Associations between moral injury, PTSD clusters, and depression among Israeli veterans: a network approach

The impact of potentially morally injurious experience of betrayal on PTSD and depression following the October 7th terror attack

With about 1200 individuals murdered, the massacre of October 7th was one of the deadliest terrorist attacks in modern history. The mental health consequences of terrorist attacks have been documented. However, little is known of the impact of the potentially morally injurious experience (PMIE) of betrayal--in which individuals feel betrayed by leaders they once trusted--on levels of psychological burden in the aftermath of such an attack. In this national prospective cohort study, we examined to what extent the PMIE of betrayal exacerbates the risk for posttraumatic stress disorder (PTSD) and depression in the wake of the October 7th terrorist attack. A representative sample of 710 Israeli adults (362 female, 51.1%), Jews (557, 79.9%) and Arabs (153, 20.1%), aged 18-85 (M = 41.01, SD = 13.72) completed validated self-report questionnaires assessing PTSD, depression, and PMIE-betrayal at two timepoints: T1, in August 2023 (6-7 weeks before the attack) and T2, in November 2023 (5-6 weeks after the attack). In two hierarchical logistic regressions, we found that experience of PMIE-betrayal predicted diagnoses of both PTSD (OR 1.92, 95% CI 1.26-2.92) and depression (OR 2.03, 95% CI 1.37-3.01) at T2, beyond probable PTSD/depression at T1 and demographic and trauma-related variables. Moreover, in two repeated-measure analyses predicting PTSD/depression symptoms, we found significant interactions between PTSD/depression trajectories and PMIE-betrayal, meaning that the increase of PTSD/depression symptoms was significantly higher among participants experiencing betrayal in the context of the attack. Our study highlights the impact of PMIE of betrayal on the dramatic increase in psychopathology following the October 7th terror attack on Israel's population. Clinicians treating individuals coping with PTSD and depression should attend to their patients' possible exposure to betrayal following the attack. Moreover, national leaders and policymakers should take significant steps to repair the public's betrayal experience.

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.

The impact of moral injury on trajectories of depression: a five-year longitudinal study among recently discharged Israeli veterans

BACKGROUND

Perpetrating or witnessing acts that violate one's moral code are frequent among military personnel and active combatants. These events, termed potentially morally injurious events (PMIEs), were found to be associated with an increased risk of depression, in cross-sectional studies. However, the longitudinal contribution of PMIEs to depression among combatants remains unclear.

METHOD

Participants were 374 active-duty combatants who participated in a longitudinal study with four measurement points: T1-one year before enlistment, T2-at discharge from army service, and then again 6- and 12-months following discharge (T3 and T4, respectively). At T1, personal characteristics assessed through semi-structured interviews. At T2-T4, PMIEs and depressive symptoms were assessed.

RESULTS

At discharge (T2), a total of 48.7% of combatants reported experiencing PMIEs incident, compared with 42.4% at T3 and 30.7% at T4. We found a significant interaction effect in which combatants endorsing PMIEs at discharge reported higher severity of depression symptoms at discharge (T2) than combatants who reported no PMIEs. This effect decreased over time as depression levels were lower at T3 and T4.

CONCLUSIONS

PMIE experiences, and especially PMIE-Betrayal experiences, were found to be valid predictors of higher severity of depression symptoms after the first year following discharge.

Moral Injury Post-COVID-19: More Than Military? A Theological Perspective

The author of this article considers moral distress theologically, as a potential shattering of core sustaining belief systems, hope, securities, self-identities, and organizing principles of one's existence. Shattering of individual moral expectations can occur in both medical and military 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.

Light Personality Style and Moral Injury Among Chinese Health Professionals

Moral injury has attracted attention widely in various occupations, particularly health professionals. Personality traits involve the professional values in clinical decision-making associated with mental outcomes. The current study examines the relationship between "light personality" style and moral injury. Scores on three subscales of the Light Triad Scale were negatively correlated with the Moral Injury Symptoms Scale-Health Professional. Health professionals more likely to have light personality styles may be less likely to suffer from moral injury under high-stake situations. The findings provide evidence to better understand the inner core of the moral injury, suggesting a potential pathway to improve the moral well-being of health professionals by strengthening key elements of light personality.

