An important aspect of veterans' mental health is moral injury (MI) and its impact. A moral injury can occur in response to acting or witnessing behaviors that go against an individual's values and moral beliefs. In traumatic situations, people may perpetrate, fail to prevent, or witness events that contradict deeply held moral beliefs and expectations (Norman & Maguen, 2021). Of veterans, over half have experienced moral injuries (Koenig et al., 2019). It’s often associated with a comorbidity of mental health issues such as suicide ideation and post-traumatic stress disorder (PTSD).
Research has shown that moral injury is common among veterans with PTSD (Currier et al., 2019). Moral injury can accompany feelings of guilt, shame, self-condemnation, loss of trust, loss of meaning, and spiritual struggles. Veterans who experience PTSD symptoms might struggle with co-occurring cognitive, emotional, and behavioral conflicts that may have been caused by moral injuries. For some individuals, transgressing cherished moral values or experiencing betrayal by trusted others in high-stakes situations may be severely traumatic (Koenig et al., 2019). The identification and treatment of MI among those with PTSD may help in the management of symptoms.
Recent research suggests that exposure to potentially morally injurious experiences may be associated with an increased risk for suicidal behavior among US combat veterans. Data from survey results were analyzed and showed that depression and PTSD were strong correlators of suicide ideation and attempts among those who experienced moral injury (Nichter et al., 2021). The events in combat and other missions may violate one’s deeply held belief systems and, for some service members, may result in inner conflict. Exposure to wartime atrocities and combat-related guilt has been shown to predict increased suicidal ideation (Bravo et al., 2020). To better inform prevention and treatment efforts among veterans, it’s important to identify risk factors that may moderate associations between moral injury and suicidal behavior.
Moral injury can be self-directed or other-directed. The two categories are defined by the attribution of responsibility for the event: personal responsibility (veteran's reported distress is related to his own behavior) versus responsibility of others (veteran's distress is related to actions taken by others) (Schorr et al., 2018). In one study, self-compassion was found to combat feelings of overidentification, or a tendency to overidentify with one’s failings and shortcomings that resulted after self-directed moral injury. Mindfulness and social connectedness also were found to weaken the impact of other-directed moral injury (Kelley et al., 2019). Prayer and meditation teach individuals to bring awareness to the present moment, with a sense of nonjudgment and acceptance of current thoughts, emotions, and sensations. These may be variables that mental health professionals should consider when working with veterans who have experienced moral injuries.
Some resources on moral injury include:
Bipolar disorder is a chronic mood disorder that affects about 2.8% of the US adult population annually (National Alliance on Mental Health, 2022). It’s characterized by manic or hypomanic states alternating or intermixed with cycles of depression. It consists of three types (Bipolar 1, Bipolar 2, and Cyclothymia) which involve clear changes in mood, energy, and activity levels. (National Institute of Mental Health, 2020).
The median age of onset for bipolar disorder is 25 years, and it can develop equally in men and women of all races, ethnic groups, and social classes (National Alliance on Mental Health, 2022). The way they may differ, however, is how rapid each mood cycle is and how often they occur. In addition, more than two-thirds of people with bipolar disorder have at least one close relative with the disorder or with unipolar major depression, indicating that the disease has a heritable component (National Institute of Mental Health, 2020).
Some bipolar disorder symptoms are similar to those of other illnesses, which can make it challenging for a healthcare provider to make a diagnosis. Also, many individuals with bipolar disorder may have another mental condition or disorder such as anxiety disorder, substance use disorder, ADHD, or an eating disorder (National Institute of Mental Health, 2020). Sometimes, a person with severe episodes of mania or depression may experience psychotic symptoms, such as hallucinations or delusions that tend to match the person’s extreme mood. As a result, people with bipolar disorder who also have psychotic symptoms are often incorrectly diagnosed with schizophrenia. When those who have symptoms of bipolar disorder also experience periods of psychosis that are separate from mood episodes, the diagnosis may be schizoaffective disorder (National Institute of Mental Health, 2020).
Bipolar disorder carries one of the highest risks of suicide compared to all other mental disorders, meaning almost half of people with bipolar disorder attempt suicide in their life (National Alliance on Mental Health, 2022). Suicidal behavior is primarily associated with depressed mood cycles - major depressive episodes are associated with the highest risk of suicide, followed by mixed episodes, and finally manic episodes, which are associated with the lowest risk of suicide. In addition, researchers found that risk factors for suicide include male gender, living alone, divorced, no children, Caucasian, unemployment, and a personal history of suicide attempt and family history of suicide attempt or suicide (Miller & Black, 2020). By assessing the risk of suicide in those with bipolar disorder, early intervention and treatment of bipolar depression along with close observation and follow-up is the most effective way to mitigate the risk of suicide.
