assessed using the 10-item Center for Epidemiological Studies Depression Scale (CES-D-10; Kohout, Berkman, Evans, & Cornoni-Huntley, 1993; α = .73). Rather than a 0 = no, 1 = yes scale, we used the CES-D’s (Radloff, 1977) original 4-point scale, which ranges from 0 (Rarely or none of the time [less than 1 day]) to 3 (Most or all of the time [5–7 days]). González et al. (2017) and Cheung, Liu, and Yip (2007) have also used 4-point response codes, similar to that used in the original CESD, for the 10-item version of the CESD. Further, González et al. found a score of 8 for the 10-item CESD using this response scale corresponded to a cut-off of 16 on the original CESD. In the present sample, 87.8% (n = 137) of men and 82.0% (n = 82) of women were above a score of 8, for a total of 85.5% (n = 219) scoring at or above the cut-off indicating the need for additional screening.

Anxiety symptoms.

Anxiety symptoms were measured using the 14-item Kremen Anxiety Scale (KAS; Kremen, 1996) which assesses worries, apprehension, and nervousness. Similar to a study of military mothers (Kelley et al., 2002), we used a 5-point scale ranging from 1 (Never) to 5 (Always). Cronbach’s alpha was .90.

Suicidality symptoms.

Suicidal symptoms were assessed with the 6-item Suicide Subscale from the Inventory of Depression and Anxiety Symptoms (IDAS) (Watson et al., 2007). Item responses range from 1 (Not at all) to 5 (Extremely). Internal consistency was excellent (α = .91). Watson et al. (2007) demonstrated internal consistency, strong short-term stability, and good convergent and discriminant validity.

Hazardous alcohol use.

The 10-item Alcohol Use Disorder Identification Test (AUDIT; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001) was used to examine hazardous alcohol consumption and problems (α = .87). Responses are scored from 0 to 4; higher scores indicate greater hazardous alcohol use. To provide a comparison to studies that have categorized subjected based on a cut-off score, we looked at the percentage of men and women who exceeded a total AUDIT score of 8 or higher which traditionally suggests alcohol misuse (Babor et al., 2001). In the present study, 74.4% (n = 116) of men and 66.0% (n = 66) of women met this cut-off score, for a total of 71.1% (n = 182) of the entire sample.

Drug abuse symptoms.

The 10-item Drug Abuse Screening Test-10 (DAST-10; Skinner, 1982) assessed drug abuse symptoms using a dichotomous response scale (1 = yes, 0 = no). For the present study, α = .72. In a comprehensive review of the DAST 10, 20, and 28-item versions, Yudko, Lozhkina, & Fouts, 2007) found all versions yield good measures of reliability and validity and are beneficial for clinical or research use. Further, the DAST-10 correlates nearly perfectly with the DAST-20 (.97; Cocco & Carey, 1998). A score of 3 or more suggests a probable drug use disorder (Carey, Carey, & Chandra, 2003; Skinner, 1982). Using a cut-off of 3 for the DAST-10, 60.3% (n = 94) of male and 55.0% (n = 55) of female veterans in our sample exceeded the cut-off for likely drug use disorder, for a total of 58.2% (n = 149) of the entire sample.

Results

Normality was confirmed as was the absence of outliers. A series of multiple regressions were conducted. Dummy coded sex (0 = male, 1 = female), mean-centered moral injury symptomology scores, and the interaction between the two were included as predictors. Separate analyses were conducted for each outcome resulting in six total regressions. A Bonferroni correction (α = .0083 [.05/6]) adjusted for Type I family-wise error. Independent samples t tests indicated no significant sex differences on any MIE factors, moral injury, depression, anxiety, PTSD, suicidality, AUDIT, or DAST (see Table 1).

Table 1.

