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IIR 09-359 – HSR&D Study

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IIR 09-359
Beyond service connection: what helps PTSD-disabled Veterans get better?
Maureen Murdoch MD MPH
Minneapolis VA Health Care System, Minneapolis, MN
Minneapolis, MN
Funding Period: October 2010 - September 2014

BACKGROUND/RATIONALE:
Do disability benefits help people with potentially treatable mental illnesses recover, or do such benefits "pay them to remain ill"? The answer is controversial and poorly researched. Rosenheck et al.'s study of Supplemental Security Income/Social Security Disability Insurance (SSI/SSDI) benefits showed that, shortly after receiving SSI/SSDI beneficiaries, mentally ill Veterans had substantially better life quality, less homelessness, and less reliance on welfare and food stamps than mentally ill Veterans denied such benefits. In the VA disability system, which amalgamates disability support and compensation for service-related disorders, we too showed that Veterans receiving VA service connection for posttraumatic stress disorder (PTSD) had reduced poverty and homelessness approximately 6 years later compared to Veterans denied PTSD service connection. Furthermore, the service connected Veterans had a larger net, clinically relevant reduction in their PTSD symptoms compared to the denied applicants. This net effect was small, however. Subsets of Veterans from both the service connected and non-service connected groups had clinically important improvements in their PTSD symptoms, while smaller subsets from both had clinically important deteriorations.

OBJECTIVE(S):
1)To identify factors associated with getting clinically better or clinically worse among former applicants for VA PTSD disability benefits, 2) To identify the strategies and lessons learned by these Veterans that might help similar Veterans and 3) To see if results differed by PTSD service-connected status, gender, or service era.

METHODS:
We conducted a sequential, explanatory mixed methods study of 2,100 nationally representative former applicants for VA PTSD disability benefits. Participants had completed 2 prior mailed surveys about their symptoms and functioning, once between 1998 and 2000 (Time 1) and again between 2004 and 2006 (Time 2). For the present study (Time 3), only Veterans who served during or after the Vietnam Conflict were included. Women were oversampled, resulting in a 0.71 male:female ratio.
1,728 (82.4%) Veterans returned Time 3 surveys. From these, we created 16 strata of Veterans based on clinical status (had their PTSD symptoms and their work, role, and social function meaningfully improved or worsened since Time 2?), service era (during or after the Vietnam Conflict), gender, and PTSD service connected status (continuously service connected since 1998 or never service connected). We randomly selected 64 Veterans from the 16 strata for in-depth, semi-structured telephone interviews. Two of us followed Siedel's 3-step process to independently and collaboratively identify themes from the interviews and to conduct cross-case comparisons of themes across strata. Results were periodically reviewed with the entire research team to obtain outside viewpoints.

FINDINGS/RESULTS:
Time 3 survey respondents did not differ substantially from non-respondents on any characteristic. Respondents' mean age was 57.1 years (SD = 9.2), and 41.3% were male. Although 75.9% reported at least some college education, almost a quarter (22.5%) described low family income (<$20,000/year), and less than a fifth (19.0%) were currently working for pay. Almost three fourths (72.9%) of respondents were currently service connected for PTSD, up from 62.7% at Time 1; 94.4% were currently service connected for any kind of disorder, even if not PTSD, compared to 85.0% at Time 1.
At Time 1, 12.7% of survey respondents' combined PTSD and work, role, and social functioning scores fell into the unimpaired range; 30.3%, into the intermediately impaired range; and 56.9%, into the severely impaired range. By Time 3, 15.8% of respondents had scores in the unimpaired range; 35.1%, in the intermediately impaired range; and 49.1%, in the severely impaired range. However, net improvement at the population level did not equal consistent improvement at the individual level. For example, approximately half the Veterans in the unimpaired range of scores at Time 2 reported intermediate or severe impairment at Time 3.
Interview themes covered topics related to recovery/non-recovery, including issues related to the original stressor; subsequent stressors; interactions with friends, family, co-workers, and strangers; interactions with the military and VA; female Veterans' unique experiences; loss of roles; searches for confidence in one's self-worth; specific skills and training; and hard-won insights and other changes in cognition. Regardless of interview stratum, Veterans often described histories of frequent, recurrent psychiatric hospitalizations; prolonged stays in homeless shelters; and receiving case management. These are not typical PTSD features. The result prompted us to revisit the entire sample's VA mental health chart diagnoses, which had been extracted at Time 2.
Chart findings showed that 43.0% of Veterans in this sample had been diagnosed with either bipolar disorder, schizophrenia, or both in at least 3 separate years between 1994 and 2006. Almost two thirds (64.7%) had received such a diagnosis at least once between 1994 and 2006. At all three survey time points, PTSD symptom severity and work, role, and social functioning were unsurprisingly worse in Veterans diagnosed with persistent bipolar disorder and schizophrenia compared to other Veterans.

IMPACT:
These results demonstrate nicely the value of mixed methods research. Through our qualitative interviews, we identified a "surprise" that carries important policy implications. Namely, nearly half of the Veterans in this population have persistent schizophrenia or bipolar disorder. This prevalence is approximately 10-fold higher than that of the US general population. The total burden of serious mental illness in this population is actually higher yet, because our data did not permit us to distinguish major depression and panic disorder from milder cases of affective disorder, and we did not have access to mental health diagnoses after 2006. Persistent serious mental illness is a well-known barrier to competitive employment. Furthermore, the efficacy of exposure-based PTSD therapies has not been has not been established in Veterans with serious comorbid bipolar and psychotic disorders. Policies to "encourage" Veterans with PTSD to leave the disability rolls will therefore need to account for these Veterans' serious comorbid mental conditions. Our results do not pertain to OEF/OIF/OND Veterans, who were not included in the study. Research will be needed to see if serious comorbid mental illness is also common among OEF/OIF/OND Veterans who apply for PTSD disability benefits.

PUBLICATIONS:

Journal Articles

  1. Murdoch M, Kehle-Forbes S, Spoont M, Sayer NA, Noorbaloochi S, Arbisi P. Changes in Post-traumatic Stress Disorder Service Connection Among Veterans Under Age 55: An 18-Year Ecological Cohort Study. Military medicine. 2019 Dec 1; 184(11-12):715-722.
  2. Kehle-Forbes SM, Harwood EM, Spoont MR, Sayer NA, Gerould H, Murdoch M. Experiences with VHA care: a qualitative study of U.S. women veterans with self-reported trauma histories. BMC women's health. 2017 May 30; 17(1):38.
  3. Murdoch M, Kehle-Forbes SM, Partin MR. Changes in affect after completing a mailed survey about trauma: two pre- and post-test studies in former disability applicants for posttraumatic stress disorder. BMC medical research methodology. 2017 May 10; 17(1):81.
  4. Murdoch M, Spoont MR, Kehle-Forbes SM, Harwood EM, Sayer NA, Clothier BA, Bangerter AK. Persistent Serious Mental Illness Among Former Applicants for VA PTSD Disability Benefits and Long-Term Outcomes: Symptoms, Functioning, and Employment. Journal of traumatic stress. 2017 Feb 1; 30(1):36-44.
Conference Presentations

  1. Kehle-Forbes SM, Harwood E, Spoont MR, Sayer NA, Murdoch M. Qualitative Analysis of Women Veterans’ Experiences Seeking VA Care: Findings from a Sample of Former PTSD Disability Applicants. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Etiology
Keywords: Gender Differences, PTSD
MeSH Terms: none

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