Moral Injury is Independently—and Significantly—Associated with Suicidal Thoughts and Behaviors Among Veterans

BACKGROUND:
This study investigated the connection between moral injury—the distressing psychological, behavioral, social, and sometimes spiritual aftermath of witnessing, failing to prevent, or participating in events that contradict one’s values and beliefs—and suicidal thoughts and behaviors. The research team used the Moral Injury and Distress Scale (MIDS), a measure developed and validated by VA clinicians and researchers. The MIDS uses a cutoff score to differentiate between moral distress, a negative emotional reaction any person is likely to feel after a traumatic event, and moral injury, the deeper wounds of the mind and spirit that persist and interfere with day-to-day living. Researchers surveyed a national sample of 1,232 participants comprising 401 combat Veterans, 431 healthcare workers, and 400 first responders from July-September 2021 to determine the association of probable moral injury with suicidal ideation and suicide attempts.

FINDINGS:

• Overall, 6% of the sample screened positive for probable moral injury. Screening positive was associated with approximately three times higher odds of experiencing suicidal ideation in the past two weeks and six times higher odds of attempting suicide in one's lifetime, even after controlling for demographics and probable PTSD and depressive disorder.
• Among those who screened positive for probable moral injury, 66% endorsed suicidal ideation in the past 2 weeks, compared to 9% of those who screened negative. Additionally, 41% of those who screened positive endorsed having attempted suicide in their lifetime compared to 5% of those who screened negative.

IMPLICATIONS:

• Moral injury is a distinct suicide risk factor for Veterans, independent of other conditions. This finding suggests that screening for moral injury may help to reduce Veteran suicide.
• The MIDS cutoff score may help VA clinicians identify Veterans at particularly high risk for suicidal thoughts and behaviors.
• Veterans may benefit from interventions that specifically target moral injury.

LIMITATIONS:

• While the study’s data suggest an important relationship between moral injury and suicide, a causal relationship cannot be inferred from the results.
• Because women are more likely to survive a suicide attempt than men, a “survivorship bias” may have affected the results.

AUTHOR/FUNDING INFORMATION:
This study was internally supported by the National Center for PTSD (NCPTSD) where Dr. Norman is a researcher and HSR’s Center for Mental Healthcare and Outcomes Research (CeMHOR), where Dr. Griffin is a researcher. Dr. Maguen is with HSR’s Center for Data to Discovery and Delivery Innovation (3DI). Dr. McCue is with the VA Center of Excellence for Stress and Mental Health (CESAMH).

Griffin BJ, Maguen S, McCue ML, Pietrzak RH, McLean CP, Hamblen JL, Jendro AM, and Norman SB. Moral Injury is Independently Associated with Suicidal Ideation and Suicide Attempt in High-Stress, Service-Oriented Occupations. NPJ Mental Health Research. August 1, 2025;4:32.