Longitudinal Associations between Trauma-Related Guilt, Potentially Morally Injurious Events, and Mental Health Disorders

Background and Purpose: Potentially morally injurious events (PMIEs) have been linked to a range of adverse mental health outcomes among veterans, including posttraumatic stress disorder (PTSD), depression, and anxiety. Trauma-related guilt has been identified as a key component of moral injury, yet less is known about how trauma-related guilt shapes associations between PMIE exposure and subsequent psychological distress over time. The present study examined longitudinal main and moderating effects of PMIE exposure and trauma-related guilt on PTSD, depression, and anxiety symptoms among U.S. veterans.

Methods: Data were drawn from a longitudinal survey of U.S. veterans (N = 1,230) assessed at 12-, 18-, and 24-month follow-ups. PMIE exposure was assessed at Time 1, trauma-related guilt domains at Time 2, and mental health outcomes at Time 3. Outcomes included symptoms of PTSD, depression, and anxiety. Models controlled for demographic characteristics, combat exposure, and prior levels of each outcome. Two models were estimated for each outcome. Model 1 examined main effects of PMIE exposure and trauma-related guilt domains. Model 2 tested moderation effects by including interactions between PMIE exposure and trauma-related guilt domains. Analyses were conducted using regression-based longitudinal models.

Results: Trauma-related guilt demonstrated differential main effects across outcomes, whereas PMIE exposure was associated with anxiety and PTSD symptoms but not depression. Moderation findings were selective rather than uniform. Trauma-related guilt distress significantly moderated associations between PMIEs and anxiety (B = −0.49, 95% CI [−0.81, −0.17]) and PTSD symptoms (B = −1.01, 95% CI [−1.89, −0.14]). Global guilt significantly moderated associations between PMIEs and anxiety (B = 0.49, 95% CI [0.10, 0.87]) and depression symptoms (B = 0.49, 95% CI [0.06, 0.93]). Guilt cognitions did not significantly moderate any outcome.

Conclusions and Implications:

Findings suggest that trauma-related guilt may shape variability in psychological responses following PMIE exposure, with different guilt domains influencing associations with PTSD, depression, and anxiety in distinct ways. This interpretation is consistent with prior longitudinal work indicating that trauma-related guilt did not mediate associations between PMIEs and mental health outcomes. Together, these findings suggest that trauma-related guilt may reflect processes that operate outside traditional PTSD pathways, consistent with the Dual-Process Model of Moral Injury. These findings further suggest that guilt may function as an important emotional response to morally injurious experiences that is not fully captured by PTSD symptom frameworks. Clinically, assessing trauma-related guilt domains may help identify veterans who are more vulnerable to distress following PMIE exposure and inform treatment planning by highlighting whether interventions should target emotional distress, global self-evaluations, or responsibility-related cognitions. Future research should further examine how moral injury–related emotional responses influence variability in mental health outcomes following PMIE exposure.