Income inequality among American states and the conditional risk of post-traumatic stress disorder

Neighborhood context: Understanding the relationship between national indices of neighborhood risk, individual perception, and posttraumatic stress

Although understudied, emerging research suggests an important link between neighborhood environments and posttraumatic stress disorder (PTSD). National indices of neighborhood disadvantage offer a unique way to objectively assess neighborhoods by linking indices of risk to geocoded residential addresses and research suggests living in a more disadvantaged neighborhood is associated with poorer mental health. Self-report measures offer a subjective appraisal of the circumstances in one's neighborhood yet it is unclear how well perception maps onto objective indices of risk. This study examined the association between three national indices of neighborhood disadvantage and neighborhood perceptions of cohesion, disorder, and danger and whether these relationships were impacted by prior trauma history or PTSD in a sample of 3378 U.S. veterans enrolled in the Longitudinal Investigation of Gender Health, and Trauma (LIGHT) study. Veterans with PTSD resided in more disadvantaged neighborhoods and reported poorer neighborhood cohesion, greater neighborhood disorder, and greater neighborhood danger compared to trauma exposed veterans without PTSD and non-trauma exposed veterans. Findings additionally highlight the ways in which trauma exposure and PTSD symptomology impact the relationship between objective neighborhood indices and perceptions of contextual neighborhood factors and point to important future directions investigating the salience of community level conditions on traumatic stress.

Hospitalizations with post-traumatic stress disorder in France between 2013 and 2022: a nationwide retrospective study

INTRODUCTION

The lifetime prevalence of PTSD ranges from 6 to 20% and is often associated with comorbid disorders. Despite the significant impact of PTSD, specific data on healthcare utilization related to PTSD remain limited. This study aims to characterize PTSD-related hospitalizations in France over the past decade.

METHODS

This nationwide longitudinal retrospective study analyzed PTSD-related hospitalizations in France from 2013 to 2022 using the French National Hospitals Database. Data included discharge records from general and psychiatric hospitals, detailing demographics, admission/discharge dates, ICD-10 diagnoses, and hospitalization specifics.

RESULTS

Between 2013 and 2022, 69,108 patients underwent 125,349 hospitalizations with a PTSD diagnosis (0.4% of all inpatient cases) in France. Psychiatric facilities accounted for 74,988 hospitalizations (1% of all psychiatric inpatient cases in France), while general hospitals recorded 50,361 hospitalizations (0.02% of all non-psychiatric inpatient cases). The percentage of inpatients diagnosed with PTSD increased from 0.68 to 2.22% in psychiatric facilities and from 0.02 to 0.04% in general hospitals over the study period. Females were younger in both settings and had longer stays compared to males in psychiatric facilities. Over time, there was a decrease in median age and an increase in part-time hospitalizations in psychiatric facilities. Mood disorders, stress-related disorders, and substance use disorders were prevalent comorbidities in both settings.

CONCLUSIONS

This study highlights a rise in PTSD-related hospitalizations in France, particularly in psychiatric facilities and after 2019, with high rates among women and an increase in hospitalization of younger individuals. These findings highlight the necessity for improved care strategies tailored to the increasing number of younger patients with PTSD.

Neighborhood-level economic characteristics and depression and PTSD symptoms among Houstonians who have experienced Hurricane Harvey and COVID-19

Little is known about how neighborhood economic characteristics relate to risk of depression and Posttraumatic Stress Disorder (PTSD) in the context of multiple disasters. We sampled 88 super neighborhoods in Houston, Texas and surveyed 872 residents who were living in Houston during Hurricane Harvey and COVID-19 and lived in the same residence since Hurricane Harvey, about their demographics and symptoms of depression and PTSD. Using data from the American Community Survey, we estimated neighborhood-level unemployment, median income, and income inequality (i.e., Gini coefficient). We investigated whether these underlying neighborhood socioeconomic factors were associated with the mental health consequences of mass traumatic events. We examined associations between neighborhood-level constructs and individual-level depression and PTSD, using multilevel linear models. Partially adjusted multilevel models showed that lower neighborhood median income was associated with higher symptom scores of PTSD, while greater neighborhood income inequality was associated with higher symptom scores of depression and PTSD. However, fully adjusted models showed that these associations are better accounted for by event-specific stressors and traumas. These findings suggest that in the context of multiple large scale traumatic events, neighborhood socioeconomic context may structure individual-level exposure to stressful and traumatic events.

