Moral Injury as a Unique Predictor of Suicidal Ideation in a Veteran Sample With a Substance Use Disorder

Objective: Suicide among military veterans accounts for 22.2% of all suicide deaths in the United States per year, and veterans with a substance use disorder (SUD) are at an even higher risk for death by suicide. This prevalence has led to increased efforts to identify and investigate both potential risks and protective factors for veterans. This study examines relationships between depression symptomology, exposure to potentially morally injurious events, posttraumatic stress disorder (PTSD) diagnosis, and suicidal ideation, with the primary aim of examining exposure to moral injurious events as a risk factor for suicide in veterans with SUD. Method: An inpatient sample of 40 veterans with an active SUD admitted for suicidal ideation was evaluated to examine differences in suicidal ideation, depression symptomology, and exposure to morally injurious events in participants with and without a PTSD diagnosis. Further, exposure to morally injurious events and depression symptomology were examined as predictors of suicidal ideation. Results: Analyses revealed that exposure to morally injurious events (d = 1.72) and depression symptomology (d = 0.72) were higher in participants with a PTSD diagnosis compared to those without a diagnosis, though no significant differences emerged between the two groups on suicidality. A hierarchical regression analysis indicated that only exposure to morally injurious events significantly accounted for variance in suicidality (beta = .31, p = .04, 95% confidence interval [.01, .37]). Conclusions: These results suggest that although PTSD may be associated with exposure to morally injurious events and depression symptoms, exposure to morally injurious events may potentially lead to higher suicide risk among veterans above and beyond PTSD and depressive symptoms. Clinical Impact Statement Suicide among veterans with a substance use disorder is a significant problem. This study seeks to improve researchers' knowledge about suicide risk and potential risk factors by examining the links between exposure to exposure to morally injurious events and suicidal thoughts in a sample of veterans who were recently hospitalized. Better understanding the associations between exposure to morally injurious events, substance use, and suicide risk is important for improving clinical care of veterans with exposure to morally injurious events.