Moral injury, perceived burdensomeness, thwarted belongingness, and suicidal ideation in post-9/11 US combat veterans

Background: Moral injury – the psychological harm resulting from acts of wrongdoing or betrayals – correlates with negative psychosocial outcomes, including increased suicide risk. The Interpersonal Theory of Suicide (IPTS) suggests that perceived burdensomeness (the belief that one is a burden to others), and thwarted belongingness (psychological pain from unmet social connectedness) confer risk of suicidal ideation. Objective: The current study evaluates the degree to which perceived burdensomeness and thwarted belongingness mediates the associations of acts of wrongdoing and betrayal with current suicidal ideation. Method: We used a generative modelling approach with Bayesian latent variable models in a sample of 312 United States combat-deployed veterans. Results: Acts of wrongdoing were (1) directly associated with current suicidal ideation, with small effect (β = 0.15, 95% credible interval (CI): −0.01, 0.30); (2) indirectly associated via perceived burdensomeness, with small effect (β = 0.14, 95% CI: 0.06, 0.24); and (3) indirectly associated with thwarted belongingness, with negligible effect (β = 0.04, 95% CI: 0.00, 0.10). Acts of betrayal had negligible associations with current suicidal ideation. Conclusions: Feelings of burdensomeness warrant further investigation as a potential clinical target for veterans with moral injury exposure. Thwarted belongingness may be less potent, although measurement error complicates its interpretation. We explored the association between potentially morally injurious events and suicidal ideation using a model derived from the Interpersonal Theory of Suicide and we distinguished between acts of wrongdoing- and betrayal-related potentially morally injurious events.We tested this mediation model using a generative modelling approach with Bayesian latent variables which accounted for nonnormal and skewed suicidal ideation data.We found that acts of wrongdoing were associated with increased suicidal ideation via increased perceived burdensomeness, with small effect, but not via thwarted belongingness.Betrayal was not directly or indirectly associated with suicidal ideation.Clinical interventions could address a sense of being a burden because of perceived wrongdoing to decrease suicide ideation. We explored the association between potentially morally injurious events and suicidal ideation using a model derived from the Interpersonal Theory of Suicide and we distinguished between acts of wrongdoing- and betrayal-related potentially morally injurious events. We tested this mediation model using a generative modelling approach with Bayesian latent variables which accounted for nonnormal and skewed suicidal ideation data. We found that acts of wrongdoing were associated with increased suicidal ideation via increased perceived burdensomeness, with small effect, but not via thwarted belongingness. Betrayal was not directly or indirectly associated with suicidal ideation. Clinical interventions could address a sense of being a burden because of perceived wrongdoing to decrease suicide ideation.