Occupational moral injury and mental health: systematic review and meta-analysis

Br J Psychiatry. 2018 Jun;212(6):339-346. doi: 10.1192/bjp.2018.55.


Background: Many people confront potentially morally injurious experiences (PMIEs) in the course of their work which can violate deeply held moral values or beliefs, putting them at risk for psychological difficulties (e.g. post-traumatic stress disorder (PTSD), depression, etc.).AimsWe aimed to assess the effect of moral injury on mental health outcomes.

Method: We conducted a systematic review and meta-analysis to assess the association between work-related PMIEs and mental health disorders. Studies were independently assessed for methodological quality and potential moderator variables, including participant age, gender and PMIE factors, were also examined.

Results: Thirteen studies were included, representing 6373 participants. PMIEs accounted for 9.4% of the variance in PTSD, 5.2% of the variance in depression and 2.0% of the variance in suicidality. PMIEs were associated with more symptoms of anxiety and behavioural problems (e.g. hostility), although this relationship was not consistently significant. Moderator analyses indicated that methodological factors (e.g. PMIE measurement tool), demographic characteristics and PMIE variables (e.g. military v. non-military context) did not affect the association between a PMIE and mental health outcomes.

Conclusions: Most studies examined occupational PMIEs in military samples and additional studies investigating the effect of PMIEs on civilians are needed. Given the limited number of high-quality studies available, only tentative conclusions about the association between exposure to PMIEs and mental health disorders can be made.Declaration of interestNone.

Keywords: Moral injury; PTSD; depression; meta-analysis; occupation; suicidality; systematic review.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Depressive Disorder / epidemiology*
  • Humans
  • Military Personnel / statistics & numerical data*
  • Morals*
  • Occupational Diseases / epidemiology*
  • Stress Disorders, Post-Traumatic / epidemiology*
  • Suicide / statistics & numerical data*