Moral Injury Constructs and Mental Health Symptomology by Sex

Male
(n=156)
 Female
(n=100)
Variable M SD M SD M diff SE diff t df p
MIEs Factor 1 1.94 0.61 1.81 0.58 0.14 0.077 1.77 254 .078
MIEs Factor 2 2.18 0.63 2.05 0.56 0.13 0.077 1.64 254 .102
MIEs Factor 3 2.22 0.77 2.18 0.72 0.04 0.096 0.43 254 .667
MI Sx 2.16 0.63 2.13 0.61 0.03 0.080 0.32 250 .752
Depressive Sx 13.03 5.26 12.74 5.47 0.29 0.684 0.42 254 .677
Anxiety Sx 38.13 10.79 37.87 12.19 0.25 1.401 0.18 254 .857
Suicidality 14.71 6.03 13.63 5.67 1.08 0.754 1.43 254 .155
PTSD 36.15 18.06 34.68 17.68 1.47 2.295 0.64 254 .524
AUDIT 14.67 8.39 13.65 8.66 1.02 1.088 0.94 254 .348
DAST 3.35 2.32 3.17 2.45 0.18 0.304 0.59 254 .555
Open in a new tab

Note. MIE = Morally injurious experiences, MI Sx = Moral injury reaction/symptoms, PTSD = Post-traumatic stress disorder, AUDIT = Alcohol Use Disorders Identification Test, DAST = Drug Abuse Screening Test. Sex was dummy coded (0 = male, 1 = female).

Multiple regressions (see Table 2) showed moral injury symptomology was associated with significantly poorer outcomes with squared semi-partial correlations indicating medium to large effects. Although a similar trend was observed for drug abuse symptomology, it failed to reach significance using the more conservative cutoff of alpha = .0083. Sex was not associated with outcomes after controlling for moral injury symptomology, nor did it moderate the observed effects.

Table 2.

Multiple Regression Results Predicting Mental Health Symptomology

β B SE p rp2
Depressive Symptoms
 Sex −0.03 −0.27 0.598 .657 .001
 MI Symptoms 0.46 3.95* 0.597 <.001 .132
 Sex X MI Symptoms 0.06 0.80 0.969 .411 .002
Anxiety Symptoms
 Sex −0.002 −0.05 1.171 .966 .000
 MI Symptoms 0.56 9.85* 1.168 <.001 .196
 Sex X MI Symptoms −0.003 −0.08 1.897 .967 .000
Suicidality
 Sex −0.10 −1.18 0.687 .086 .010
 MI Symptoms 0.38 3.59* 0.686 <.001 .090
 Sex X MI Symptoms 0.06 0.95 1.114 .394 .002
PTSD Sx
 Sex −0.04 −1.42 1.651 .389 .002
 MI Symptoms 0.65 18.60* 1.647 <.001 .264
 Sex X MI Symptoms 0.07 3.07 2.675 .252 .003
AUDIT
 Sex −0.06 −1.00 0.973 .304 .003
 MI Symptoms 0.44 5.97* 0.971 <.001 .122
 Sex X MI Symptoms −0.002 −0.04 1.577 .981 .000
DAST
 Sex −0.04 −0.19 0.302 .536 .002
 MI Symptoms 0.20 0.76 0.302 .013 .025
 Sex X MI Symptoms −0.05 −0.28 0.490 .570 .001
Open in a new tab

Note. MI = Moral Injury, PTSD = Post-traumatic stress disorder, AUDIT = Alcohol Use Disorders Identification Test, DAST = Drug Abuse Screening Test. Sex was coded 0 = male, 1 = female. Significant findings are indicated in bold.

*

p < .0083 (consistent with the Bonferroni correction).

Discussion

Moral injury predicted negative mental health symptoms and hazardous alcohol use; sex did not moderate these associations. The nature of recent wars, which have been marked by increases in unconventional warfare, such as unmarked combatants, civilian threats, and extensive use of improvised explosive devices (IEDs), put veterans at risk for MIEs. Specifically, 98% of our sample indicated that they had experienced one or more MIEs.