Pastoral Narrative Disclosure: The Development and Evaluation of an Australian Chaplaincy Intervention Strategy for Addressing Moral Injury

This paper describes the development and initial chaplaincy user evaluation of 'Pastoral Narrative Disclosure' (PND) as a rehabilitation strategy developed for chaplains to address moral injury among veterans. PND is an empirically informed and integrated intervention comprising eight stages of pastoral counselling, guidance and education that was developed by combining two previously existing therapeutic techniques, namely Litz et al's (2017) 'Adaptive Disclosure' and 'Confessional Practice' (Joob & Kettunen, 2013). The development and results of PND can be categorized into five phases. Phase 1: PND Strategy Formation-based upon extensive international research demonstrating that MI is a complex bio-psycho-social-spiritual syndrome with symptoms sufficiently distinct from post-traumatic stress disorder. The review also provided evidence of the importance of chaplains being involved in moral injury rehabilitation. Phase II: Development and Implementation of 'Moral Injury Skills Training' (MIST)-which involved the majority of available Australian Defence Force (ADF) Chaplains (n = 242/255: 94.9%) completing a basic 'Introduction to Moral Injury' (MIST-1) as well as an 'Introduction to PND' (MIST-2). Phase III: MIST-3-PND-Pilot evaluation-involved a representative chaplaincy cohort (n = 13) undergoing the PND eight-stage strategy to ensure the integrity and quality of PND from a chaplaincy perspective prior to wider implementation. The pilot PND evaluation indicated a favourable satisfaction rating (n = 11/13: 84.6%; M = 4.73/5.0 satisfaction). Phase IV: MIST-3-PND Implementation-involved a larger cohort of ADF Chaplaincy participants (n = 210) completing a revised and finalized PND strategy which was regarded favourably by the majority of ADF Chaplains (n = 201/210: 95.7%; M = 4.73/5.0 satisfaction). Phase V: Summation. In conclusion the positive satisfaction ratings by a significant number of ADF chaplaincy personnel completing MIST-3-PND, provided evidence that chaplains evaluated PND as a suitable counselling, guidance and education strategy, which affirmed its utilisation and justifies further research for using PND to address MI among veterans, that may also prove valuable for other chaplains working in community health and first responder contexts.

Moral injury and its mental health consequences among protesters: findings from Israel's civil protest against the government's judicial reform

Background: Government actions and participating in protracted-duration protests against it affect protesters' mental health, leading to high distress levels, such as posttraumatic and depressive symptoms. Aside from exposure to violence and other issues, protest participation can pose unique challenges to the protesters as they may be exposed to potentially morally injurious events (PMIEs), such as the betrayal of leaders they once trusted. This study's primary objective was to examine the extent of psychological difficulties among civilians participating in long-duration protests in Israel. More specifically, the study aimed to understand the contribution of exposure to protest-related PMIEs to psychological difficulties such as posttraumatic and depressive symptoms.Method: Participants comprised 4036 Israelis who were actively involved in the unfolding civil protest movement against the government-led judicial overhaul between January 2023 and August 2023. The protesters completed validated self-report questionnaires that included measures of PMIE exposure, PTSD and depressive symptoms.Results: About half (44.3%) of the sample met the criteria for self-report diagnosis of major depression and 10.6% for PTSD. Most of the protesters indicated their exposure to at least one moral injury event, with 63.9% reporting exposure to PMIE-Betrayal. Protesters exposed to PMIEs reported significantly higher levels of both PTSD and depression than non-PMIE-exposed protesters. Hierarchical regression analyses revealed that, beyond demographics and protest-related characteristics such as exposure to violence, PMIE dimensions significantly contributed to both PTSD and depression levels.Conclusions: The findings highlight the mental burden of protesters during the civil protests against the judicial overhaul in Israel. More central to the present research, the findings highlight the critical contribution of PMIEs exposure to this burden. Clinicians treating protesters coping with depression and PTSD following the civil actions should attend to their exposure to PMIEs, which may relate to the deleterious psychological effects among protesters.

The relationship of posttraumatic stress disorder and developmental trauma disorder with childhood psychopathology: A network analysis

OBJECTIVE

Potentially traumatic experiences are a major risk factor for mental disorders in children and adolescents. Posttraumatic psychopathology includes trauma-specific disorders such as posttraumatic stress disorder (PTSD) as well as other psychiatric disorders. Developmental Trauma Disorder (DTD) has been proposed as a developmentally sensitive diagnosis. We aimed to further illuminate the co-occurrence of psychiatric conditions with DTD and PTSD.

