Moral injury entails emotional distress associated with perceived violations of one's moral code and has been proposed to be a possible contributor to self-injurious thoughts and behaviors (SITB) among military personnel. Three dimensions of moral injury have previously been empirically derived: transgressions committed by others (Transgressions-Others), transgressions committed by oneself (Transgressions-Self), and perceived betrayal by others (Betrayal). The current study examined the relationship of these dimensions of moral injury with SITB in a clinical sample of 151 active duty military personnel. Transgressions-Other and Transgressions-Self were significantly higher among personnel with a history of suicide attempt relative to history of suicidal ideation and no suicidality (Hedge's g's Ͼ .64). Transgressions-Self was associated with significantly more severe suicidal ideation during the past week (p ϭ .018).

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.

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.

Patients treated within an integrated primary care behavioral health service demonstrate significant improvements in clinical status, even those with the most severe levels of distress at baseline.