Measuring morality: Analyzing the factor structure of the moral foundations questionnaire in veterans.

OBJECTIVES: Moral reasoning is an underexamined and potentially useful area of research relative to the care of moral injury in veterans. However, the most widely used measure of moral reasoning, the moral foundations questionnaire (MFQ), has not been validated in this population. METHODS: Post-9/11 veterans (N = 311) completed questionnaires which included the MFQ. Veterans' scores were compared to the general US population. Confirmatory factor analysis was used to test existing models of the MFQ in the sample. Exploratory factor analysis (EFA) was also used to examine potentially improved model fits. RESULTS: The two leading, preexisting MFQ models were both poor fits for the data. EFA results produced a four-factor model for the veteran sample using 25 of the original 30 items of the MFQ. CONCLUSIONS: Measuring moral reasoning among veterans may be important in understanding the experience of moral injury. However, the most widely used scale (MFQ) performs poorly among a sample of post-9/11 veterans, indicating that veterans may respond differently to the measure than the general US population. Military culture may uniquely influence veterans' moral reasoning, suggesting the need for military specific measures for this construct.

Patterns of Potential Moral Injury in Post-9/11 Combat Veterans and COVID-19 Healthcare Workers.

BACKGROUND: Moral injury has primarily been studied in combat veterans but might also affect healthcare workers (HCWs) due to the COVID-19 pandemic. OBJECTIVE: To compare patterns of potential moral injury (PMI) between post-9/11 military combat veterans and healthcare workers (HCWs) surveyed during the COVID-19 pandemic. DESIGN: Cross-sectional surveys of veterans (2015-2019) and HCWs (2020-2021) in the USA. PARTICIPANTS: 618 military veterans who were deployed to a combat zone after September 11, 2001, and 2099 HCWs working in healthcare during the COVID-19 pandemic. MAIN MEASURES: Other-induced PMI (disturbed by others' immoral acts) and self-induced PMI (disturbed by having violated own morals) were the primary outcomes. Sociodemographic variables, combat/COVID-19 experience, depression, quality of life, and burnout were measured as correlates. KEY RESULTS: 46.1% of post-9/11 veterans and 50.7% of HCWs endorsed other-induced PMI, whereas 24.1% of post-9/11 veterans and 18.2% of HCWs endorsed self-induced PMI. Different types of PMI were significantly associated with gender, race, enlisted vs. officer status, and post-battle traumatic experiences among veterans and with age, race, working in a high COVID-19-risk setting, and reported COVID-19 exposure among HCWs. Endorsing either type of PMI was associated with significantly higher depressive symptoms and worse quality of life in both samples and higher burnout among HCWs. CONCLUSIONS: The potential for moral injury is relatively high among combat veterans and COVID-19 HCWs, with deleterious consequences for mental health and burnout. Demographic characteristics suggestive of less social empowerment may increase risk for moral injury. Longitudinal research among COVID-19 HCWs is needed. Moral injury prevention and intervention efforts for HCWs may benefit from consulting models used with veterans.

Screening for moral injury and comparatively evaluating moral injury measures in relation to mental illness symptomatology and diagnosis.

Moral injury merits further study to clarify its identification, prevalence, assessment and intersection with psychosocial and psychiatric problems. The present study investigated the screening potential of the Brief Moral Injury Screen (BMIS) in a sample of post-9/11 veterans (N = 315) and comparatively evaluated how this tool, the Moral Injury Events Scale (MIES), and the Moral Injury Questionnaire-Military Version (MIQ-M) relate to psychiatric diagnoses and mental illness symptom severity. Those who endorsed failing to prevent or doing something morally wrong had the highest symptomatology scores on measures of posttraumatic stress disorder, depression, suicidality, alcohol abuse and drug abuse, followed by those who reported solely witnessing a moral injury event. Posttraumatic stress disorder and depressive symptoms correlated most strongly with scores on the MIQ-M; suicidality, alcohol abuse and drug abuse scores correlated most strongly with scores on the BMIS and MIQ-M. Moral injury, as measured by three scales, was robustly correlated with worse outcomes on various symptom measures. The three scales appear to differentially predict mental illness symptomatology and diagnoses, with the BMIS predicting suicidality and alcohol and drug abuse as well as better than other measures.