Structural inequities contribute to racial/ethnic differences in neurophysiological tone, but not threat reactivity, after trauma exposure

Considerable racial/ethnic disparities persist in exposure to life stressors and socioeconomic resources that can directly affect threat neurocircuitry, particularly the amygdala, that partially mediates susceptibility to adverse posttraumatic outcomes. Limited work to date, however, has investigated potential racial/ethnic variability in amygdala reactivity or connectivity that may in turn be related to outcomes such as post-traumatic stress disorder (PTSD). Participants from the AURORA study (n = 283), a multisite longitudinal study of trauma outcomes, completed functional magnetic resonance imaging and psychophysiology within approximately two-weeks of trauma exposure. Seed-based amygdala connectivity and amygdala reactivity during passive viewing of fearful and neutral faces were assessed during fMRI. Physiological activity was assessed during Pavlovian threat conditioning. Participants also reported the severity of posttraumatic symptoms 3 and 6 months after trauma. Black individuals showed lower baseline skin conductance levels and startle compared to White individuals, but no differences were observed in physiological reactions to threat. Further, Hispanic and Black participants showed greater amygdala connectivity to regions including the dorsolateral prefrontal cortex (PFC), dorsal anterior cingulate cortex, insula, and cerebellum compared to White participants. No differences were observed in amygdala reactivity to threat. Amygdala connectivity was associated with 3-month PTSD symptoms, but the associations differed by racial/ethnic group and were partly driven by group differences in structural inequities. The present findings suggest variability in tonic neurophysiological arousal in the early aftermath of trauma between racial/ethnic groups, driven by structural inequality, impacts neural processes that mediate susceptibility to later PTSD symptoms.

The buffering effect of social capital for daily mental stress in an unequal society: a lesson from Seoul

This study attempted to illustrate whether mental health deterioration could be alleviated by high social capital in an environment with high economic inequality. Daily mental stress was employed as a mental health factor when analyzing the association with economic inequality in the Seoul Survey data. Regarding social capital, community trust and altruism were included as cognitive dimensions, and participation and cooperation were included as structural dimensions in each model. The first finding showed a significantly positive relationship between economic inequality and daily stress, meaning that, like other mental health problems, daily mental stress is also high in regions with high economic inequality. Second, the slope of the daily stress increased in respondents with high social trust and participation was alleviated in an economically unequal environment. This indicates that social trust and participation have a buffering effect by moderating the slope of daily stress in societies with high inequality. Third, the buffering effect differs depending on the social capital factor. The buffering effect of trust and participation showed in an unequal environment, while the buffering effect of cooperation showed regardless of the unequal environment. In summary, social capital factors showed the effect of relieving daily mental stress in the relationship with economic inequality. Also, the buffering effect of social capital on mental health may show different aspects for each element.

Associations between relative deprivation with opioid use among working-age adults during the great recession

Recessions, poverty, and unemployment have been associated with opioid use. However, these measures of financial hardship may be imprecise, limiting our ability to understand this relationship. We tested associations between relative deprivation and non-medical prescription opioid use (NMPOU) and heroin use among working-age adults (ages 18-64) during the Great Recession. Our sample included working-age adults in the 2005-2013 United States National Survey of Drug Use and Health (n = 320,186). Relative deprivation compared the lowest limit of participants' income category to the national 25th percentile individual income for people with similar socio-demographic characteristics (race and ethnicity, gender, year). We distinguished the period before (1/2005-11/2007), during (12/2007-06/2009), and after (07/2007-12/2013) the Great Recession. We estimated odds of past-year NMPOU and heroin use for each past-year exposure (i.e., relative deprivation, poverty, unemployment) using separate logistic regressions adjusting for individual-level covariates (gender, age, race/ethnicity, marital status, and education) and national-level annual Gini coefficient. Our results show that NMPOU was higher among people experiencing relative deprivation (aOR = 1.13, 95% CI = 1.06-1.20), poverty (aOR = 1.22, 95% CI = 1.16-1.29), and unemployment (aOR = 1.42, 95% CI = 1.32-1.53) between 2005 and 2013, as was heroin use (aORs = 2.54, 2.09, 3.55, respectively). The association between relative deprivation and NMPOU was modified by recession timing, and was significantly higher after the Recession (aOR = 1.21, 95% CI = 1.11-1.33). Relative deprivation was associated with higher odds of NMPOU and heroin use, and higher odds of NMPOU after the Great Recession. Our findings suggest contextual-level factors may modify the relationship between relative deprivation and opioid use, and support the need for new measures of financial hardship.

How Income and Income Inequality Drive Depressive Symptoms in U.S. Adults, Does Sex Matter: 2005-2016

IMPORTANCE

Depression is one of the leading causes of disability in the United States. Depression prevalence varies by income and sex, but more evidence is needed on the role income inequality may play in these associations.

