Establishing Clinically Significant Change Benchmarks for the Moral Injury Outcome Scale in VA Behavioral Health Settings

Abstract

This study aimed to establish benchmarks for clinically significant change for the Moral Injury Outcome Scale (MIOS) using national data from Veterans treated in U.S. Department of Veterans Affairs (VA) behavioral health settings. We analyzed archival electronic health record data from 2,521 Veterans administered the MIOS between July 2022 and March 2025. A subset of 361 Veterans who completed at least two MIOS administrations within 4 months constituted the episode-of-care cohort. Reliable change indices (RCIs) and functional recovery thresholds were calculated using the Jacobson and Truax method. A change score of 13 points on the MIOS indicated clinically significant improvement and the critical value suggesting functional recovery for endpoint scores was ≤9. Most Veterans were unchanged (81%), with 11.9% showing reliable improvement, 4.2% probable recovery, and 2.8% deterioration. In the larger cohort, nearly half met the criterion for probable moral injury. MIOS administration was most common in general mental health and post-traumatic stress disorder (PTSD) specialty care clinics. These initial findings provide the first clinically significant change benchmarks for the MIOS, supporting its integration into measurement-based care and routine outcome monitoring for moral injury in Veterans.