Religion, spirituality, and suicide risk in Iraq and Afghanistan era veterans.

BACKGROUND: United States military veterans experience disproportionate rates of suicide relative to the general population. Evidence suggests religion and spirituality may impact suicide risk, but less is known about which religious/spiritual factors are most salient. The present study sought to identify the religious/spiritual factors most associated with the likelihood of having experienced suicidal ideation and attempting suicide in a sample of recent veterans. METHODS: Data were collected from 1002 Iraq/Afghanistan-era veterans (Mage = 37.68; 79.6% male; 54.1% non-Hispanic White) enrolled in the ongoing Veterans Affairs Mid-Atlantic Mental Illness Research, Education and Clinical Center multi-site Study of Post-Deployment Mental Health. RESULTS: In multiple regression models with stepwise deletion (p < .05), after controlling for depression and posttraumatic stress disorder (PTSD) diagnoses, independent variables that demonstrated a significant effect on suicidal ideation were perceived lack of control and problems with self-forgiveness. After controlling for age, PTSD diagnosis, and substance use problems, independent variables that demonstrated a significant effect on suicide attempt history were perceived as punishment by God and lack of meaning/purpose. CONCLUSIONS: Clinical screening for spiritual difficulties may improve detection of suicidality risk factors and refine treatment planning. Collaboration with spiritual care providers, such as chaplains, may enhance suicide prevention efforts.

Resting-state brain fluctuation and functional connectivity dissociate moral injury from posttraumatic stress disorder.

Moral injury is closely associated with posttraumatic stress disorder (PTSD) and characterized by disturbances in social and moral cognition. Little is known about the neural underpinnings of moral injury, and whether the neural correlates are different between moral injury and PTSD. A sample of 26 U.S. military veterans (two females: 28-55 years old) were investigated to determine how subjective appraisals of morally injurious events measured by Moral Injury Event Scale (MIES) and PTSD symptoms are differentially related to spontaneous fluctuations indexed by amplitude of low frequency fluctuation (ALFF) as well as functional connectivity during resting-state functional magnetic resonance imaging scanning. ALFF in the left inferior parietal lobule (L-IPL) was positively associated with MIES subscores of transgressions, negatively associated with subscores of betrayals, and not related with PTSD symptoms. Moreover, functional connectivity between the L-IPL and bilateral precuneus was positively related with PTSD symptoms and negatively related with MIES total scores. Our results provide the first evidence that morally injurious events and PTSD symptoms have dissociable neural underpinnings, and behaviorally distinct subcomponents of morally injurious events are different in neural responses. The findings increase our knowledge of the neural distinctions between moral injury and PTSD and may contribute to developing nosology and interventions for military veterans afflicted by moral injury.

What Ought We to Do With "Thick Terms"? A Response to Frankfurt & Coady's "Bringing Philosophy to Bear on Moral Injury and Posttraumatic Stress Disorder Construct Validation".

