Measuring Moral Injury: Psychometric Properties of the Moral Injury Events Scale in Two Military Samples.

As the construct of moral injury has gained increased conceptual and empirical attention among military personnel and veterans, preliminary attempts to operationalize and measure the construct have emerged. One such measure is the Moral Injury Event Scale (MIES). The aim of the current study was to further evaluate the MIES's psychometric properties in two military samples: a clinical sample of Air Force personnel and a nonclinical sample of Army National Guard personnel. Exploratory and confirmatory factor analyses across both samples supported a three-factor solution: transgressions by others, transgressions by self, and betrayal. Transgressions-Others was most strongly associated with posttraumatic stress; Transgressions-Self was most strongly associated with hopelessness, pessimism, and anger; and Betrayal was most strongly associated with posttraumatic stress and anger. Results support the construct validity of the MIES, although areas for improvement are indicated and discussed.

DEPRESSION MEDIATES THE RELATION OF INSOMNIA SEVERITY WITH SUICIDE RISK IN THREE CLINICAL SAMPLES OF U.S. MILITARY PERSONNEL.

BACKGROUND: A growing body of empirical research suggests insomnia severity is directly related to suicide ideation, attempts, and death in nonmilitary samples, even when controlling for depression and other suicide risk factors. Few studies have explored this relationship in U.S. military personnel. METHODS: The present study entailed secondary data analyses examining the associations of insomnia severity with suicide ideation and attempts in three clinical samples: Air Force psychiatric outpatients (n = 158), recently discharged Army psychiatric inpatients (n = 168), and Army psychiatric outpatients (n = 54). Participants completed the Beck Scale for Suicide Ideation, the Beck Depression Inventory-II or Patient Health Questionnaire-9, the Insomnia Severity Index, and the Posttraumatic Stress Disorder Checklist at baseline; two samples also completed these measures during follow-up. RESULTS: Sleep disturbance was associated with concurrent (ß's > 0.21; P's < 0.059) and prospective (ß's > 0.39; P's < 0.001) suicide ideation in all three samples. When adjusting for age, gender, depression, and posttraumatic stress, insomnia severity was no longer directly associated with suicide ideation either concurrently (ß's < 0.19; P's > 0.200) or prospectively (ß's < 0.26; P's > 0.063), but depression was (ß's > 0.22; P's < 0.012). Results of a latent difference score mediation model indicated that depression mediated the relation of insomnia severity with suicide ideation. CONCLUSIONS: Across three clinical samples of military personnel, depression explained the relationship between insomnia severity and suicide risk.

Improving the detection and prediction of suicidal behavior among military personnel by measuring suicidal beliefs: an evaluation of the Suicide Cognitions Scale.

BACKGROUND: Newer approaches for understanding suicidal behavior suggest the assessment of suicide-specific beliefs and cognitions may improve the detection and prediction of suicidal thoughts and behaviors. The Suicide Cognitions Scale (SCS) was developed to measure suicide-specific beliefs, but it has not been tested in a military setting. METHODS: Data were analyzed from two separate studies conducted at three military mental health clinics (one U.S. Army, two U.S. Air Force). Participants included 175 active duty Army personnel with acute suicidal ideation and/or a recent suicide attempt referred for a treatment study (Sample 1) and 151 active duty Air Force personnel receiving routine outpatient mental health care (Sample 2). In both samples, participants completed self-report measures and clinician-administered interviews. Follow-up suicide attempts were assessed via clinician-administered interview for Sample 1. Statistical analyses included confirmatory factor analysis, between-group comparisons by history of suicidality, and generalized regression modeling. RESULTS: Two latent factors were confirmed for the SCS: Unloveability and Unbearability. Each demonstrated good internal consistency, convergent validity, and divergent validity. Both scales significantly predicted current suicidal ideation (ßs >0.316, ps <0.002) and significantly differentiated suicide attempts from nonsuicidal self-injury and control groups (F(6, 286)=9.801, p<0.001). Both scales significantly predicted future suicide attempts (AORs>1.07, ps <0.050) better than other risk factors. LIMITATIONS: Self-report methodology, small sample sizes, predominantly male samples. CONCLUSIONS: The SCS is a reliable and valid measure that predicts suicidal ideation and suicide attempts among military personnel better than other well-established risk factors.

Suicide attempts before joining the military increase risk for suicide attempts and severity of suicidal ideation among military personnel and veterans.

OBJECTIVE: Past self-injurious thoughts and behaviors (SITB) are robust predictors of future suicide risk, but no studies have explored the prevalence of SITB occurring prior to military service among military personnel and veterans, or the association of premilitary SITB with suicidal ideation and suicide attempts during or after military service. The current study explores these issues in two separate samples. METHOD: Self-report data were collected from 374 college student veterans via anonymous only survey (Study 1) and from 151 military personnel receiving outpatient mental health treatment (Study 2). RESULTS: Across both studies, premilitary suicide attempts were among the most prominent predictor of subsequent suicide attempts that occurred after joining the military, even when controlling for demographics and more recent emotional distress. Among military personnel who made a suicide attempt during or after military service, approximately 50% across both samples experienced suicidal ideation and up to 25% made a suicide attempt prior to joining the military. Military personnel and veterans who made suicide attempts prior to joining the military were over six times more likely to make a later suicide attempt after joining the military. In Study 2, significantly more severe current suicidal ideation was reported by participants with histories of premilitary suicide risk, even when controlling for SITB occurring while in the military. CONCLUSIONS: Military personnel and veterans who experienced SITB, especially suicide attempts, prior to joining the military are more likely to attempt suicide while in the military and/or as a veteran, and experience more severe suicidal crises.