Although veterans who report greater symptoms of moral injury appear at greatest risk of hazardous alcohol use, on average, men and women met the cut-off for hazardous alcohol use as determined by the elevated means listed in Table 1. Specifically, 71% of the sample exceeded the cut-off for hazardous drinking on the AUDIT (Babor et al., 2001).

Among civilian men and women, rates of alcohol use and alcohol use disorder narrowed between 2002 and 2012 (White et al., 2015). In particular, the gender gap in hazardous drinking appears to be decreasing particularly at younger ages. Further, a 2013 Institute of Medicine (IOM) report found significantly higher rates of heavy alcohol use (5 or more drinks per occasion at least once a week for men or women) among active duty personnel as compared to civilians. This finding was especially true in younger age groups (i.e., 18 to 25 and 25–36). Although our sample had relatively few active duty members (only 7.4%), our results show high rates of hazardous alcohol use among recent-era veterans. Other studies have also found high levels of alcohol use following deployment among post 9/11 veterans. For instance, using data from the Millennium Cohort Study, Reserve and National Guard women who deployed and reported combat exposures were at increased risk of new-onset for heavy weekly drinking, and men were at risk for alcohol-related problems (e.g., Jacobson et al., 2008). Among Navy personnel deployed in 2014, an increase in work stressors over the course of deployment was associated with increases in depressive symptoms, which in turn, predicted increases in hazardous drinking from pre- to post-deployment and 6 months post-deployment (Kelley, Bravo, Hollis, 2017). Taken together, these studies suggest that both combat experiences and operational stress associated with deployments may be associated with high levels of alcohol use post-deployment for young military members.

Contrary to expectations, sex did not moderate the association between moral injury and drug abuse symptoms. Although there was a trend for moral injury to predict drug abuse symptomology, results failed to reach significance at the more stringent alpha value. Although moral injury did not significantly predict drug abuse symptoms, we should point out that over half of our sample met the cut-off for likely drug use problems (Carey et al., 2003; Skinner, 1982). The finding that so many veterans endorsed drug abuse symptoms indicative of the need for screening suggests that drug use is common among young male and female young post 9/11 veterans. This finding is especially interesting as active duty samples typically have low levels of drug use (Bray et al., 2010). The low level of drug use among active duty military members is likely to reflect the strict no tolerance policy against drug use in the military. With respect to wartime events and drug use, Held et al. (2018) found causing harm, injury, or death was associated with PTSD, drug use, and anger; however, this association was not significant when total number of lifetime traumas was entered in the multivariate analyses (Held, Boley, Karnik, Pollack, & Zalta, 2018). Likewise, Kelley et al. (found for both 2015) female and female veterans of recent wars, both combat exposure and non-combat-related trauma prior to the military were associated with drug abuse symptoms, and that depression mediated this association. In short, recent-era veterans were likely to exceed cut-offs indicating possible drug abuse problems. While there was a tendency for moral injury to predict drug abuse symptoms, clearly, other variables such as previous trauma that may contribute to drug use symptoms should be examined in future research.

Findings also revealed that none of the mental health variables (e.g., suicidality, PTSD, depression, anxiety) were significantly different for men and women. Sex differences on mental health outcomes among military personnel are mixed with some studies revealing that women are more likely than men to report symptoms of depression and anxiety (Gibbons, Hickling, Barnett, Herbig-Wall, & Watts, 2012; Hourani, Williams, Bray, & Kandel, 2015), however, other studies find no differences on mental health outcomes (e.g., Elbogen et al., 2013; Maguen, Luxton, Skopp, & Madden, 2012).