We respond to the commentary by Frankfurt and Coady (this issue) regarding the descriptive-prescriptive framework for partially distinguishing between posttraumatic stress disorder (PTSD) and moral injury (Farnsworth, 2019). In their commentary, Frankfurt & Coady raise concerns about the application of R. M. Hare's (2014) philosophical approach of prescriptivism to military-related moral injury (MI) and the potential philosophical and ethical implications that may follow. In this response, we clarify that Farnsworth's descriptive-prescriptive framework is not tied to or aligned with Hare's prescriptivism and, as a result, many of Frankfurt and Coady's critiques become tangential to Farnsworth's original argument. We go on to clarify that Farnsworth's descriptive-prescriptive framework does not deny the utility of all cognitive therapies for moral injury, nor does it attempt to fully separate descriptive and prescriptive cognitions from one another, as was asserted by Frankfurt and Coady. We also provide a counterargument to Frankfurt and Coady's ethical concerns regarding the potential of Farnsworth's framework to enable militarism and instead assert its value for increasing peace and understanding. Finally, we address the relevance of "thick terms" for MI, highlighting their potential strengths and clinical weaknesses. We conclude by joining with Frankfurt and Coady in expressing our hopes for future research on the association between PTSD and MI. We argue that future research must go beyond defining content-level boundaries between the two constructs and instead grapple with the processes that give rise to them and the philosophical, empirical, and professional questions that they imply.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) ¿Qué debemos hacer con "términos contundentes"? Respuesta a la (s) autor (es) 'Aportando a la filosofía sobre el daño moral y TEPT' QUÉ PODEMOS HACER Respondemos al comentario de Frankfurt y Cody (de este número) sobre el marco descriptivo y prescriptivo para distinguir, parcialmente, entre el trastorno de estrés postraumático (TEPT) y el daño moral (Farnsworth, 2019). En su comentario, Frankfurt y Cody plantean inquietudes sobre la aplicación del enfoque filosófico del prescriptivismo de R. M. Hare (2014) al daño moral (DM) relacionado con el ejército y las posibles implicaciones filosóficas y éticas que pueden surgir. En esta respuesta, aclaramos que el marco descriptivo-prescriptivo de Farnsworth no está ligado ni alineado con el prescriptivismo de Hare y, como resultado, muchas de las críticas de Frankfurt y Cody se vuelven tangenciales al artículo original de Farnsworth. Continuamos para aclarar que el marco descriptivo-prescriptivo de Farnsworth no niega la utilidad de todas las terapias cognitivas para el daño moral, ni intenta separar las cogniciones descriptivas y prescriptivas por completo, como afirmaron Frankfurt y Cody. También proporcionamos un argumento en contra de las preocupaciones éticas de Frankfurt y Cody sobre el potencial del marco de Farnsworth para permitir el militarismo y, en cambio, afirmar su valor para aumentar la paz y la comprensión. Finalmente, abordamos la relevancia de los "términos contundentes" para el DM, destacando sus potenciales fortalezas y debilidades clínicas. Concluimos uniéndonos a Frankfurt y Cody para expresar nuestras esperanzas de futuras investigaciones sobre la asociación entre TEPT y DM. Argumentamos que la investigación futura debe ir más allá de definir límites a nivel de contenido entre las dos construcciones y, en su lugar, lidiar con los procesos que las originan y las preguntas filosóficas, empíricas y profesionales que implican.

Diagnostic Accuracy of Screening Tests and Treatment for Post-Acute Coronary Syndrome Depression: A Systematic Review.

BACKGROUND: Patients who have had an acute coronary syndrome (ACS) event have an increased risk for depression. PURPOSE: To evaluate the diagnostic accuracy of depression screening instruments and to compare safety and effectiveness of depression treatments in adults within 3 months of an ACS event. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Database of Systematic Reviews from January 2003 to August 2017, and a manual search of citations from key primary and review articles. STUDY SELECTION: English-language studies of post-ACS patients that evaluated the diagnostic accuracy of depression screening tools or compared the safety and effectiveness of a broad range of pharmacologic and nonpharmacologic depression treatments. DATA EXTRACTION: 2 investigators independently screened each article for inclusion; abstracted the data; and rated the quality, applicability, and strength of evidence. DATA SYNTHESIS: Evidence from 6 of the 10 included studies showed that a range of depression screening instruments produces acceptable levels of diagnostic sensitivity, specificity, and negative predictive values (70% to 100%) but low positive predictive values (below 50%). The Beck Depression Inventory-II was the most studied tool. A large study found that a combination of cognitive behavioral therapy (CBT) and antidepressant medication improved depression symptoms, mental health-related function, and overall life satisfaction more than usual care. LIMITATION: Few studies, no evaluation of the influence of screening on clinical outcomes, and no studies addressing several clinical interventions of interest. CONCLUSION: Depression screening instruments produce diagnostic accuracy metrics that are similar in post-ACS patients and other clinical populations. Depression interventions have an uncertain effect on cardiovascular outcomes, but CBT combined with antidepressant medication produces modest improvement in psychosocial outcomes. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality (PROSPERO: CRD42016047032).

A Qualitative Examination of VA Chaplains' Understandings and Interventions Related to Moral Injury in Military Veterans.