Guilt, shame, and suicidal ideation in a military outpatient clinical sample.

BACKGROUND: Increased suicide risk among US military personnel is a growing concern. Research has linked trauma exposure, including exposure to combat-related injuries, death, and atrocities to suicidal ideation among combat veterans. Guilt (feeling bad about what you did to another) and shame (feeling bad about who you are) have been proposed as potential contributors to suicidal ideation among military personnel, but have not yet received much empirical attention. METHODS: Sixty-nine active duty military personnel receiving outpatient mental health treatment at a military clinic completed self-report symptom measures of guilt, shame, depression, posttraumatic stress disorder, and suicidal ideation while engaged in treatment. Generalized linear regression modeling was utilized to test the association of guilt and shame with suicidal ideation. RESULTS: Mean levels of guilt and shame were significantly higher among military personnel with a history of suicidal ideation. Guilt (B = 0.203, SE = .046, P < .001) and shame (B = 0.111, SE = .037, P = .002) were independently associated with severity of current suicidal ideation above and beyond the effects of depression, PTSD symptoms, and the depression-by-PTSD interaction, and fully mediated the relationships of depression and PTSD symptom severity with suicidal ideation. When considered simultaneously, only guilt (B = 0.167, SE = .053, P = .001) was significantly associated with increased suicidal ideation. CONCLUSIONS: Guilt and shame are associated with increased severity of suicidal ideation in military mental health outpatients. Guilt has a particularly strong relationship with suicidal ideation.

Shame, pride, and suicidal ideation in a military clinical sample.

BACKGROUND: Suicide risk among U.S. military personnel has been increasing over the past decade. Fluid vulnerability theory (FVT; Rudd, 2006) posits that acute suicidal episodes increase in severity when trait-based (e.g., shame) and state-based (e.g., hopelessness) risk factors interact, especially among individuals who have been previously suicidal. In contrast, trait-based protective factors (e.g., pride) should buffer the deleterious effects of risk factors. METHODS: 77 active duty military personnel (95% Air Force; 58.4% male, 39.0% female; 67.5% Caucasian, 19.5% African-American, 1.3% Native American, 1.3% Native Hawaiian/Pacific Islander, 1.3% Asian, and 5.2% other) engaged in outpatient mental health treatment completed self-report surveys of shame, hopelessness, pride, and suicidal ideation. Multiple generalized regression was utilized to test the associations and interactive effects of shame, hopelessness, and worst-point past suicidal ideation on severity of current suicidal ideation. RESULTS: Shame significantly interacted with hopelessness (B=-0.013, SE=0.004, p<0.001) and worst-point suicidal ideation (B=0.027, SE=0.010, p=0.010), augmenting each variable's effect on severity of current suicidal ideation. A significant three-way interaction among shame, worst-point suicidal ideation, and pride was also observed (B=-0.010, SE=0.0043, p=0.021), indicating that pride buffered the interactive effects of shame with worst-point suicidal ideation. LIMITATIONS: Small sample size, cross-sectional design, and primarily Air Force sample. CONCLUSIONS: Among military outpatients with histories of severe suicidal episodes, pride buffers the effects of hopelessness on current suicidal ideation. Results are consistent with FVT.

Guilt is more strongly associated with suicidal ideation among military personnel with direct combat exposure.

BACKGROUND: Suicide rates in the U.S. military have been rising rapidly in the past decade. Research suggests guilt is a significant predictor of suicidal ideation among military personnel, and may be especially pronounced among those who have been exposure to combat-related traumas. The current study explored the interactive effect of direct combat exposure and guilt on suicidal ideation in a clinical sample of military personnel. METHODS: Ninety-seven active duty U.S. Air Force personnel receiving outpatient mental health treatment at two military clinics completed self-report symptom measures of guilt, depression, hopelessness, perceived burdensomeness, posttraumatic stress disorder, and suicidal ideation. RESULTS: Generalized multiple regression analyses indicated a significant interaction of guilt and direct combat exposure (B=.124, SE=.053, p=.020), suggesting a stronger relationship of guilt with suicidal ideation among participants who had direct combat exposure as compared to those who had not. The interactions of direct combat exposure with depression (B=.004, SE=.040, p=.926), PTSD symptoms (B=.016, SE=.018, p=.382), perceived burdensomeness (B=.159, SE=.152, p=.300) and hopelessness (B=.069, SE=.036, p=.057) were nonsignificant. CONCLUSIONS: Although guilt is associated with more severe suicidal ideation in general among military personnel, it is especially pronounced among those who have had direct combat exposure.