OBJECTIVE

To examine the association between the Poverty to Income Ratio (PIR)-as a proxy for income-and depressive symptoms in adults ages 20 years and older, and to test how depression was concentrated among PIR.

DESIGN

Using the 2005-2016 National Health and Nutrition Examination Survey (NHANES), we employed Negative Binomial Regression (NBRG) in a sample of 24,166 adults. We used a 9-item PHQ (Public Health Questionnaire, PHQ-9) to measure the presence of depressive symptoms as an outcome variable. Additionally, we plotted a concentration curve to explain how depression is distributed among PIR.

RESULTS

In comparison with high-income, the low-income population in the study suffered more from greater than or equal to ten on the PHQ-9 by 4.5 and 3.5 times, respectively. The results of NBRG have shown that people with low-PIR (IRR: 1.30, 95% CI: 1.23-1.37) and medium-PIR (IRR: 1.55, 95% CI: 1.46-1.65) have experienced a higher relative risk ratio of having depressive symptoms. Women have a higher IRR (IRR: 1.29, 95% CI: 1.24-1.34) than men. We observed that depression was concentrated among low-PIR men and women, with a higher concentration among women.

CONCLUSION AND RELEVANCE

Addressing depression should target low-income populations and populations with higher income inequality.

The association between income inequality and adult mental health at the subnational level-a systematic review

PURPOSE

A systematic review was undertaken to determine whether research supports: (i) an association between income inequality and adult mental health when measured at the subnational level, and if so, (ii) in a way that supports the Income Inequality Hypothesis (i.e. between higher inequality and poorer mental health) or the Mixed Neighbourhood Hypothesis (higher inequality and better mental health).

METHODS

Systematic searches of PsycINFO, Medline and Web of Science databases were undertaken from database inception to September 2020. Included studies appeared in English-language, peer-reviewed journals and incorporated measure/s of objective income inequality and adult mental illness. Papers were excluded if they focused on highly specialised population samples. Study quality was assessed using a custom-developed tool and data synthesised using the vote-count method.

RESULTS

Forty-two studies met criteria for inclusion representing nearly eight million participants and more than 110,000 geographical units. Of these, 54.76% supported the Income Inequality Hypothesis and 11.9% supported the Mixed Neighbourhood Hypothesis. This held for highest quality studies and after controlling for absolute deprivation. The results were consistent across mental health conditions, size of geographical units, and held for low/middle and high income countries.

CONCLUSIONS

A number of limitations in the literature were identified, including a lack of appropriate (multi-level) analyses and modelling of relevant confounders (deprivation) in many studies. Nonetheless, the findings suggest that area-level income inequality is associated with poorer mental health, and provides support for the introduction of social, economic and public health policies that ameliorate the deleterious effects of income inequality.

CLINICAL REGISTRATION NUMBER

PROSPERO 2020 CRD42020181507.

Correlates of Obtaining Employment among Veterans Receiving Treatment for Severe PTSD in Specialized Intensive Programs

Severe Post-Traumatic Stress Disorder (PTSD) has been identified as a significant impediment to employment. However, little is known about correlates of employment recovery after a period of not working among veterans with severe PTSD treated in specialized intensive treatment programs. This study examines rates and correlates of transitioning from not being employed at admission to working four months after discharge using national Veterans Health Administration (VHA) program evaluation data on veterans engaged in specialized intensive PTSD treatment (N = 27,339). Results suggest that only 5.68% of the sample made the transition to employment while 10.6% lost employment, 8.9% worked both at admission and following discharge, and 74.9%, did not work either at admission or following discharge. Multinomial regression analysis found that compared to other groups, veterans who became employed were younger, less likely to receive service-connected disability payments, and experienced a significantly greater reduction in PTSD symptoms. Findings from this study highlight that this distinct population has very poor employment outcomes and deserves more attention, and that reducing PTSD symptoms can lead to improved employment outcomes. Efforts to integrate evidence-based vocational rehabilitation practice into residential PTSD treatment targeting PTSD symptoms is encouraged.