This study examines VA chaplains' understandings of moral injury (MI) and preferred intervention strategies. Drawing qualitative responses with a nationally-representative sample, content analyses indicated that chaplains' definitions of MI comprised three higher order clusters: (1) MI events, (2) mechanisms in development of MI, and (3) warning signs of MI. Similarly, chaplains' intervention foci could be grouped into three categories: (1) pastoral/therapeutic presence, (2) implementing specific interventions, and (3) therapeutic processes to promote moral repair. Findings are discussed related to emerging conceptualizations of MI, efforts to adapt existing evidence-based interventions to better address MI, and the potential benefits of better integrating chaplains into VA mental health service delivery.

Does This Patient Have Posttraumatic Stress Disorder?: Rational Clinical Examination Systematic Review.

IMPORTANCE: Posttraumatic stress disorder (PTSD) is a relatively common mental health condition frequently seen, though often unrecognized, in primary care settings. Identifying and treating PTSD can greatly improve patient health and well-being. OBJECTIVE: To systematically review the utility of self-report screening instruments for PTSD among primary care and high-risk populations. EVIDENCE REVIEW: We searched MEDLINE and the National Center for PTSD's Published International Literature on Traumatic Stress (PILOTS) databases for articles published on screening instruments for PTSD published from January 1981 through March 2015. Study quality was rated using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. STUDY SELECTION: Studies of screening instruments for PTSD evaluated using gold standard structured clinical diagnostic interviews that had interview samples of at least 50 individuals. FINDINGS: We identified 2522 citations, retrieved 318 for further review, and retained 23 cohort studies that evaluated 15 screening instruments for PTSD. Of the 23 studies, 15 were conducted in primary care settings in the United States (n = 14,707 were screened, n = 5374 given diagnostic interview, n = 814 had PTSD) and 8 were conducted in community settings following probable trauma exposure (ie, natural disaster, terrorism, and military deployment; n = 5302 were screened, n = 4263 given diagnostic interview, n = 393 were known to have PTSD with an additional 50 inferred by rates reported by authors). Two screens, the Primary Care PTSD Screen (PC-PTSD) and the PTSD Checklist were the best performing instruments. The 4-item PC-PTSD has a positive likelihood ratio of 6.9 (95% CI, 5.5-8.8) and a negative likelihood ratio of 0.30 (95% CI, 0.21-0.44) using the same score indicating a positive screen as used by the Department of Veterans Affairs in all of its primary care clinics. The 17-item PTSD Checklist has a positive likelihood ratio of 5.2 (95% CI, 3.6-7.5) and a negative likelihood ratio of 0.33 (95% CI, 0.29-0.37) using scores of around 40 as indicating a positive screen. Using the same score employed by primary care clinics in the Department of Veterans Affairs to indicate a positive screen, the 4-item PC-PTSD has a sensitivity of 0.69 (95% CI, 0.55-0.81), a specificity of 0.92 (95% CI, 0.86-0.95), a positive likelihood ratio of 8.49 (95% CI, 5.56-12.96) and a negative likelihood ratio of 0.34 (95% CI, 0.22-0.48). For the 17-item PTSD Checklist, scores around 40 as indicating a positive screen, have a sensitivity of 0.70 (95% CI, 0.64-0.77), a specificity of 0.90 (95% CI, 0.84-0.93), a positive likelihood ratio of 6.8 (95% CI, 4.7-9.9) and a negative likelihood ratio of 0.33 (95% CI, 0.27-0.40). CONCLUSIONS AND RELEVANCE: Two screening instruments, the PC-PTSD and the PTSD Checklist, show reasonable performance characteristics for use in primary care clinics or in community settings with high-risk populations. Both are easy to administer and interpret and can readily be incorporated into a busy practice setting.

Collaborating across the Departments of Veterans Affairs and Defense to integrate mental health and chaplaincy services.

