Using the Moral Injury and Distress Scale to identify clinically meaningful moral injury
Shira Maguen
Mental Health Services, San Francisco VA Health Care System, San Francisco, California, USA
Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
Search for more papers by this authorBrandon J. Griffin
Center for Mental Health Care and Outcomes Research, Central Arkansas VA, Little Rock, Arkansas, USA
Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
Search for more papers by this authorRobert H. Pietrzak
Clinical Neurosciences Division, National Center for PTSD, VA Connecticut Healthcare System, West Haven, Connecticut, USA
Department of Psychiatry, Yale School of Medicine, West Haven, Connecticut, USA
Search for more papers by this authorCarmen P. McLean
Dissemination and Training Division, National Center for PTSD, Menlo Park, California, USA
Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
Search for more papers by this authorJessica L. Hamblen
Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
Executive Division, National Center for PTSD, White River Junction, Vermont, USA
Search for more papers by this authorCorresponding Author
Sonya B. Norman
Executive Division, National Center for PTSD, White River Junction, Vermont, USA
Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, California, USA
Correspondence
Sonya Norman, University of California San Diego, 3350 La Jolla Village Drive, MC116B, San Diego, CA 92161, USA.
Email: snorman@ucsd.edu
Search for more papers by this authorShira Maguen
Mental Health Services, San Francisco VA Health Care System, San Francisco, California, USA
Department of Psychiatry and Behavioral Sciences, University of California San Francisco School of Medicine, San Francisco, California, USA
Search for more papers by this authorBrandon J. Griffin
Center for Mental Health Care and Outcomes Research, Central Arkansas VA, Little Rock, Arkansas, USA
Psychiatric Research Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
Search for more papers by this authorRobert H. Pietrzak
Clinical Neurosciences Division, National Center for PTSD, VA Connecticut Healthcare System, West Haven, Connecticut, USA
Department of Psychiatry, Yale School of Medicine, West Haven, Connecticut, USA
Search for more papers by this authorCarmen P. McLean
Dissemination and Training Division, National Center for PTSD, Menlo Park, California, USA
Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
Search for more papers by this authorJessica L. Hamblen
Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
Executive Division, National Center for PTSD, White River Junction, Vermont, USA
Search for more papers by this authorCorresponding Author
Sonya B. Norman
Executive Division, National Center for PTSD, White River Junction, Vermont, USA
Department of Psychiatry, University of California San Diego School of Medicine, La Jolla, California, USA
Correspondence
Sonya Norman, University of California San Diego, 3350 La Jolla Village Drive, MC116B, San Diego, CA 92161, USA.
Email: snorman@ucsd.edu
Search for more papers by this authorAbstract
Despite the proliferation of moral injury studies, a remaining gap is distinguishing moral injury from normative distress following exposure to potentially morally injurious events (PMIEs). Our goal was to leverage mental health and functional measures to identify clinically meaningful and functionally impairing moral injury using the Moral Injury and Distress Scale (MIDS). Participants who endorsed PMIE exposure (N = 645) were drawn from a population-based sample of military veterans, health care workers, and first responders. Using signal detection methods, we identified the optimally efficient MIDS score for detecting clinically significant posttraumatic stress and depressive symptom severity, trauma-related guilt, and functional impairment. The most efficient cut scores across outcomes converged between 24 and 27. We recommend a cut score of 27 given that roughly 70% of participants who screened positive on the MIDS at this threshold reported clinically significant mental health symptoms, and approximately 50% reported severe trauma-related guilt and/or functional impairment. Overall, 10.2% of respondents exposed to a PMIE screened positive for moral injury at this threshold, particularly those who identified as a member of a minoritized racial or ethnic group (17.9%) relative to those who identified as White, non-Hispanic (8.0%), aOR = 2.52, 95% CI [1.45, 4.42]. This is the first known study to establish a cut score indicative of clinically meaningful and impairing moral injury. Such scores may enhance clinicians’ abilities to conduct measurement-based moral injury care by enabling them to identify individuals at risk of negative outcomes and better understand risk and protective factors for moral injury.
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