BACKGROUND/RATIONALE:
OEF/OIF veterans are returning with high rates of mental health (MH) disorders such as posttraumatic stress disorder (PTSD), depression, substance use disorders, and sequelae of traumatic brain injury (TBI). Rates of unemployment among OEF/OIF veterans are about twice those of non-veterans, and ending homelessness among veterans is a top VA priority. Thus, vocational services to help veterans return to the workforce are urgently needed. Our San Diego data suggested that only 4% of OEF/OIF veterans with these mental health diagnoses who were referred for vocational services received evidence-based supported employment, and only 1% were successfully placed in competitive employment. We sought to investigate patterns of vocational service use among OEF/OIF veterans with these mental health conditions nationwide, as we speculated that there may be national-level difficulties with provision of easy-to-access, engaging, evidence-based vocational services within the VA. To our knowledge, no such national-level investigation had been undertaken.

OBJECTIVE(S):
Our goal was to analyze national-level data on vocational service utilization among OEF/OIF veterans with mental health conditions to identify the needs as well as the barriers to vocational service provision and utilization. We also sought to further understand veteran and provider perspectives by completing a qualitative study of 60 veterans and 12 VA clinicians at three sites (Los Angeles, Houston, and Bedford).

METHODS:
Our quantitative data analyses used a national-level database prepared by the Northeast Program Evaluation Center (NEPEC) from the Austin Information and Technology Center (AITC) data encounter files and OEF/OIF registry. 75,607 OEF/OIF veterans who had a diagnosis of PTSD, depression/mood disorder, substance use disorder, or TBI sequelae in FY2008/2009 were included in the database. Descriptive statistics were computed. We then linked the AITC data to longitudinal data collected by NEPEC as part of their tracking of vocational services and outcomes. For the qualitative part of our study, we sought to interview 30 veterans with mental health conditions who engaged in vocational services at one of three sites (Los Angeles, Houston, and Bedford) during FY2008/2009 and 30 veterans who did not engage. IRB and R&D delays at Houston and Bedford prevented us from completing the veteran interviews for those sites. We conducted telephone interviews with 8 Los Angeles veterans (out of 40 invited to participate). We also interviewed each site's vocational services director and three mental health providers (a psychologist, a psychiatrist, and a social worker) regarding their perceptions of vocational services for OEF/OIF veterans.

FINDINGS/RESULTS:
There were 75,607 OEF/OIF veterans with diagnoses of PTSD, depression/mood disorders, substance use disorders, or TBI sequelae in FY2008/2009. Of these 75,607 veterans, 6,345 (8.4%) had at least one vocational services encounter during FY2008/2009 (i.e., had at least one service contact under stop codes 535, 536, 568, 569, 570, 573, 574, or 575). Note that it is not possible to ascertain how many veterans were referred for vocational services, as consults are not tracked. Compared to those who did not have a vocational encounter, veterans with at least one vocational encounter had greater levels of comorbidity. Those with TBI sequelae were particularly likely to have a vocational encounter. Presence and level of service connected disability does not appear to be a disincentive to seek vocational services.

Next, we examined what types of services were provided. 91.6% of veterans received no vocational services. 4.2% of veterans received "other" vocational services, 1.8% received transitional work experience, and 0.2% received incentive therapy. Supported employment, the evidence-based practice, was provided to 2.2% of veterans.

Next, we examined the number of vocational service encounters among the 6,345 veterans who had at least one vocational encounter. 40% of these veterans had only one vocational services encounter; 16% had 2 encounters; 9% had 3 encounters; 7% had 4 encounters; and 28% had 5 or more encounters in FY2008/2009.

Next, we used NEPEC data to examine paid work outcomes in 1,010 OEF/OIF veterans with the mental health conditions of interest who were enrolled in NEPEC-tracked vocational programs at any point in FY2008/2009. Diagnostically, 79% had a PTSD diagnosis, 76% had a mood disorder diagnosis, 74% had a substance use disorder diagnosis, and 37% had a TBI-related diagnosis. Stop codes were used to determine what vocational services were provided. The sample was divided into veterans who had no supported employment encounters and those who had at least 1 supported employment encounter. Differences between these groups are in Table 3, below, which shows that work outcomes were significantly better for veterans who had at least one supported employment encounter (e.g., 243/479 of these veterans worked competitively). These results suggest that compared to other services, supported employment engages veterans for a longer time and produces significantly better work outcomes.