In 2013, the ban on women serving in combat was removed potentially putting women at increasing risk for combat exposure. Consistent with this shift in military policy, Kelley et al. (2013) found 92.6 % of men and 85.1% of women who took part in a post-deployment mental health survey reported exposure to combat. However, hand-to-hand combat was rare in recent wars (Afari et al., 2015). Rather, recent wars were characterized by the use of guerrilla warfare, which includes irregular warfare such as roadside IEDs, armed civilians, sniper attacks, raids, and so forth (Bird & Fairweather, 2007). In fact, over half of all casualties in Iraq and Afghanistan were due to IEDs (Shell, 2017). All of these features resulted in complex and unexpected MIEs for men and women. Thus, it is not surprising that men and women veterans report comparable levels of mental health symptoms as the experiences of male and female veterans were much more similar than in the past

With respect to the lack of differences in MIEs and moral injury between men and women, in comparison to PTSD, which often results from threats to one’s physical safety and arousal, moral injury results from a shattering of one’s beliefs about larger worldview, one’s relationship to a higher power, and beliefs about one’s self (Litz et al., 2009). It is possible that experiences that result in an existential crisis or moral injury create a similar need to make sense of combat experiences. If this is the case, the lack of integration of one’s experiences may result in similarities in post-deployment mental health and substance use outcomes.

Limitations

Several limitations should be noted. First, the current study was cross-sectional, limiting causal inferences about MIEs, moral injury, and mental health outcomes. Second, it is possible that pre-military mental health, and other variables not examined here, may be associated with moral injury, as well as later mental health and substance use. Third, a current problem in the assessment of moral injury is that causes and consequences are often confounded (see Frankfurt Frazier, 2016 for a discussion). In the present study, we assessed MIEs with a modified version of the MIQ-M that was adapted to avoid assessing causes and consequences (Author, in press). Nevertheless, factor analysis of the modified MIQ-M led to three domains, one of which, Cognitive/emotional changes from combat, conflates exposure with its consequences. Ideally, future research should further differentiate exposure from consequences, as well as incorporate longitudinal designs to explore how pre-military experiences and exposure to MIEs are associated with changes across military service. Finally, our sample is comprised of post 9/11 veterans. These results may not generalize to pre-9/11 veterans.

Clinical Implications

Results point to the importance of screening for moral injury and integrated treatment for moral injury for both men and women veterans. Also, the nature of recent wars have resulted in high likelihood of MIEs. Although some veterans may be able to integrate these experiences, many others may not. For many veterans, discussing MIEs and their part in these events, and in some instances, serious violation of rules of engagement or acts of omission may lead to withdrawal or guilt and shame and difficulty initiating treatment. Clearly, this presents challenges to the clinician to help veterans develop the trust necessary to work through these events and begin to forgive themselves (Litz et al., 2009). A second challenge may be to look past PTSD, and so forth, to consider how moral injury may be associated with current behavior such as alcohol and drug use. Currently, moral injury may not typically be assessed by clinicians. Therefore, how moral injury and MIEs may be impacting substance use behavior and negative thoughts may be ignored if not considered separate from a diagnosis of PTSD.

Conclusions

Moral injury predicted negative mental health symptoms and hazardous alcohol use; sex did not moderate these associations. The nature of recent wars, in which both men and women veterans experienced MIEs, may be expected to result in similar levels of moral injury. Further, moral injury is associated with more negative mental health symptoms and hazardous alcohol use for both men and women.

Clinical Impact Statement:

Reactions to violating one’s personal beliefs (i.e., moral injury) as the result of combat is common, but whether moral injury is associated with similar outcomes for male and female veterans is not known. From this study, moral injury does not appear to be associated with different mental health and substance abuse outcomes for veterans across sex.

Acknowledgments:

This work was supported by a grant from the American Psychological Association to Michelle L. Kelley from the Society for Military Psychology (Division 19). Abby L. Braitman is supported by a research career development award (K01- AA023849) from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

