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RRP 12-511 – HSR&D Study

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RRP 12-511
Employment support needs of VA primary care patients with depression and anxiety
Kara Zivin PhD MS MA
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: November 2013 - February 2015

BACKGROUND/RATIONALE:
Ensuring Veteran employment needs are met is a top priority for the Department of Veterans Affairs (VA). President Obama issued the first strategic plan to increase hiring Veterans in the federal civil service, the Vow to Hire Heroes Act, and the Veterans Job Corps. These initiatives recognized a critical need to identify and address obstacles to obtaining and maintaining employment for returning Veterans. Our previous research found substantially lower employment rates among working-aged VA patients than non-Veterans and Veterans who do not use the VA, with the lowest rates among VA patients with mental disorders. Less than one-third of VA patients with mental disorders and documented needs receive any employment assistance, and less than 20% receive as much help as needed. Employment status or need for employment services among VA patients treated outside specialty mental health settings remains unknown.

OBJECTIVE(S):
The goal of this proposal was to assess VA primary care (PC) patient employment status, needs, and preferences, overall, and among those with depression and anxiety. The objectives of this study were to: 1) assess the employment status of PC patients with and without depression and anxiety, 2) assess perceived barriers to and facilitators of employment among PC patients with and without depression and anxiety, and 3) assess the use of and preferences for employment services among PC patients with and without depression and anxiety.

METHODS:
We used a mixed-methods approach, incorporating patient surveys and semi-structured interviews with a subgroup of respondents. We sought to recruit a representative sample of ~900 VA PC patients to complete a standardized survey instrument to assess determinants of employment status, including clinically significant depression and anxiety symptoms, employment support preferences, and employment barriers. We collected qualitative data from interviews to assess experiences with employment, and preferences for, and barriers to using VA and non-VA mental health treatment and employment support services. Qualitative analyses were designed to identify themes of patient experiences coping with unemployment, insecure employment, mental health problems, and preferences for additional services. Specifically, respondents were eligible for the interview portion of the study if they screened positive for depression or anxiety and if they were unemployed. Quantitative and qualitative data obtained from this proposal could assist in identifying key components for a future intervention designed to maximize effectiveness, satisfaction, and outcomes when implementing employment support services or integrated mental health services and employment support services in a VA PC population.

FINDINGS/RESULTS:
We have four papers in progress for this study, however, analyses are complete. Paper 1 examines employment outcomes, productivity, and barriers to employment in the study respondents (N=287). 154 (54%) were employed, 104 were not employed (36%), and 29 were other employed (10%). In unadjusted analyses, respondents with mental disorders were more likely to be unemployed. Respondents with mental disorders were less likely to be employed, had lower job search self-efficacy, lower levels of work performance, greater likelihood of pending job loss, and more total employment barriers. Mental disorders did not appear to have a measurable impact on likelihood of job seeking among the unemployed. In adjusted analyses, few covariates remained statistically significant predictors of study outcomes, however, mental disorders including depression and anxiety had a negative impact on job search self-efficacy and work performance. Paper 2 examines employment service use in the study respondents, and found that VHA employment service use was very low. Poor physical and mental health were associated with increased VHA employment service utilization across some but not all respondents (e.g., respondents with depressive symptoms had increased service use but those with anxiety and PTSD did not). Paper 3 found that respondents that screened positive for PTSD were less likely to be employed than those without PTSD. Respondents with PTSD also had had lower job-search self-efficacy, higher barriers to employment, and higher barriers to employment service use. Only 14% of those with PTSD had used VHA employment services but 86% said they would use those services. Finally, Paper 4 uses the data from respondents who completed interviews. Our findings reflect the difficulties Veterans' may face when trying to find and maintain a job. When they were discharged from the military, the information they received was minimal, overwhelming, or inapplicable to their situation. Because they did not know of any services the VA offered, it remained an untapped source of help. More importantly, all had stated that no one within their local VA had ever talked with them about employment or suggested employment resources they could contact. Not only is there a need for support for obtaining a job, but Veterans also need support in maintaining their employment. The VA has an opportunity to provide outreach and support to Veterans who continue to struggle.

IMPACT:
This study obtained data to define the scope of employment support needs among Veterans treated in VA primary care (PC) settings who have a clinical diagnosis of a depression or anxiety disorder. Study findings will inform future employment interventions to ensure access to and maintenance of appropriate jobs among working-aged VA patients, a top priority for the VA.

PUBLICATIONS:

Journal Articles

  1. Sripada RK, Henry J, Yosef M, Levine DS, Bohnert KM, Miller E, Zivin K. Occupational functioning and employment services use among VA primary care patients with posttraumatic stress disorder. Psychological trauma : theory, research, practice and policy. 2018 Mar 1; 10(2):140-143.
  2. Zivin K, Yosef M, Levine DS, Abraham KM, Miller EM, Henry J, Nelson CB, Pfeiffer PN, Sripada RK, Harrod M, Valenstein M. Employment status, employment functioning, and barriers to employment among VA primary care patients. Journal of affective disorders. 2016 Mar 15; 193:194-202.
Conference Presentations

  1. Zivin K. Health and employment resources opportunities for success: findings from the HEROS study. Paper presented at: American Psychological Association Annual Convention; 2015 Aug 9; Toronto, Canada.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: QUERI Implementation
MeSH Terms: none

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