METHOD

In a convenience sample of families of 507 children and adolescents (mean age = 12.11 years old, SD = 2.92; 48.5% female), we assessed DTD, PTSD, and screened for psychiatric disorders. We estimated network models including DTD, PTSD and ten psychiatric conditions.

RESULTS

We found that DTD and PTSD share both common and differential comorbidity features on disorder-, domain-, and symptom-level. The differential comorbidity patterns of the DTD and PTSD domains placed DTD close to both externalizing and internalizing psychopathology while PTSD was primarily linked to internalizing conditions.

CONCLUSIONS

Our study provides evidence for the complex clinical presentation of posttraumatic psychopathology over and above PTSD in children. DTD and PTSD provide useful and distinct diagnostic categories for children who are also experiencing internalizing conditions, and DTD may be especially relevant for children who are experiencing externalizing psychopathology.

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

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.

Moving Forward from Moral Injury: A Mixed Methods Study Investigating the Use of 3MDR for Treatment-Resistant PTSD

BACKGROUND

Exposure to trauma and potentially morally injurious events may lead to moral injury (MI). The link between MI and posttraumatic stress disorder (PTSD) may have particularly relevant implications for treatment-resistant PTSD (TR-PTSD). Multi-modal Motion-Assisted Memory Desensitization and Reconsolidation (3MDR), a technology-assisted exposure-based trauma therapy that has been used in the treatment of PTSD, may also be an acceptable modality for patients in the treatment of TR-PTSD and MI. This proof-of-concept study aimed to investigate (1) whether MI co-occurs in military members (MMs) and veterans with TR-PTSD, and (2) the perspectives of MMs and veterans with TR-PTSD utilizing 3MDR for MI.

METHODS

This study employed a mixed-methods clinical trial. Military Members and veterans participated in this study (N = 11) through self-reported questionnaires, video recordings of treatment sessions, and semi-structured interviews post-session and post-intervention, with longitudinal follow-up to 6 months.

RESULTS

MI scores correlated with self-reported measures of mental health symptoms related to PTSD. The thematic analysis revealed three emergent themes: (1) Realities of War, (2) Wrestling Scruples, and (3) Moral Sensemaking.

CONCLUSION

MI was highly correlated with TR-PTSD and themes regarding MI. This result, while preliminary, allows for the postulation that MI may be contributing to the continuation of PTSD symptoms in TR-PTSD, and that 3MDR may be an acceptable modality for addressing these symptoms in MMs and veterans.

Moral injury symptoms and related problems among service members and Veterans: A network analysis

LAY SUMMARY

Both moral injury (MI) and posttraumatic stress disorder (PTSD) can result from adverse experiences (potentially morally injurious events [PMIEs] for the former and Criterion A events for the latter) and may lead to similar symptoms. Thus, debate is ongoing as to whether MI and PTSD are distinct. Depressive symptoms can also follow these events and may also overlap with symptoms of MI and PTSD. This study investigated how distinct MI is from PTSD and depression by examining networks composed of MI-related outcomes (trust violation, shame, functioning), PTSD symptom clusters, and depression for participants who reported experiencing a PMIE and those who did not. This study is the first of its kind to use MI outcomes with PTSD and depression in a network analysis. The results suggest that MI, PTSD, and depression are distinct but related phenomena, with more connections between these phenomena present particularly among those who experienced a PMIE. Moreover, the negative alterations in cognition and mood cluster of PTSD and MI-related functioning appears to explain some of the co-occurrence among constructs.