References

  1. Afari N, Pittman J, Floto E, Owen L, Buttner M, Hossain N, …Lohr J (2015). Differential impact of combat on postdeployment symptoms in female and male veterans of Iraq and Afghanistan. Military Medicine, 180, 296–303. 10.7205/MILMED-D-14-00255 [DOI] [PubMed] [Google Scholar]
  2. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Author (in press). [Google Scholar]
  3. Battles AR, Bravo AJ, Kelley ML, White TD, Braitman AL, & Hamrick HC (2018). Moral injury and PTSD as mediators of the associations between morally injurious experiences and mental health and substance use. Traumatology Advance online publication. 10.1037/trm0000153 [DOI]
  4. Babor TF, Higgins-Biddle JC, Saunders JB, & Monteiro MG (2001). AUDIT - The Alcohol Use Disorders Identification Test: Guidelines for use in primary health care (2nd ed). Geneva, Switzerland: World Health Organization. [Google Scholar]
  5. Bird SM, & Fairweather CB (2007). Military fatality rates (by cause) in Afghanistan and Iraq: A measure of hostilities. International Journal of Epidemiology, 36, 841–846. 10.1093/ije/dym103 [DOI] [PubMed] [Google Scholar]
  6. Blosnich JR, Brenner LA, & Bossarte RM (2016). Population mental health among US military veterans: Results of the Veterans Health Module of the Behavioral Risk Factor Surveillance System, 2011–2012. Annals of Epidemiology, 26, 592–596. 10.1016/j.annepidem.2016.06.009 [DOI] [PubMed] [Google Scholar]
  7. Bray RM, Pemberton MR, Lane ME, Hourani LL, Mattiko MJ, & Babeu LA (2010). Substance use and mental health trends among US military active duty personnel: key findings from the 2008 DoD Health Behavior Survey. Military Medicine, 175, 390–399. https://academic.oup.com/milmed/article-abstract/175/6/390/4344597 [DOI] [PubMed] [Google Scholar]
  8. Bryan CJ, Bryan AO, Anestis MD, Anestis JC, Green BA, Etienne N Morrow CE, & Ray-Sannerud B (2016). Measuring moral injury: Psychometric properties of the Moral Injury Events Scale in two military samples. Assessment, 23, 557–570. 10.1177/1073191115590855 [DOI] [PubMed] [Google Scholar]
  9. Bryan AO, Bryan CJ, Morrow CE, Etienne N, & Ray-Sannerud B (2014). Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology, 20, 154–160. 10.1037/h0099852 [DOI] [Google Scholar]
  10. Carey KB, Carey MP, & Chandra PS (2003). Psychometric evaluation of the Alcohol Use Disorders Identification Test and Short Drug Abuse Screening Test with psychiatric patients in India. Journal of Clinical Psychiatry, 64, 757–774. 10.4088/JCP.v64n0705 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Cheung YB, Liu KY, & Yip PS (2007). Performance of the CES-D and its short forms in screening suicidality and hopeless-ness in the community. Suicide & Life-Threatening Behavior, 37, 79–88. 10.1521/suli.2007.37.1.79 [DOI] [PubMed] [Google Scholar]
  12. Cocco KM, & Carey KB (1998). Psychometric properties of the Drug Abuse Screening Test in psychiatric outpatients. Psychological Assessment, 10, 408–414. 10.1037/1040-3590.10.4.408 [DOI] [Google Scholar]
  13. Currier JM, Holland JM, Drescher K, & Foy D (2015). Initial psychometric evaluation of the Moral Injury Questionnaire—Military version. Clinical Psychology & Psychotherapy, 22, 54–63. 10.1002/cpp.1866 [DOI] [PubMed] [Google Scholar]
  14. Currier JM, Holland JM, & Malott J (2015). Moral injury, meaning making, and mental health in returning veterans. Journal of Clinical Psychology, 71, 229–240. 10.1002/jclp.22134 [DOI] [PubMed] [Google Scholar]