The Impact of Income Inequality on Subjective Environmental Pollution: Individual Evidence from China

Numerous studies have investigated the relationship between income inequality and objective environmental pollution, but few focus on the nexus between income inequality and subjective environmental pollution (SEP). Using micro data from the Chinese General Society Survey (CGSS) in 2013 and official statistical data at the provincial level, this paper tests the impact of individual-level income inequality on subjective environmental pollution in China. The results show that individual-level income inequality has an inverted U-shape relationship with subjective environmental pollution, which indicates that increasing the income inequality at the individual level will first rise and then reduce their perceived subjective environmental pollution after reaching the peak. For about 84% of respondents, their subjective environmental pollution decreases with the increase of individual-level income inequality. Furthermore, the heterogeneity analyses show that the income inequality of urban residents and of the locals have an inverted U-shape effect on SEP, and the SEP of females and of individuals with positive environmental attitude are more sensitive to the effect of income inequality. Additionally, we find that subjective well-being plays a mediating role in the relation between income inequality and SEP. Individual income inequality decreases their self-reported well-being, and an increase in well-being has a negative effect on their subjectively perceived environmental quality. We also find non-television media exposures, such as newspaper, magazine, broadcasting, Internet, and mobile custom messages, will amplify the effect of individual-level income inequality on subjective environmental pollution.

Incidence and Direct Medical Cost of Acute Stress Disorder and Post-traumatic Stress Disorder in Korea: Based on National Health Insurance Service Claims Data from 2011 to 2017

BACKGROUND

We aimed to investigate the annual incidence of trauma and stress-related mental disorder including acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) using the National Health Insurance Service Database. In addition, we estimated direct medical cost of ASD and PTSD in Korea.

METHODS

To examine the incidence, we selected patients who had at least one medical claim containing a 10th revision of the International Statistical Classification of Diseases and Related Health Problems code for ASD (F43.0) and PTSD (F43.1) and had not been diagnosed in the previous 360 days, from 2010 to 2017. We estimated annual incidence and the number of newly diagnosed patients of ASD and PTSD. Annual prevalence and direct medical cost of ASD and PTSD were also estimated.

RESULTS

The number of newly diagnosed cases of ASD and PTSD from 2011 to 2017 totaled 38,298 and 21,402, respectively. The mean annual incidence of ASD ranged from 8.4 to 13.7 per 100,000 population and that of PTSD ranged from 4.2 to 8.3 per 100,000 population, respectively. The incidence of ASD was found more in females and was highest among the 70-79 years of age group and the self-employed individuals group. The incidence of PTSD was also more common in the female group. However, the incidence of PTSD was highest in the 60-69 years of age group and in the medical aid beneficiaries group. The annual estimated medical cost per person of ASD ranged from 104 to 149 US dollars (USD). In addition, that of PTSD ranged from 310 to 426 USD.

CONCLUSION

From 2011 to 2017, the annual incidence and direct medical cost of ASD and PTSD in Korea were increased. Proper information on ASD and PTSD will not only allows us to accumulate more knowledge about these disorders themselves but also lead to more appropriate therapeutic interventions by improving the ability to cope with these trauma related psychiatric sequelae.

Neighborhood disadvantage is associated with stable deficits in neurocognitive functioning in traumatically-injured adults

BACKGROUND

In trauma-exposed adults, the relationship between an individual's socioeconomic position (SEP) and post-traumatic stress disorder (PTSD) has been well demonstrated. One potential mechanism by which the stress associated with lower SEPs may impact trauma outcomes is through changes in neurocognition. In both healthy and clinical samples, area-level factors also appear to be independently related to neurocognition. Far less is known about how neighborhood socioeconomic disadvantage, may impact cognition in traumatically-injured adults. The current study employed hierarchical linear modeling to longitudinally investigate whether neighborhood disadvantage was associated with neurocognitive functioning in five domains: processing speed, sustained attention, controlled attention, cognitive flexibility, and response inhibition.

METHODS

One-hundred and ninety-five socioeconomically diverse traumatically-injured subjects (mean age = 32.8, 52.8% female) were recruited from an Emergency Department. Two-weeks, three-months, and six-months post-trauma, participants completed self-report measures and a computerized test battery to evaluate neurocognition. An Area Deprivation Index (ADI) score, a measure of a neighborhood's socioeconomic disadvantage, was derived from each participants' home address.

RESULTS

Greater neighborhood disadvantage was significantly related to lower scores in all domains. Results of hierarchical linear models revealed neighborhood disadvantage was significantly associated with processing speed, controlled attention, cognitive flexibility, and response inhibition across time, even after adjusting for individual annual household income, baseline PTSD symptoms, and previous adverse life experiences. This relationship was stable for all domains except sustained attention, which varied across time.

CONCLUSION

These findings indicate neighborhood disadvantage contributes uniquely to neurocognitive functioning and, for the majority of domains, these contributions are stable across time. The relationship between area-level variables and cognitive function may underlie individual vulnerability to developing psychiatric disorders. Future work should continue to examine the interaction between socioenvironmental stressors and PTSD symptoms longitudinally.