We also examined whether competitive job attainment was related to demographic, financial, or clinical factors. Competitive work attainment was not related to sex, PTSD, depression, or TBI-related diagnosis. Veterans with a substance use disorder diagnosis were less likely to work competitively (30% vs. 49%; 2=29.6, df=1, p<.001; =.17), and those with any level of service connected disability were more likely to work competitively (42% vs. 31%; 2=12.3, df=1, p<.001; =.11). However, the effect sizes associated with these results suggested only weak associations. Age (t=2.4, df=1008, p=.018) and percentage of service connection (t=2.5, df=704.1, p=.012) also had negligible to small effects on competitive work outcomes, with those who were slightly younger or with a slightly higher percentage of service connection being more likely to work competitively.

Qualitative data findings:
Our staff interviews revealed that staff viewed OEF/OIF veterans with mental health conditions as having high motivation to work or go to school and high levels of interest in competitive employment. Although there is a high no-show rate and low engagement overall, once engaged in services, they tend to remain engaged. Multiple veteran-level and system-level barriers to engagement were identified; modifiable system-level barriers included lack of awareness of services available, "fit" of services available, and limitations in services available. Suggestions for engagement improvement included use of texting and social media to connect veterans to services, individualization of services, availability of services after hours, on weekends, and at low-stigma locations, partnering with campus veterans groups and GI Bill representatives, and peer support. Our interviews with veterans echoed the views of staff. Veterans commented that that school, transportation, mental health and substance problems, and lack of housing kept them from engaging in vocational services.

IMPACT:
This project is relevant to the broad goal of the VA Office of Research and Development to support research and implementation of evidence-based practices, and is consistent with the VA's Uniform Mental Health Services mandate to provide recovery-oriented, evidence-based mental healthcare and enhanced access to mental health services such as vocational rehabilitation. Our main findings demonstrate that only 8% of OEF/OIF veterans with mental health conditions accessed VA vocational services at all, and only 2% received evidence-based supported employment. This is striking because we know that the unemployment rate among OEF/OIF veterans is about 18%, and is suspected to be even higher among veterans with mental health conditions. Thus, it is likely that less than half of OEF/OIF veterans with mental health conditions who could benefit from vocational services are actually accessing these services. Those with multiple comorbid mental health conditions, but especially TBI sequelae, were most likely to access vocational services. Most veterans who accessed any vocational services had only one or two encounters with a provider; it is not likely that an adequate assessment or job search can occur within one or two visits. Even though most veterans did not receive supported employment, it was remarkably effective among those who did. Supported employment engaged veterans longer and 51% of veterans in supported employment obtained competitive jobs. It is likely that one of the reasons for supported employment's success is that it focuses on job development in the community with employers interested in hiring veterans (as was recently discussed in the oversight hearing by the House Subcommittee on Oversight and Investigations, http://veterans.house.gov/press-release/cwt-program-helps-wounded-veterans-adjust-to-civilian-employment).

Supported employment is an evidence-based treatment for people with severe mental illness, a population that was traditionally underserved; thus, current VA supported employment guidelines reserve 75% of each employment specialist's caseload for veterans who have a psychotic disorder. The new Homeless Veterans Supported Employment Program is available for veterans who are homeless, but resources are limited for OEF/OIF veterans without psychosis or homelessness. Given the success rate of supported employment in OEF/OIF veterans without a psychotic disorder, additional supported employment specialists for this population would be expected to improve work outcomes for post-9/11 veterans who need assistance returning to work. Increased return to work in this population could also reduce homelessness.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Twamley EW, Baker DG, Norman SB, Pittman JO, Lohr JB, Resnick SG. Veterans Health Administration vocational services for Operation Iraqi Freedom/Operation Enduring Freedom Veterans with mental health conditions. Journal of rehabilitation research and development. 2013 Jan 1; 50(5):663-70. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Brain and Spinal Cord Injuries and Disorders
DRE: Treatment - Observational
Keywords: none
MeSH Terms: none