  15. Drescher KD, Foy DW, Kelly C, Leshner A, Schutz K, & Litz B (2011). An exploration of the viability and usefulness of the construct of moral injury in war veterans. Traumatology, 17, 8–13. 10.1177/1534765610395615 [DOI] [Google Scholar]
  16. Elbogen EB, Wagner HR, Johnson SC, Kinneer P, Kang H, Vasterling JJ, Timko C, & Beckham JC (2013). Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatric Services, 64, 134–141. 10.1176/appi.ps.004792011 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Farnsworth JK, Drescher KD, Nieuwsma JS, Walser RB, & Currier JM (2014). The role of moral emotions in military trauma: Implications for the study and treatment of moral injury. Review of General Psychology, 18(4), 249–262. 10.1037/gpr0000018 [DOI] [Google Scholar]
  18. Frankfurt S, & Frazier P (2016). A review of research on moral injury in combat veterans. Military Psychology, 28, 318–330. 10.1037/mil0000132 [DOI] [Google Scholar]
  19. Gibbons SW, Hickling EJ, Barnett SD, Herbig-Wall PL, & Watts DD (2012). Gender differences in response to deployment among military healthcare providers in Afghanistan and Iraq. Journal of Women’s Health, 21, 496–504. 10.1089/jwh.2011.3097 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Godfrey KM, Mostoufi S, Rodgers C, Backhaus A, Floto E, Pittman J, & Afari N (2015). Associations of military sexual trauma, combat exposure, and number of deployments with physical and mental health indicators in Iraq and Afghanistan veterans. Psychological Services, 12, 366–377. 10.1037/ser0000059 [DOI] [PubMed] [Google Scholar]
  21. González P, Nuñez A, Merz E, Brintz C, Weitzman O, Navas EL, Camacho A, Buelna C, Penedo FJ, Wassertheil-Smoller S, Perreira K, Isasi CR, Choca J, Talavera GA, & Gallo LC (2017). Measurement properties of the Center for Epidemiologic Studies Depression Scale (CESD-10): Findings from HCHS/SOL. Psychological Assessment, 29, 372–381. 10.1037/pas0000330 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Held P, Boley RA, Karnik NS, Pollack MH, & Zalta AK (2018). Characteristics of veterans and military service members who endorse causing harm, injury, or death to others in the military. Psychological Trauma: Theory, Research, Practice, and Policy, 10, 352–359. 10.1037/tra0000294 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Held P, Klassen BJ, Brennan MB, & Zalta AK (2018). Using prolonged exposure and cognitive processing therapy to treat veterans with moral injury-based PTSD: Two case examples. Cognitive and Behavioral Practice, 225, 377–390. 10.1016/j.cbpra.2017.09.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Hoge CW, & Castro CA (2006). Post-traumatic stress disorder in UK and US forces deployed to Iraq. Lancet, 368, 837 Retrieved from https://www.thelancet.com/pdfs/journals/lancet/PIIS0140673606693173.pdf [DOI] [PubMed] [Google Scholar]
  25. Hoggatt KJ, Jamison AL, Lehavot K, Cucciare MA, Timko C, & Simpson TL (2015). Alcohol and drug misuse, abuse, and dependence in women veterans. Epidemiologic Reviews, 37, 23–37. 10.1093/epirev/mxu010 [DOI] [PubMed] [Google Scholar]
  26. Hourani L, Williams J, Bray R, & Kandel D (2015). Gender differences in the expression of PTSD symptoms among active duty military personnel. Journal of Anxiety Disorders, 29, 101–108. 10.1016/j.janxdis.2014.11.007 [DOI] [PubMed] [Google Scholar]
  27. Jacobson IG, Donoho CJ, Crum-Cianflone NF, Maguen S (2015). Longitudinal assessment of gender differences in the development of PTSD among US militarypersonnel deployed in support of the operations in Iraq and Afghanistan. Journal of Psychiatric Research, 68, 30–36. 10.1016/j.jpsychires.2015.05.015 [DOI] [PubMed] [Google Scholar]
