Exploring the relationship between moral injury and ICD-11 PTSD/complex PTSD: a comparative study of Danish and UK veteran populations

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INTRODUCTION: Moral injury is an important construct in veteran mental health and is associated with adverse psychological outcomes yet cross-national data are limited. Moral injury in Danish veterans remains underexplored. This study aims to provide the first descriptive data on moral injury among Danish veterans and provides a descriptive comparison of moral injury, demographic and health-related outcomes with those of UK veterans. Second, it explores the associations between Moral Injury Outcome Scale (MIOS) scores and ICD-11 post-traumatic stress disorder (PTSD)/complex PTSD in both samples. METHODS: Data were extracted from 742 treatment-seeking veterans who self-referred for psychological treatment (the UK: n=428, August 2020-October 2020; Denmark: n=314, July 2024-June 2025). Comparisons were made across demographic (eg, age, gender, relationship status), military (branch, rank) and health measures (adverse childhood experiences, PTSD and complex PTSD, alcohol misuse, sleep difficulties, drug use and moral injury). RESULTS: UK and Danish veterans reported similar exposure to potentially morally injurious events (57.0% vs 52.5%) and MIOS scores (33.5 vs 26.9), with modest cohort differences. Compared with Danish veterans, UK veterans reported higher levels of any PTSD (68.7% vs 46.5%), and complex PTSD was more common in both cohorts (the UK: 62.5% complex PTSD vs 6.2% PTSD; Denmark: 29.0% complex PTSD vs 17.5% PTSD). Non-alcohol drug use was similar (the UK: 10.3%; Denmark: 11.1%), but UK veterans showed higher weekly alcohol consumption (32.0 g vs 24.0 g) and more sleep difficulties (70.1% vs 55.3%). Across cohorts, higher PTSD/disturbances in self-organisation (DSO) symptom scores were associated with greater moral injury across regression models. CONCLUSIONS: Although modest cross-national differences were observed, the consistent associations between PTSD/DSO symptoms and moral injury underscore important similarities in clinical presentation. These findings highlight the value of international collaboration in veteran mental health research.

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