Exposure to morally injurious events, PTSD, and suicidal ideation in U.S. combat veterans: Moderating effects of attachment security and gratitude.

INTRODUCTION

Exposure to potentially morally injurious events (PMIEs) has emerged as a critical determinant of veteran mental health, with growing evidence linking exposure to PMIEs to heightened risk for posttraumatic stress disorder (PTSD) and suicidal ideation (SI). This study evaluated whether protective psychosocial characteristics may moderate associations between PMIE exposure severity and PTSD and SI in a nationally representative sample of combat-exposed U.S. veterans.

METHODS

Data were analyzed from a nationally representative sample of 1321 combat-exposed veterans who participated in the National Health and Resilience in Veterans Study. PMIE exposures, PTSD symptoms, SI, and multiple psychosocial and social-connectedness variables were assessed using validated measures, and multivariable logistic regression models tested main and interactive effects while adjusting for sociodemographic, military, trauma, and health-related covariates.

RESULTS

PMIE exposure severity was significantly associated with increased odds of both PTSD and SI. Attachment style and gratitude moderated these associations. Veterans with insecure attachment demonstrated the steepest increases in PTSD and SI probability as a function of greater PMIE exposure severity. In contrast, securely attached veterans showed comparatively attenuated risk, even at higher levels of PMIE exposure. Gratitude also buffered the association between moral injury and SI, with higher gratitude linked to a less pronounced increase in SI probability.

DISCUSSION: Secure attachment style and gratitude may help protect against the adverse mental health effects of PMIE exposure. Interventions that strengthen these modifiable psychosocial capacities may help mitigate PTSD symptoms and SI among veterans exposed to morally injurious events.