  28. Jacobson IG, Ryan MA, Hooper TI, Smith TC, Amoroso PJ, Boyko EJ, Gackstetter GD, Wells TS, & Bell NS (2008). Alcohol use and alcohol-related problems before and after military combat deployment. JAMA, 300, 663–675. 10.1001/jama.300.6.663 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Jinkerson JD (2016). Defining and assessing moral injury: A syndrome perspective. Traumatology, 22, 122–130. 10.1037/trm0000069 [DOI] [Google Scholar]
  30. Jinkerson JD (2017). Moral injury in combat veterans: A theoretical and empirical explanation of the moderating role of worldview relationships (Doctoral dissertation). Retrieved from ProQuest Dissertations and Theses database. (Accession No. 10168606)
  31. Kelley ML, Hock E, Jarvis MS, Smith KM, Gaffney MA, & Bonney JF (2002). Psychological adjustment of Navy mothers experiencing deployment. Military Psychology, 14, 199–216. 10.1207/S15327876MP1403_2 [DOI] [Google Scholar]
  32. Kelley ML, Brancu M, Robbins A, D’Lima GM, Strauss JL, Curry JF, Fairbank JA, Runnals J, VA Mid-Atlantic MIRECC Women Veterans Workgroup, & VA Mid-Atlantic MIRECC Workgroup. (2015). Drug use and childhood-, military- and post-military trauma exposure among women and men veterans. Drug and Alcohol Dependence, 152, 201–208. 10.1016/j.drugalcdep.2015.03.038 [DOI] [PubMed] [Google Scholar]
  33. Kelley ML, Bravo AB & Hollis BF (2017). Work stressors, depressive symptoms, and hazardous drinking among Navy members across deployment? Military Psychology, 28, 396–406. 10.1037/mil0000177 [DOI] [Google Scholar]
  34. Kohout FJ, Berkman LF, Evans DA, & Cornoni-Huntley J (1993). Two shorter forms of the CES-D depression symptoms index. Journal of Aging and Health, 5, 179–193. 10.1177/089826439300500202 [DOI] [PubMed] [Google Scholar]
  35. Kremen AM (1996). Depressive tendencies and susceptibility to anxiety: Differential personality correlates. Journal of Personality, 64, 209–242. 10.1111/j.1467-6494.1996.tb00820.x [DOI] [PubMed] [Google Scholar]
  36. Lancaster SL, & Erbes CR (2017). Importance of moral appraisals in military veterans. Traumatology, 23, 317–322. 10.1037/trm0000123 [DOI] [Google Scholar]
  37. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, & Maguen S (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706. 10.1016/j.cpr.2009.07.003 [DOI] [PubMed] [Google Scholar]
  38. Luxton DD, Skopp NA, & Maguen S (2010). Gender differences in depression and PTSD symptoms following combat exposure. Depression and Anxiety, 27, 1027–1033. 10.1002/da.20730 [DOI] [PubMed] [Google Scholar]
  39. Maguen S, & Litz B (2012). Moral injury in veterans of war. PTSD Research Quarterly, 23, 1–6 Retrieved from http://www.ptsd.va.gov/professional/newsletters/research-quarterly/v23n1.pdf. [Google Scholar]
  40. Maguen S, Luxton DD, Skopp NA, & Madden E (2012). Gender differences in traumatic experiences and mental health in active duty soldiers redeployed from Iraq and Afghanistan. Journal of Psychiatric Research, 46, 311–316. 10.1016/j.jpsychires.2011.11.007 [DOI] [PubMed] [Google Scholar]
  41. McLean CP, Zang Y, Zandberg L, Bryan CJ, Gay N, Yarvis JS, Foa EB, & the STRONG STAR Consortium. (2017). Predictors of suicidal ideation among active duty military personnel with posttraumatic stress disorder. Journal of Affective Disorders, 208, 392–398. 10.1016/j.jad.2016.08.061 [DOI] [PubMed] [Google Scholar]
  42. National Center for Veterans Analysis and Statistics. (2017). Women veterans report: The past, present, and future of women veterans Retrieved from https://www.va.gov/vetdata/docs/SpecialReports/Women_Veterans_2015_Final.pdf
