Among 215 Israeli combat veterans who used cannabis regularly, moral injury from perpetrating or witnessing betrayal was associated with cannabis use disorder, with depression mediating the relationship.
Military psychologists, veteran addiction counselors, PTSD researchers, and moral injury clinicians.
Depression mediated the moral injury to cannabis use disorder pathway
What the researchers found
Moral injury from self-perpetration and betrayal were positively associated with CUD. Depression mediated the MI-CUD relationship. Surprisingly, the MI-CUD association was significant only among those with average or high perceived social support, suggesting social support alone does not protect against this pathway.
Why it matters
Understanding that moral injury drives cannabis dependence through depression in veterans opens specific therapeutic targets: treating the depression and moral distress rather than focusing solely on cannabis cessation.
The numbers in context
Sample: 215 male combat veterans. Cannabis use: 3+ days weekly for 6+ months. Depression mediated MI-self to CUD (direct effect beta=0.13, p=0.1). Depression mediated MI-betrayal to CUD (beta=0.20, p=0.04). MI-CUD link only significant with average/high social support.
How the study worked
Cross-sectional survey of 215 male Israeli combat veterans discharged within 5 years who used cannabis 3+ days weekly for 6+ months. Validated questionnaires assessed moral injury, CUD, depression, and perceived social support. Serial mediation and moderation analyses.
What this study cannot tell us
Cross-sectional design. Self-report measures. Israeli combat veterans may not generalize to other militaries. Only males included. Cannabis use was an inclusion criterion, limiting variance.
How to read the evidence
Well-designed mediation analysis with validated instruments, but cross-sectional and single-sex sample.
When this study was published
Published in 2022.
The bigger picture
The finding that social support did not protect against MI-driven CUD, and may have even facilitated the connection, challenges assumptions about protective factors in veteran mental health.
Questions still open
- Why does social support fail to protect against MI-driven CUD? Would treating depression first improve cannabis outcomes in morally injured veterans?
Common questions
Does moral injury lead to cannabis problems in veterans?
Does social support help protect against cannabis problems?
Read the original research
Moral injury and cannabis use disorder among Israeli combat veterans: The role of depression and perceived social support.
Addictive behaviors, 124, 107114
Citation
Ashwal-Malka, Aviya; Tal-Kishner, Keren; Feingold, Daniel. (2022). Moral injury and cannabis use disorder among Israeli combat veterans: The role of depression and perceived social support.. Addictive behaviors, 124, 107114. https://doi.org/10.1016/j.addbeh.2021.107114
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