BACKGROUND: Recognizing that clergy and spiritual care providers are a key part of mental health care systems, the Department of Veterans Affairs (VA) and Department of Defense (DoD) jointly examined chaplains' current and potential roles in caring for veterans and service members with mental health needs. OBJECTIVE: Our aim was to evaluate the intersection of chaplain and mental health care practices in VA and DoD in order to determine if improvement is needed, and if so, to develop actionable recommendations as indicated by evaluation findings. DESIGN: A 38-member multidisciplinary task group partnered with researchers in designing, implementing, and interpreting a mixed methods study that included: 1) a quantitative survey of VA and DoD chaplains; and 2) qualitative interviews with mental health providers and chaplains. PARTICIPANTS: Quantitative: the survey included all full-time VA chaplains and all active duty military chaplains (n = 2,163 completed of 3,464 invited; 62 % response rate). Qualitative: a total of 291 interviews were conducted with mental health providers and chaplains during site visits to 33 VA and DoD facilities. MAIN MEASURES: Quantitative: the online survey assessed intersections between chaplaincy and mental health care and took an average of 37 min to complete. Qualitative: the interviews assessed current integration of mental health and chaplain services and took an average of 1 h to complete. KEY RESULTS: When included on interdisciplinary mental health care teams, chaplains feel understood and valued (82.8-100 % of chaplains indicated this, depending on the team). However, findings from the survey and site visits suggest that integration of services is often lacking and can be improved. CONCLUSIONS: Closely coordinating with a multidisciplinary task group in conducting a mixed method evaluation of chaplain-mental health integration in VA and DoD helped to ensure that researchers assessed relevant domains and that findings could be rapidly translated into actionable recommendations.

Utilization of hospital-based chaplain services among newly diagnosed male Veterans Affairs colorectal cancer patients.

The aim of the study was to examine utilization of chaplain services among Veterans Affairs patients with colorectal cancer (CRC). In 2009, the Cancer Care Assessment and Responsive Evaluation Studies questionnaire was mailed to VA CRC patients diagnosed in 2008 (67 % response rate). Multivariable logistic regression examined factors associated with chaplain utilization. Of 918 male respondents, 36 % reported utilizing chaplains. Chaplain services were more likely to be utilized by patients with higher pain levels (OR = 1.017; 95 % CI = 0.999-1.035), younger age (age OR = 0.979; 95 % CI = 0.964-0.996), and later cancer stage (early stage OR = 0.743; 95 % CI = 0.559-0.985). Chaplain services are most utilized by younger, sicker patients.

Validation of the Moral Injury Outcome Scale in acute care nurses.

Introduction: Moral injury, predominantly studied in military populations, has garnered increased attention in the healthcare setting, in large part due to the psychological and emotional consequences of the COVID-19 pandemic. The measurement of moral injury with instrumentation adapted from military settings and validated by frontline healthcare personnel is essential to assess prevalence and guide intervention. This study aimed to validate the Moral Injury Outcome Scale (MIOS) in the population of acute care. Methods: A sample of 309 acute care nurses completed surveys regarding moral injury, depression, anxiety, burnout, professional fulfillment, spiritual wellbeing, and post-traumatic stress disorder symptoms. Confirmatory factor analysis was conducted as well as an assessment of reliability and validity. Results: The internal consistency of the 14-item MIOS was 0.89. The scale demonstrated significant convergent and discriminant validity, and the test of construct validity confirmed the two-factor structure of shame and trust violations in this clinical population. Regression analysis indicated age, race, and marital status-related differences in the experience of moral injury. Discussion: The MIOS is valid and reliable in acute care nursing populations and demonstrates sound psychometric properties. Scores among nurses diverge from those of military personnel in areas that may inform distinctions in interventions to address moral injury in these populations.

Chaplain Training in Evidence-Based Practices to Promote Mental Health and Improve Care for Suicidality in Veterans and Service Members.

