Moral Injury (MI) is the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, bearing witness to, or being the victim of acts that transgress deeply held beliefs about right and wrong. There is widespread acceptance of and interest in MI, but this has outpaced scientific examination. To date, the knowledge gaps are: (1) no consensus definition of the symptoms that comprise the MI syndrome; (2) no gold standard clinical assessment measure of MI as an outcome; (3) no definition of functionally impairing clinically significant MI; (4) no epidemiological studies of the prevalence of different types of potentially morally injurious events (PMIEs) and MI; (5) insufficient evidence that MI has incremental clinical and explanatory validity; and (6) a lack of information about risk and resilience and the clinical care needs of Veterans with MI. In this project, we have the following five aims: (1) to determine the US Veteran population prevalence of exposure to different types of PMIEs. We have shown that different types of PMIEs are associated with a unique constellation of problems. We hypothesize that non-perpetration based PMIEs (e.g., high stakes betrayal by trusted others) will be most prevalent; (2) to generate an optimally efficient threshold severity score on the Moral Injury Outcome Scale (MIOS) that suggests probable functionally impairing MI. Currently, there is no method that can be used by clinicians and researchers to determine the clinical significance of MI as an outcome. This means that there is no way to distinguish moral frustration and moral distress, which are common, from MI, a low base-rate clinical problem greatly affecting functioning, quality of life, and potentially requiring treatment. A threshold score for caseness will help clinicians and researchers screen and assess MI. We will use Receiver Operating Characteristic analyses, using upper quartile scores on a quality of life and functioning measure as the criterion; (3) (primary) is to determine the prevalence of MI cases and to explore prevalence by type of PMIE (we have no predictions about whether different types of PMIEs will be associated with greater or lesser case prevalence). A secondary aim is to determine the normative mean severity (and SD) of MIOS total and subscale scores and to explore these variables by type of PMIEs (or no PMIE endorsement). We hypothesize that Veterans who endorse perpetration-based PMIEs will have higher MIOS shame scores relative to those that endorse non-perpetration-based PMIEs, and vice versa; (4) to examine the incremental validity of MI relative to PTSD and Depression, by testing the association between MIOS scores and a measure of quality of life and functioning, relative to PTSD and depression. We predict that MI symptoms will account for unique variance in functional problems; and (5) to conduct qualitative interviews of randomly selected MI cases and matched Veterans who endorse exposure to PMIEs but low MI symptoms and functional impact, to explore the PMIE and event context, as well as personal, professional, and social risk and protective factors affecting outcomes after exposure to PMIEs. This exploratory aim is designed to generate hypotheses about risk and resilience for MI and unaddressed targets for prevention and treatment to mitigate the functional impact of MI in Veterans. We will accomplish these aims by conducting a web survey of Veterans recruited from KnowledgePanel® (KP), a research panel of more than 50,000 households maintained by Ipsos. KP is the largest online panel that is representative of the US population. Ipsos currently has ~5,000 Veterans in KP and has been conducting epidemiological surveys with Veterans for 20 years. Ipsos uses random probabilistic sampling methods, which means that results will be representative of US Veterans. Sampling weights will be applied to inferential analyses to yield US Veteran population-based estimates of exposure to different types of PMIEs for Aim 1 and the prevalence of MI as an outcome for Aim 3. Aim 5 entails conducting qualitative interviews with MI cases and matched controls from the survey sample. Data will be coded themes about the impact of PMIEs and strategies to repair MI will be extracted.

Moral Injury (MI) is defined as the lasting psychological, biological, spiritual, behavioral, and social impact of perpetrating, failing to prevent, bearing witness to, or being the victim of acts that transgress deeply held moral beliefs and expectations. Until recently, there has been no gold standard measure of MI and no information about the extent of this problem among Veterans. This proposal entails the first national representative epidemiological survey study of reports of exposure to potentially morally injurious events, and the extent of MI in US Veterans. Because there is no way to define clinical cases of MI, we will use the survey results to generate a cut-score on a new gold standard measure of MI that indicates clinically impairing levels of MI symptoms and report the prevalence of such cases. We will also determine the clinical value of MI, relative to PTSD and Depression, in explaining functional problems in Veterans. Finally, we will interview a random set of MI cases and controls to examine risk and resilience and the clinical care needs of Veterans with MI.