Moral injury and PTSD among Ukrainians exposed to full-scale war

Background: Russia's full-scale invasion of Ukraine has exposed millions of civilians and military personnel to chronic traumatic stress, creating conditions for both posttraumatic stress disorder (PTSD) and moral injury (MI).Objective: This study examined probable PTSD prevalence, dimensional associations between PTSD severity and MI outcomes, PTSD symptom-cluster associations with MI, covariate- adjusted MI differences by probable PTSD status, construct-overlap sensitivity analyses, and the structural validity and reliability of the Ukrainian PCL-5 and MIOS Part 2.Method: A cross-sectional survey was completed by 5,523 Ukrainian adults residing inside Ukraine during May–July 2025 (M_age = 37.2 years; 88.9% male; 66.6% civilians). Probable PTSD was defined as PCL-5 ≥ 33, with prevalence also examined across cutoffs of 31 -33. Pearson correlations, cluster-level correlations, continuous PCL-5 regression models, and ANCOVAs were conducted. ANCOVAs compared MIOS total, shame-related, and trust- violation-related scores by probable PTSD status, adjusting for gender, education, and combat status. Sensitivity analyses removed overlapping PCL-5 Cluster D and Negative Affect items. CFAs evaluated the PCL-5 and MIOS factor structures.Results: Probable PTSD was identified in 8.6% of participants, with estimates of 8.6%–9.5% across cutoffs of 31–33. PTSD severity correlated moderately to strongly with MIOS total, shame, and trust violation, with Cluster D showing the strongest associations. Continuous PCL-5 models were significant for all MIOS outcomes. Adjusted ANCOVAs showed higher MIOS total, shame, and trust-violation scores among participants with probable PTSD. Associations remained moderate to strong after removing overlapping PCL-5 content. CFAs supported the Hybrid 7-factor PCL-5 structure and two-factor MIOS structure, with excellent reliability.Conclusions: The Ukrainian PCL-5 and MIOS Part 2 showed structural validity and reliability. PTSD symptoms were associated with MI outcomes, especially trust violation, suggesting that Ukrainian mental health care should address betrayal, loss of faith in humanity, and disrupted moral assumptions alongside PTSD symptoms.