OBJECTIVE: Chaplains are key care providers in a comprehensive approach to suicide prevention, which is a priority area for the U.S. Department of Veterans Affairs (VA) and the Department of Defense (DoD). In a cohort of 87 VA and military chaplains who completed the Mental Health Integration for Chaplain Services (MHICS) training-an intensive, specialty education in evidence-based psychosocial and collaborative approaches to mental health care-we assessed chaplains' self-perceptions, intervention behaviors, and use of evidence-based practices, including Acceptance and Commitment Therapy (ACT), Problem-Solving Therapy (PST), and Motivational Interviewing (MI), in providing care for suicidality. METHOD: Chaplains responded to a battery of items Pre- and Post-training and provided deidentified case examples describing their use of evidence-based practices in spiritual care for service members and veterans (SM/V) on various levels of a suicide prevention continuum. RESULTS: Post-training, chaplains reported increased abilities to provide care and mobilize collaborative resources. Over the course of MHICS, 87% of chaplains used one or more evidence-based practices with a SM/V at risk for suicide or acutely suicidal. Fifty-six percent of chaplains reported intervening with an acutely suicidal SM/V by using principles from ACT, 36% PST, and 48% MI. With persons at risk for suicide, 81% used principles from ACT, 66% PST, and 71% MI. Cases exemplified diverse evidence-based practice applications. CONCLUSIONS: Findings indicate chaplains trained in evidence-based practices report effective application in caring for SM/V who are suicidal, thus offering a valuable resource to meet needs in a priority area for VA and DoD.HIGHLIGHTSChaplains provide essential care for SM/V who are at risk for suicide or acutely suicidalTraining helps chaplains mobilize interdisciplinary and community resources in suicide careEvidence-based practices can effectively integrate within the scope of chaplaincy practice for suicide care.

Introduction to the special issue "Moral injury care: Practices and collaboration".

Since moral injury was introduced in the psychological literature little more than a decade ago, it has received substantial attention from mental health professionals as well as chaplains. This special issue features ways that chaplains are and can be engaged in addressing moral injury within health care contexts, especially the Department of Veterans Affairs. The efforts highlighted in this special issue provide building blocks for advancing moral injury care practices, research agendas, and interdisciplinary collaborations into the future.

Core Components of Moral Injury Groups Co-Facilitated by Mental Health Providers and Chaplains.

Despite increasing interest in moral injury, there is not yet consensus around what it is (and is not), who can have it and under what circumstances, or the degree and form of distress necessary to distinguish moral injury from other psychological and spiritual difficulties. The novelty of moral injury has created space for frontline Veterans Health Administration mental health and spiritual care providers to creatively apply their core professional skills and identities to moral injury. This paper presents findings of a core components analysis (CCA) derived from seven co-led chaplain-mental health moral injury group facilitation teams that were involved in a 16-month quality improvement endeavor of the Dynamic Diffusion Network (DDN). The DDN initiative engages providers in collaborative and iterative refinement of practices to promote rapid improvements in care for complex problems that lack a codified evidence base. Using CCA, we identified 10 core components of co-facilitated moral injury group care. Components include a clear conceptualization of moral injury, an inclusive approach to spirituality, and exploration of forgiveness, among others. This paper offers guidance that can be widely applied and readily adapted as our collective understanding of moral injury continues to expand and clarify. The core components are articulated here as principles for ongoing review and revision in response to future moral injury advances in the DDN and elsewhere.

Increasing chaplain support for veterans at high risk for suicide through targeted outreach: A quality improvement initiative.

The Department of Veterans Affairs (VA) has prioritized improving the identification of veterans at risk for suicide and ensuring adequate staffing of personnel to assist veterans in need. It is imperative that suicide prevention efforts make use of the full range of available resources, including diverse professionals with distinctive skillsets. Chaplains are engaged in suicide prevention efforts in VA, but the literature lacks examples of chaplain-involved suicide prevention efforts that clearly describe how chaplains are engaged, the training and/or qualifications chaplains possess in the area of suicide prevention, and the reach and impact of such efforts. The purpose of this report is to describe the development and implementation of a novel, innovative, and ongoing chaplain-led suicide prevention outreach initiative for veterans at high risk for suicide. Results indicated the program was feasible and supported at the systems level, and chaplains were able to collaboratively sustain outreach efforts over the course of a year. Chaplain suicide prevention outreach was found to be acceptable to veterans, who overwhelmingly indicated openness to and appreciation for outreach. Chaplains can address the spiritual crisis underlying suicidality, bolster spiritual protective factors, and are a part of holistic care. Considerations for implementation and future investigation are discussed.

Collaborative spiritual care for moral injury in the veterans Affairs Healthcare System (VA): Results from a national survey of VA chaplains.