  43. Nieuwsma JD, Walser RK, Farnsworth JD, Drescher KG, Meador K, & Nash W (2015). Possibilities within acceptance and commitment therapy for approaching moral injury. Current Psychiatry Reviews, 11, 193–206. 10.1037/gpr0000018 [DOI] [Google Scholar]
  44. Radloff LS (1977). The CES-D scale a self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. 10.1177/014662167700100306 [DOI] [Google Scholar]
  45. Shell J (2017, May 1). How the IED won: Dispelling the myth of tactical success and innovation Retrieved from https://warontherocks.com/2017/05/how-the-ied-won-dispelling-the-myth-of-tactical-success-and-innovation.
  46. Seal KH, Cohen G, Waldrop A, Cohen BE, Maguen S, & Ren L (2011). Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001–2010: Implications for screening, diagnosis and treatment. Drug & Alcohol Dependence, 116, 93–101. 10.1016/j.drugalcdep.2010.11.027 [DOI] [PubMed] [Google Scholar]
  47. Shay J (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York: Atheneum. [Google Scholar]
  48. Shay J (2014). Moral injury. Psychoanalytic Psychology, 31, 182–191. 10.1037/a0036090 [DOI] [Google Scholar]
  49. Shell J (2017, May 1). How the IED won: Dispelling the myth of tactical success and innovation Retrieved from https://warontherocks.com/2017/05/how-the-ied-won-dispelling-the-myth-of-tactical-success-and-innovation.
  50. Skinner HA (1982). The drug abuse screening test. Addictive Behaviors, 7, 363–371. 10.1016/0306-4603(82)90005-3 [DOI] [PubMed] [Google Scholar]
  51. Substance Abuse and Mental Health Services Administration (SAMHSA; 2014). Results from the 2013 national survey on drug use and health: Summary of national findings (NSDUH Series H-48, HHS Publication No. [SMA] 14–4863). Rockville, MD: SAMHSA. [PubMed] [Google Scholar]
  52. U.S. Department of Veterans Affairs (2018). Profile of post-9/11 veterans: 2016 National Center for Veterans Analysis and Statistics, March, 2018. https://www.va.gov/vetdata/report.asp [Google Scholar]
  53. Vogt D, Vaughn R, Glickman ME, Schultz M, Drainoni M, Elwy R, & Eisen S, (2011). Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF veterans. Journal of Abnormal Psychology, 120, 797–806. 10.1037/a0023452 [DOI] [PubMed] [Google Scholar]
  54. Watson D, O’Hara MW, Simms LJ, Kotov R, Chmielewski M, McDade-Montez EA, Gamez W, & Stuart S (2007). Development and validation of the Inventory of Depression and Anxiety Symptoms (IDAS). Psychological Assessment, 19, 253–268. 10.1037/1040-3590.19.3.253 [DOI] [PubMed] [Google Scholar]
  55. Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, & Schnurr PP (2013). The PTSD Checklist for DSN-5 (PCL-5) Retrieved from http://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp
  56. White A, Castle IJP, Chen CM, Shirley M, Roach D, & Hingson R (2015). Converging patterns of alcohol use and related outcomes among females and males in the United States, 2002 to 2012. Alcoholism: Clinical and Experimental Research, 39, 1712–1726. 10.1111/acer.12815 [DOI] [PubMed] [Google Scholar]
  57. Wortmann JH, Jordan AH, Weathers FW, Resick PA, Dondanville KA, Hall-Clark B, Foa EB, Young-McCaughan S, Yarvis JS, Hembree EA, Mintz J, Peterson AL, & Litz BT (2016). Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychological Assessment, 28, 1392–1403. 10.1037/pas0000260 [DOI] [PubMed] [Google Scholar]
  58. Yudko E, Lozhkina O, & Fouts A (2007). A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. Journal of Substance Abuse Treatment, 32, 189–198. 10.1016/j.jsat.2006.08.002 [DOI] [PubMed] [Google Scholar]

RESOURCES