The prevalence of moral distress and moral injury among U.S. veterans

Moral injury is a syndrome that involves adverse outcomes stemming from experiences violating deeply held moral beliefs. Moral injury has emerged as a distinct mental health concern, yet its prevalence among U.S. veterans remains uncertain. The aim of this study was to determine the prevalence of potentially morally injurious events (PMIEs), moral distress, and moral injury among U.S. veterans. This cross-sectional study surveyed a nationally representative sample of 3002 U.S. veterans using KnowledgePanel. The Moral Injury Outcome Scale assessed PMIE exposure, moral distress (subclinical), moral injury (clinical syndrome), and their functional impact. Among respondents, 44.7 % (95 % CI, 42.1-47.2) endorsed PMIEs; 45.2 % reported witnessing inhumanity, 40.2 % were directly affected by others' transgressions, and 14.0 % reported perpetrating transgressive acts. The weighted prevalence of moral distress and moral injury among PMIE endorsers was 9.1 % (95 % CI, 7.1-11.2) and 13.1 % (95 % CI, 9.9-16.3), respectively. In the full sample, prevalence was 4.1 % (95 % CI, 3.1-5.0) for moral distress and 5.9 % (95 % CI, 4.4-7.4) for moral injury. Moral injury was associated with significant functional impairment, with most cases characterized by shame-related (47.8 %) or blended subvariant symptoms (33.3 %). Approximately 664,000 and 955,000 U.S. veterans report functionally impairing moral distress and moral injury, respectively. These findings highlight the need for surveillance, mitigation, and treatment for these unique mental health challenges.