The psychospiritual nature of moral injury invites consideration regarding how chaplains understand the construct and provide care. To identify how chaplains in the VA Healthcare System conceptualize moral injury, we conducted an anonymous online survey (N = 361; 45% response rate). Chaplains responded to a battery of items and provided free-text definitions of moral injury that generally aligned with key elements in the existing literature, though with different emphases. Over 90% of chaplain respondents indicated that they encounter moral injury in their chaplaincy care, and a similar proportion agreed that chaplains and mental health professionals should collaborate in providing care for moral injury. Over one-third of chaplain respondents reported offering or planning to offer a moral injury group. Separately, nearly one-quarter indicated present or planned collaboration with mental health to provide groups that in some manner address moral injury. Previous training in evidence-based and collaborative care approaches appears to contribute to the likelihood of providing integrated psychosocial-spiritual care. Results and future directions are discussed, including a description of moral injury that may be helpful to understand present areas of emphasis in VA chaplains' care for moral injury.

Examination of the utility of psychotherapy for patients with treatment resistant depression: a systematic review.

OBJECTIVE: To examine the utility of psychotherapy in managing treatment resistant depression. DATA SOURCES: PubMed, PsycInfo, Embase, Cochrane Registry of Controlled Clinical Trials, article bibliographies. REVIEW METHODS: Eligible articles had to be in English and include English-speaking adult outpatients from general medical or mental health clinics. Studies had to be randomized clinical trials (RCT) involving at least one of the following psychotherapy modalities: cognitive therapy, interpersonal therapy, or behavior therapy. Patients were considered treatment resistant if they reported partial or no remission following treatment with an adequate antidepressant dose for ≥ 6 weeks. Exclusion criteria included receiving psychotherapy at the time of recruitment, and/or comorbid psychiatric conditions unlikely to be treated outside of specialized mental health care (e.g., severe substance abuse). Due to heterogeneity in study designs, a summary estimate of effect was not calculated. Studies were critically analyzed and a qualitative synthesis was conducted. RESULTS: Of 941 original titles, 13 articles evaluating 7 unique treatment comparisons were included. Psychotherapy was examined as an augmentation to antidepressants in five studies and as substitution treatment in two studies. A total of 592 patients were evaluated (Mean age ~40 y; Females = 50-85%; Caucasians ≥ 75%). The STAR*D trial used an equipoise stratified randomization design; the remaining studies were RCTs. Compared to active management, two good quality trials showed similar benefit from augmenting antidepressants with psychotherapy; one fair quality and one poor quality trial showed benefit from psychotherapy augmentation; and one good and one poor trial found similar benefit from substituting psychotherapy for antidepressants. One fair quality trial showed lithium augmentation to be more beneficial than psychotherapy. CONCLUSIONS: Review demonstrates the utility of psychotherapy in managing treatment resistant depression. However, evidence is sparse and results are mixed. Given that quality trials are lacking, rigorous clinical trials are recommended to guide practice. In the interim, primary care providers should consider psychotherapy when treating patients with treatment resistant depression.

Dynamic Diffusion Network: Advancing moral injury care and suicide prevention using an innovative model.

Healthcare providers across a wide variety of settings face a common challenge: the need to provide real time care for complex problems that are not adequately addressed by existing protocols. In response to these intervention gaps, frontline providers may utilize existing evidence to develop new approaches that are tailored to specific problems. It is imperative that such approaches undergo some form of evaluation, ensuring quality control while permitting ongoing adaptation and refinement. "Dynamic diffusion" is an innovative approach to intervention improvement and dissemination whereby care practices are delivered and continuously evaluated under real-world conditions as part of a structured network experience. This "dynamic diffusion network" (DDN) promotes cross-pollination of ideas and shared learning to generate relatively rapid improvements in care. The pilot Mental Health and Chaplaincy DDN was developed to advance suicide prevention efforts and moral injury care practices being conducted by 13 chaplain-mental health professional teams across the Veterans Health Administration. Lessons learned from the pilot DDN include the importance of the following: geographic and cultural diversity among innovation collaborators to ensure the broadest possible relevance of solutions; leadership support to facilitate engagement of frontline providers in quality improvement efforts; and participation in a community of practice to motivate providers and offer opportunities for direct collaboration and cross-pollination of ideas.