Pre-deployment aggressiveness, combat exposure and moral injury as contributors to posttraumatic stress symptoms among combatants: A two-year prospective study

Combatants who are exposed to events which transgress deeply held moral beliefs might face lasting psychopathological outcomes such as Moral Injury (MI) and posttraumatic stress symptoms (PTSS). However, insight about pre-deployment personality factors which might facilitate the MI process and its negative consequences is sparse. In this prospective study, we examined pre-deployment aggressiveness as a possible predictor of exposure to combat and potentially morally injurious events (PMIEs), trauma-related guilt and shame and PTSS among Israeli active-duty combatants. A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements (T1: 12 months before enlistment, T2: 6 months following enlistment-pre deployment, and T3: 18 months following enlistment-post deployment). Participants' characteristics were assessed via semi-structured interviews (T1) and validated self-report measures of aggressiveness (T2), combat exposure, PMIEs and PTSS (T3) between 2019 and 2021. Results show that higher levels of pre-deployment aggressiveness predicted both combat exposure and PMIEs-'betrayal'. Combat exposure mediated the association between aggressiveness and PTSS post deployment. Importantly, pre-deployment aggressiveness was significantly associated with the PMIEs-'betrayal' that are associated with trauma-related guilt and shame, which in turn were associated with high levels of PTSS post deployment. Our results highlight the implications of pre-deployment aggressiveness for different forms of exposure to potentially traumatic events during military service. Identification of at-risk combatants for PTSS following exposure to PMIEs of betrayal might provide these combatants with a tailor-made type of preparation regarding moral and ethical situations, which should be investigated in future studies.

Ethical conflicts among physicians and nurses during the COVID-19 pandemic: A qualitative study

RATIONALE, AIMS AND OBJECTIVES

The healthcare system and professionals working in the sector have experienced a high caseload during the coronavirus disease 2019 (COVID-19) pandemic. This has increased the potential for morally harmful events that violate professionals' moral codes and values. The aim of this study was to understand and explore experiences of new moral challenges emerging among physicians and nurses caring for individuals during the COVID-19 pandemic.

METHOD

The consolidated criteria for reporting qualitative research (COREQ) checklist was used in this qualitative study based on Gadamer's phenomenology. Participants were selected using a convenience sampling method. Thirteen medicine and nursing graduates were interviewed in depth. The participants all worked on the frontline at the start of the COVID-19 pandemic. Data were gathered in two basic healthcare districts in Spain, encompassing both primary care and hospital care.

RESULTS

Four main themes emerged from the data analysis: (1) Betrayal of moral and ethical values as a key source of suffering; (2) Ethical and moral sense of failure accompanying loss of meaning; (3) Lack of confidence in performance; (4) Self-demand and self-punishment as personal condemnation among healthcare workers.

CONCLUSIONS

Health institutions must implement interventions for health professionals to help mitigate the consequences of experiencing complex ethical scenarios during the pandemic. In addition, they should promote training in moral and ethical deliberation and prepare them to make decisions of great ethical significance.

Causal discovery replicates symptomatic and functional interrelations of posttraumatic stress across five patient populations

Introduction

Approximately half of individuals with posttraumatic stress disorder (PTSD) may meet criteria for other psychiatric disorders, and PTSD symptoms are associated with diminished health and psychosocial functioning. However, few studies examine the longitudinal progression of PTSD symptoms concurrent with related symptom domains and functional outcomes, such that may neglect important longitudinal patterns of symptom progression beyond PTSD specifically.

Methods

Therefore, we used longitudinal causal discovery analysis to examine the longitudinal interrelations among PTSD symptoms, depressive symptoms, substance abuse, and various other domains of functioning in five longitudinal cohorts representing veterans (n = 241), civilians seeking treatment for anxiety disorders (n = 79), civilian women seeking treatment for post-traumatic stress and substance abuse (n = 116), active duty military members assessed 0-90 days following TBI (n = 243), and civilians with a history of TBI (n = 43).

Results

The analyses revealed consistent, directed associations from PTSD symptoms to depressive symptoms, independent longitudinal trajectories of substance use problems, and cascading indirect relations from PTSD symptoms to social functioning through depression as well as direct relations from PTSD symptoms to TBI outcomes.

Discussion

Our findings suggest PTSD symptoms primarily drive depressive symptoms over time, tend to show independence from substance use symptoms, and may cascade into impairment in other domains. The results have implications for refining conceptualization of PTSD co-morbidity and can inform prognostic and treatment hypotheses about individuals experiencing PTSD symptoms along with co-occurring distress or impairment.

