Moral Injury, Mental Health, and Behavioral Health Outcomes: A Systematic Review of the Literature.

BACKGROUND: Despite a burgeoning of research on moral injury in the past decade, existing reviews have not explored the breadth of consequences and the multitude of pathways through which moral injury and potentially morally injurious experiences (PMIEs) influence mental and behavioral health outcomes. PURPOSE: To identify associations between moral injury on mental and behavioral health. PROCEDURE: Literature searches of psychological and medical databases were conducted through April 2020. Eligible studies measured moral injury or PMIEs, and health outcomes (e.g., depression, substance use, suicidality). MAIN FINDINGS: Fifty-seven publications representing 49 separate samples were included. Studies examined the impact of moral injury on PTSD (n=43); depression (n=32); anxiety (n=15); suicide (n=15); substance use (n=14); and "other" health outcomes, including pain, burnout, sleep disturbance, and treatment-seeking behaviors (n=11). The majority of studies found significant positive associations between moral injury-related constructs, mental health, and behavioral health outcomes; however, the majority were also cross-sectional and focused on military samples. Proposed mediators included lack of social support, negative cognitions, and meaning-making. Moderators included self-compassion, pre-deployment mental health education, and mindfulness. CONCLUSIONS: Moral injury is associated with a variety of negative health outcomes. Research is needed to determine the mechanisms by which moral injury may influence these outcomes over time.