Deployment-Related Moral Injury Contributes to Post-Discharge Depression and Anxiety Symptoms: A Six-Year Longitudinal Study Among Israeli Combat Veterans

Background: Military personnel and active combatants are known to be at risk for perpetrating or witnessing acts that violate their moral code. These events, termed potentially morally injurious events (PMIEs), were found to be associated in cross-sectional studies with an increased risk of mental and behavioral health problems, such as depression and anxiety symptoms. However, the longitudinal contribution of deployment-related PMIEs and moral injury (MI) outcomes to depression and anxiety symptoms among veterans remain unclear, particularly during their initial years following discharge. Method: Participants were 169 Israeli combat veterans who participated in a six-year longitudinal study with four measurement points (T1: 12 months before enlistment, T2: Six months following enlistment–pre-deployment, T3: 18 months following enlistment–post-deployment, and T4: 28 months following discharge). Participants’ characteristics were assessed between 2019–2024 via semi-structured interviews (T1) and validated self-report measures (T2-T4). Results: Exposure to PMIE-Self (i.e. self-perpetrated potentially morally injurious events) at T3 predicted severity of depressive symptoms (T4), and MI-outcomes of shame and trust-violation (T4) predicted both severity of depressive and anxiety symptoms (T4), above and beyond the pre-enlistment personal characteristics (T1), depressive and anxiety symptoms (T2 and T3), personality risk factors (T2) and combat exposure (T3). Conclusions: Deployment-related PMIE experiences, especially PMIE-Self experiences, and MI outcomes, were found to be valid predictors of higher severity of depression and anxiety symptoms following discharge. Routine screening and targeted interventions should be available to combatants upon their discharge from the military, a transition identified as vulnerable to the consequences of moral injury.