Unfortunately, bipolar disorder is left untreated in half of the diagnosed individuals in any given year. Although there is no cure, the optimal treatment plan for bipolar disorder is a combination of medication and cognitive-behavioral therapy (McIntyre et al., 2020). And while pharmacological treatments have been found to be effective in treating the disorder, they’re not universally available. Culture and society also play key roles in how mental health and mental health treatment are perceived. Luckily, there is change being made and more resources are becoming available to help bring awareness to the accessibility of mental health treatment. If you want to learn more about bipolar disorder, visit the International Society for Bipolar Disorder and International Bipolar Foundation.
In honor of Suicide Prevention Awareness Month, it’s important to discuss the effect suicide can have on different people. Secondhand suicide is an umbrella term representing both social and personal factors that can contribute to a ripple effect of suicide. Because the nature of suicide is tragic and often romanticized in books and media, suicide clusters and copycat suicides often occur. Individually, suicide can also be triggered due to the loss of a loved one and feelings of helplessness. The topic of secondhand suicide has become prevalent and is being studied by many researchers.
Secondhand suicide also refers to feelings of apathy and desire to end one’s life. People who are willing to die but won’t do it themselves hope that something else will do it for them that is out of their control such as disease, car accident, etc. This gray area is often overlooked when discussing suicide prevention. But like with suicide, these individuals may end up taking more risks because they see no value in their life. This can be just as deadly and should be acknowledged when bringing awareness. I’ve noticed that a common trend when I was a teenager and is still going on today is the “sad girl” era. Social media such as Myspace and Tumblr circulated a lot of content involving romanticized pictures and quotes of suicide. Even now with the recent news of the effects of climate change, many are joking about how they would be okay if the world ended soon. There is a sense of apathy and disassociation that is unfortunately being taken as a joke when in reality, it limits innovation and a desire to bring forth change. This must be recognized as a more serious issue.
Suicide clusters and copycat suicides have historically been triggered by shows such as “13 Reasons Why” and celebrity deaths such as Marilyn Monroe. Her death was the first ever to cause a 12% rise in suicides. In the 1970s, David Phillips coined the term “The Werther Effect” to represent the increase in suicides after a highly publicized suicide or death. Because there is a direct correlation between media coverage of suicide and contagion, results indicate that those in a “vulnerable state” should be protected from exposure to stories of suicide (Olson, 2012). However, in today’s society, this is almost virtually impossible. So it’s up to the media to practice discretion and consider suicide contagion when reporting on celebrity deaths.
According to Bridge et al. (2019), the Netflix show “13 Reasons Why” was significantly associated with a 29% increase in suicide rates among children aged 10-17 during April 2017. The results suggest that the show may have elevated suicide awareness, but it also appears to have been associated with increased suicidal ideation. Suicide contagion is often fostered by stories that sensationalize and glorify depictions of suicidal behavior, present suicide as a means of accomplishing a goal such as community change or revenge, or offer potential prescriptions of “how-to” die by suicide. Responsible portrayals of suicide, mental illness, and related issues have the potential to promote awareness, reduce stigma, and refute misperceptions that suicide cannot be prevented. Unfortunately, media depictions about suicide also have the potential to do harm, often through a process in which direct or indirect exposure to suicide increases the risk of subsequent suicidal behavior.
Within communities and organizations, suicide clusters can be prevented by establishing a group or agency that can intervene after a major event or death. Their role would be to connect community members or employees with resources from mental health professionals, support groups, suicide crisis centers and hotlines, school counselors, etc. This coordinating committee should have a response plan established so that everyone can get help when they need it.
On a personal level, overwhelming grief and regret can cause someone to commit suicide. This is often seen in parents who lose children and blame themselves for their death. There is no easy way for us to grieve after a tragedy, and the hardest part about grief is that only time will heal all. Whether it takes months, years, or decades, everyone grieves in their own way. Having people you could turn to such as family, friends, and support groups can help a great deal in the healing process. Sharing stories of loss can help you understand and empathize with others. Also, practicing spiritual and religious customs and traditions can help us come to terms with the afterlife. And if possible, always try to seek out a mental health professional when having thoughts of suicide.
Other resources for suicide prevention
Bridge, J. A., Greenhouse, J. B., Ruch, D., Stevens J., Ackerman, J., Sheftall, A. H., Horowitz, J. M., Kelleher, K. J. & Campo, J. V. (2019). Association between the release of Netflix’s 13 Reasons Why and suicide rates in the United States: An interrupted time series analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 59(2), 236-243. DOI: https://doi.org/10.1016/j.jaac.2019.04.020
Olson, R. (2012). Suicide contagion and suicide clusters. Centre for Suicide Prevention. Retrieved from https://www.suicideinfo.ca/resource/suicidecontagion/