Moral injury, depression, and anxiety symptoms among health and social care workers during the COVID-19 pandemic: The moderating role of belongingness

BACKGROUND

The COVID-19 pandemic can affect health and social care workers' (HSCWs') mental health in their role as frontline workers in this crisis. The pandemic poses unique challenges to HSCWs as they face morally daunting decisions while working with limited knowledge and resources. This study primary objective was to examine the moderating role of thwarted belongingness in the relationships between HSCWs' exposure to potentially morally injurious events (PMIEs) and moral injury symptoms, depression, and anxiety.

METHOD

A sample of 296 Israeli HSCWs completed validated self-report questionnaires that include measures of depression, anxiety, PMIE exposure, moral injury symptoms, and a sense of thwarted belongingness.

RESULTS

About one-third (33.6%) of the sample met the criteria for major depression and 21.5% for generalized anxiety. Beyond demographic and work-related characteristics, PMIEs contributed to depression and anxiety levels. The indirect effect of PMIE exposure on anxiety/depression symptoms through MI symptoms was significant only at high levels of thwarted belongingness among HSCWs. Thus, greater PMIE exposure contributes to more MI symptoms, which, in turn, is linked to higher levels of anxiety/depression symptoms among HSCWs with high levels of thwarted belongingness.

LIMITATIONS

Cross-sectional design, self-report questionnaires, sample limited to Israeli HSCWs.

CONCLUSIONS

The study's findings highlight the mental burden of HSCWs during the COVID-19 pandemic and the critical contribution of PMIE exposure and thwarted belongingness to this burden. Clinicians treating HSCWs coping with depression and anxiety following the COVID-19 should also attend to moral injury symptoms as well to the belongingness experience.

Examining the relationships between emotional disorder symptoms in a mixed sample of community adults and patients: A network analysis perspective

According to the literature, comorbidity rates observed on emotional disorders are linked to how the main diagnostic classification systems have traditionally defined these disorders. This paper aims to analyze the structure of symptoms evaluated with the Inventory of Depression and Anxiety Symptoms-II (IDAS-II) with network analysis. A mixed sample (n = 2021) of 1692 community adults and 329 patients was used. 14.79% (n = 299) of the sample met the diagnostic criteria for at least one DSM-5 mental disorder and 5.29% (n = 107) had diagnostic comorbidity. The sample was randomly divided into two sub-samples: estimation sample (n = 1010) and replication sample (n  = 1011). The detection of community structures was carried out on estimation sample using the walktrap algorithm. Four local inference measures were estimated: Strength, one-step Expected Influence, two-step Expected Influence, and node predictability. Exploratory graphic analysis of modularity yielded an optimal solution of two communities on estimation sample: first linked to symptoms of depression and anxiety and second grouping symptoms of bipolar disorder and obsessive – compulsive disorder. Mania, Panic, Claustrophobia, and Low Well-Being Bridge emerged as bridge symptoms, connecting the two substructures. Networks estimated on replication subsamples did not differ significantly in structure. Dysphoria, Traumatic Intrusions and Checking and Ordering were the symptoms with greatest number of connections with rest of the network. Results sheds light on specific links between emotional disorder symptoms and provides useful information for the development of transdiagnostic interventions by identifying the influential symptoms within the internalizing spectrum.

The wounded helper: moral injury contributes to depression and anxiety among Israeli health and social care workers during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic can affect the mental health of health and social care workers (HSCWs) who are frontline workers in this crisis. The pandemic poses unique challenges to HSCWs as they face morally daunting decisions while working with limited knowledge and resources. This study examined the relationships between exposure to potentially morally injurious events (PMIEs) and depression and anxiety among HSCWs.

METHOD

A sample of 243 Israeli HSCWs completed validated self-report questionnaires that include measures of depression, anxiety, exposure to PMIEs, perceived stress, and moral injury symptoms.

RESULTS

About one-third (33.6%) of the sample met the criteria for major depressive disorder, 21.5% met the criteria for generalized anxiety disorder, and 19.1% reported comorbidity of depression and anxiety. Beyond demographic, COVID-19, and work-related characteristics, PMIEs contributed to depression and anxiety among HSCWs. The integrative model indicated the mediating role of perceived stress and moral injury symptoms in the associations of PMIEs with depression and anxiety.

CONCLUSIONS

The study's findings highlight HSCWs' mental burden during the COVID-19 pandemic and the important contribution of exposure to PMIEs to this burden. Clinicians treating HSCWs coping with depression and anxiety following the COVID-19 should also attend to moral injury symptoms.

Potential Circumstances Associated With Moral Injury and Moral Distress in Healthcare Workers and Public Safety Personnel Across the Globe During COVID-19: A Scoping Review

Healthcare workers (HCWs) and public safety personnel (PSP) across the globe have continued to face ethically and morally challenging situations during the COVID-19 pandemic that increase their risk for the development of moral distress (MD) and moral injury (MI). To date, however, the global circumstances that confer risk for MD and MI in these cohorts have not been systematically explored, nor have the unique circumstances that may exist across countries been explored. Here, we sought to identify and compare, across the globe, potentially morally injurious or distressful events (PMIDEs) in HCWs and PSP during the COVID-19 pandemic. A scoping review was conducted to identify and synthesize global knowledge on PMIDEs in HCWs and select PSP. Six databases were searched, including MEDLINE, EMBASE, Web of Science, PsychInfo, CINAHL, and Global Health. A total of 1,412 articles were retrieved, of which 57 articles were included in this review. These articles collectively described the experiences of samples from 19 different countries, which were comprised almost exclusively of HCWs. Given the lack of PSP data, the following results should not be generalized to PSP populations without further research. Using qualitative content analysis, six themes describing circumstances associated with PMIDEs were identified: (1) Risk of contracting or transmitting COVID-19; (2) Inability to work on the frontlines; (3) Provision of suboptimal care; (4) Care prioritization and resource allocation; (5) Perceived lack of support and unfair treatment by their organization; and (6) Stigma, discrimination, and abuse. HCWs described a range of emotions related to these PMIDEs, including anxiety, fear, guilt, shame, burnout, anger, and helplessness. Most PMIDE themes appeared to be shared globally, particularly the 'Risk of contracting or transmitting COVID-19' and the 'Perceived lack of support and unfair treatment by their organization.' Articles included within the theme of 'Stigma, discrimination, and abuse' represented the smallest global distribution of all PMIDE themes. Overall, the present review provides insight into PMIDEs encountered by HCWs across the globe during COVID-19. Further research is required to differentiate the experience of PSP from HCWs, and to explore the impact of social and cultural factors on the experience of MD and MI.

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.

Moral Injury and Suicide Ideation Among Israeli Combat Veterans: The Contribution of Self-Forgiveness and Perceived Social Support

Modern warfare within a civilian setting may expose combatants to severe moral challenges. Whereas most of these challenges are handled effectively, some potentially morally injurious events (PMIEs) may have deleterious psychological, spiritual, and interpersonal effects among them, which may increase the risk for suicide ideation and behaviors (SIB). In this study, we aimed to examine the protective role of self-forgiveness and perceived social support on the relationship between exposure to PMIEs and SIB among combat veterans. A sample of 191 Israeli combat veterans completed validated self-report questionnaires in a cross-sectional design study, tapping moral injury, SIB, perceived social support, and self-forgiveness. Veterans with a history of SIB revealed higher levels of exposure to PMIEs and lower levels of self-forgiveness and perceived social support than veterans with no SIB history. Moreover, beyond the contributions of the PMIE dimensions, significant contributions of self-forgiveness and perceived social support to current suicide ideation (SI) were found. Importantly, the moderating model indicated that higher social support moderated the link between PMIEs and current SI. Based on the current findings, it can be suggested that self-forgiveness and perceived social support are important contributors to lower SI levels among veterans with PMIEs. It can be further suggested that interpersonal support may help veterans develop a sense of belongingness and bonding, which is a plausible basis for diminishing the risk of SI following PMIE exposure.

Burnout of Healthcare Workers Amid the COVID-19 Pandemic: A Follow-Up Study

The coronavirus disease 2019 (COVID-19) pandemic has posed a significant challenge to the modern healthcare system and led to increased burnout among healthcare workers (HCWs). We previously reported that HCWs who engaged in COVID-19 patient care had a significantly higher prevalence of burnout (50.0%) than those who did not in November 2020 (period 1). We performed follow-up surveys in HCWs in a Japanese national university hospital, including basic demographics, whether a participant engaged in care of COVID-19 patients in the past 2 weeks, and the Maslach Burnout Inventory in February 2021 (period 2) and May 2021 (period 3). Periods 1 and 3 were amid the surges of COVID-19 cases, and period 2 was a post-surge period with a comparatively small number of COVID-19 patients requiring hospitalization. Response rates to the surveys were 33/130 (25.4%) in period 1, 36/130 (27.7%) in period 2, and 56/162 (34.6%) in period 3, respectively. While no consistent tendency in the prevalence of burnout based on variables was observed throughout the periods, the prevalence of burnout tends to be higher in periods 1 and 3 in those who engaged in COVID-19 patient care in the last 2 weeks (50.0%, 30.8%, 43.1% in period 1, 2, and 3, respectively). Given the prolonged pandemic causing stigmatization and hatred against HCWs leading to increased prevalence of burnout, high-level interventions and supports are warranted.

Moral Injury: An Increasingly Recognized and Widespread Syndrome

Moral injury (MI), originally discussed in relationship to transgressing moral beliefs and values during wartime among military personnel, has expanded beyond this context to include similar emotions experienced by healthcare professionals, first responders, and others experiencing moral emotions resulting from actions taken or observations made during traumatic events or circumstances. In this article, we review the history, definition, measurement, prevalence, distinctiveness, psychological consequences, manifestations (in and outside of military settings), and correlates of MI in different settings. We also review secular psychological treatments, spiritually integrated therapies, and pastoral care approaches (specific for clergy and chaplains) used to treat MI and the evidence documenting their efficacy. Finally, we examine directions for future research needed to fill the many gaps in our knowledge about MI, how it develops, and how to help those suffering from it.

Exposure to combat incidents within military and civilian populations as possible correlates of potentially morally injurious events and moral injury outcomes among Israeli combat veterans

OBJECTIVES

Exposure to potentially morally injurious events (PMIEs) is considered a necessary but insufficient determinant of moral injury (MI) outcomes. However, a question remains regarding possible acts and the necessary features of PMIEs that should be considered transgressive and might lead to MI psychopathological outcomes. We aim to examine the links between exposure to combat incidents within civilian Palestinian populations (CPPs), PMIEs and MI-related outcomes of posttraumatic stress disorder (PTSD) symptoms (PTSS), trauma-related guilt and shame. We also aim to explore the mediating roles of subjective perceptions of PMIEs in the relationship between exposure to combat incidents within CPP and MI-related outcomes among combat veterans.

METHOD

A volunteer sample of 716 Israeli combat veterans responded to self-report questionnaires in a cross-sectional design study.

RESULTS

Exposure to combat incidents within CPP has been primarily associated with perpetration based PMIEs and MI-related guilt outcomes. Importantly, betrayal-based PMIEs mediated the association between reports of being the victim of verbal violence by militants and/or civilians and MI outcomes. Moreover, perpetration-based PMIEs mediated associations between reports of personal acts, or witnessing acts, of physical and verbal violence and degradation by militants and/or civilians, and MI outcomes.

CONCLUSIONS

Military incidents within civilian populations are related to subjective perceptions of PMIEs and MI-related psychopathological outcomes. While betrayal-based experiences might serve as a mechanism to being a victim of verbal violence and MI outcomes, perpetration-based experiences might serve as mechanisms to physical, verbal and degradation incidents and MI outcomes.

Emotion regulation and experiential avoidance moderate the association between posttraumatic symptoms and alcohol use disorder among Israeli combat veterans

INTRODUCTION

the association between Posttraumatic Stress symptoms (PTSS) and Alcohol Use Disorder (AUD) among combat veterans is well established. However, little is known concerning the intertwining effect of distress oriented coping mechanisms on this association. In this study, we sought to explore the moderating role of experiential avoidance (EA), cognitive reappraisal (CR) and expressive suppression (ES) on the association between PTSS and AUD among Israeli combat veterans.

METHOD

Participants were 189 Israel Defense Forces (IDF) male combat veterans (mean age = 30.03) who completed a set of validated self-report questionnaires assessing PTSS, AUD, EA, CR and ES. Moderation analyses were conducted using a four-step hierarchical regression analysis and an ordinary least squares regression analysis.

RESULTS

Analyses indicated that individuals with average or high levels of EA or ES exhibited significant positive association between PTSS and AUD, yet those with low levels of EA or ES exhibited no significant association between PTSS and AUD (b = 0.14,Confidence Interval (CI)[0.06, 0.22, SE = 0.04, t = 3.65, p = .000, 95%] for EA and b = 0.17, CI[0.07, 0.25, SE = 0.04, t = 3.69, p = .000, 95%] for ES). In addition, CR moderated the association between PTSS and AUD (b = 0.18, CI[0.07, 0.29, SE = 0.06, t = 3.24, p = .001, 95%]), so that the association between PTSS and AUD is positive and stronger for higher levels of CR.

CONCLUSIONS

Our findings imply that EA, ES and CR and emotion regulation may be major facilitators of the association between PTSS and AUD among combat veterans. These findings are discussed in the Israeli context as well as in light of a general psychological perspective.

Moral injury and mental health outcomes among Israeli health and social care workers during the COVID-19 pandemic: a latent class analysis approach

BACKGROUND

The COVID-19 pandemic poses unique challenges to health and social care workers (HSCWs) who face morally challenging and life-threatening decisions. Following exposure to events that transgress moral beliefs and expectations, HSCWs might experience psychological, social, and spiritual problems referred to as Moral Injury (MI).

OBJECTIVE

The objectives of this study were to examine patterns of exposure to potentially morally injurious events (PMIEs) among HSCWs and their associations with MI, mental health outcomes and psychological correlates.

METHOD

A sample of 296 Israeli HSCWs volunteered to complete a cross-sectional electronic survey with validated self-report questionnaires in February and March 2021. Latent Class Analysis (LCA) was used to identify classes characterized by unique patterns of exposure to PMIEs. Socio-demographic, work and COVID-related variables were used to predict patterns of exposure to PMIEs, and differences in mental-health outcomes and psychological correlates between classes were assessed.

RESULTS

Three subgroups were identified: 'high exposure' (19.5%), 'betrayal-only' (31.3%), and 'minimal exposure' (49.4%). Perceived stress increases the odds for inclusion in the 'high exposure' and 'betrayal-only' classes. Participants in both the High Exposure class and the betrayal-only classes reported higher levels of depressive, anxiety, posttraumatic and more moral injury symptoms as compared to the 'minimal exposure' class. Importantly, both 'high exposure' and 'betrayal-only' classes reported lower levels of self-compassion and higher levels of self-criticism, relative to those in the 'minimal exposure' class.

CONCLUSIONS

The study's findings offer an overview of the complex associations between patterns of exposure to PMIEs and associated predictors and outcomes. Clinicians treating HSCWs coping with COVID-19 related stress should be aware of the contribution of exposure to PMIEs to HSCWs' distress and to the unique constellation of high self-criticism and low self-compassion among HSCWs with exposure to PMIEs.

Moral injury in civilians: associations with trauma exposure, PTSD, and suicide behavior

BACKGROUND

Moral injury (MI) describes emotional, spiritual, and social suffering that can arise following psychological trauma. Prior research in military pop ulations indicates the relevance of MI to adverse psychological outcomes, such as post-traumatic stress disorder (PTSD) and suicidal behaviours, and shows evidence for MI as a unique construct. Minimal studies of MI have been implemented in civilians, usually restricted to small samples with a specific set of traumatic experiences, despite the conceptual relevance of MI to non-military trauma reactions more broadly (e.g. feelings of betrayal towards a perpetrator of sexual abuse).

OBJECTIVE

To address this problem, we assessed MI in trauma-exposed civilians to examine ways in which this construct was related to and distinct from trauma and traumatic stress-related problems, including PTSD and depression.

METHOD

We adapted an existing MI scale, Moral Injury Events Scale (MIES) and administered this measure to 81 men and women along with measures of trauma exposure, PTSD and depression, and also asked participants about past suicide attempts.

RESULTS

We observed that both greater exposure and distress related to potentially morally injurious events were associated with higher trauma exposure, particularly childhood maltreatment, as well as post-traumatic and depressive psychopathology. However, even after accounting for current PTSD and depression symptoms, MI exposure (F = 6.05, p = .017) was significantly higher among participants who had previously attempted suicide.

CONCLUSIONS

These pilot data reveal the ways in which MI is associated with trauma exposure, PTSD and depression and highlight the salience of MI in civilians. Similarly, these data demonstrate the unique relevance of MI to suicide behaviours, independent of post-traumatic psychopathology, indicating that this construct may be an understudied contributor to suicide risk in civilians.