Prospective prediction of PTSD diagnosis in a nationally representative sample using machine learning

BACKGROUND

Recent research has identified a number of pre-traumatic, peri-traumatic and post-traumatic psychological and ecological factors that put an individual at increased risk for developing PTSD following a life-threatening event. While these factors have been found to be associated with PTSD in univariate analyses, the complex interactions of these risk factors and how they contribute to individual trajectories of the illness are not yet well understood. In this study, we examine the impact of prior trauma, psychopathology, sociodemographic characteristics, community and environmental information, on PTSD onset in a nationally representative sample of adults in the United States, using machine learning methods to establish the relative contributions of each variable.

METHODS

Individual risk factors identified in Waves 1 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were combined with community-level data for the years concurrent to the NESARC Wave 1 (n = 43,093) and 2 (n = 34,653) surveys. Machine learning feature selection and classification analyses were used at the national level to create models using individual- and community-level variables that would best predict the new onset of PTSD at Wave 2.

RESULTS

Our classification algorithms yielded 89.7 to 95.6% accuracy for predicting new onset of PTSD at Wave 2. A prior diagnosis of DSM-IV-TR Borderline Personality Disorder, Major Depressive Disorder or Anxiety Disorder conferred the greatest relative influence in new diagnosis of PTSD. Distal risk factors such as prior psychiatric diagnosis accounted for significantly greater relative risk than proximal factors (such as adverse event exposure).

CONCLUSIONS

Our findings show that a machine learning classification approach can successfully integrate large numbers of known risk factors for PTSD into stronger models that account for high-dimensional interactions and collinearity between variables. We discuss the implications of these findings as pertaining to the targeted mobilization emergency mental health resources. These findings also inform the creation of a more comprehensive risk assessment profile to the likelihood of developing PTSD following an extremely adverse event.

Occupational stress and psychological health impact on hypertension of miners in noisy environment in Wulumuqi, China: a case-control study

Background

Hypertension has been declared as a global public health crisis by the World Health Organization, because of its high prevalence. It affects the health of one billion people worldwide and is directly responsible for the deaths of more than 10 million people per year. The purpose of our research was to explore the influence of occupational stress and psychological health on hypertension of miners who work in a noisy environment and provide decision reference for relevant departments to keep miners’ health.

Methods

A case-control study was carried out in this research. The study subjects were divided into case groups and control groups based on whether they had hypertension or not. Effort-Reward Imbalance questionnaire and Self-Reporting Inventory questionnaire were used to investigate the psychological health status and occupational stress of the target population. General information was balanced between case and control groups through propensity score matching method. After propensity score matching, a multifactorial analysis was used to explore the impact of occupational stress and psychological health on hypertension.

Results

According to the result of the multivariate analysis, psychological health was hazard to hypertension (t = 5.080, P<0.001) and occupational stress was not a direct risk factor for hypertension (t = 1.760, P = 0.080). The model was statistically significant (χ² = 20.4, P<0.01).

Conclusions

For miners working in the noisy environment, psychological status was a direct risk factor to hypertension, while occupational stress was an indirect factor.

Buprenorphine: prospective novel therapy for depression and PTSD

BACKGROUND

Depression and post-traumatic stress disorder (PTSD) are leading causes of disability and loss of life by suicide. Currently, there are less than satisfactory medical solutions to treat these mental disorders. Here, we explore recent preclinical and clinical studies demonstrating the potential of using buprenorphine to treat major depressive disorder, treatment-resistant depression, and PTSD.

METHOD

Bibliographic databases were searched to include preclinical and clinical studies demonstrating the therapeutic potential of buprenorphine and the involvement of the kappa opioid receptor (KOR) in mediating these effects.

RESULTS

Original clinical studies examining the effectiveness of buprenorphine to treat depression were mixed. The majority of participants in the PTSD studies were males and suffer from chronic pain and/or substance use disorders. Nonetheless, these recent studies and analyses established proof of concept warranting farther investigations. Additionally, KOR likely mediates the antidepressant and some of the anxiolytic effects of buprenorphine. Still, it appears that the full spectrum of buprenorphine's beneficial effects might be due to activity at other opioid receptors as well.

CONCLUSIONS

Pharmaceuticals' abilities to treat medical conditions directly relates to their ability to act upon the endogenous biological systems related to the conditions. Thus, these recent findings are likely a reflection of the central role that the endogenous opioid system has in these mental illnesses. Further studies are necessary to study the involvement of endogenous opioid systems, and specifically KOR, in mediating buprenorphine's beneficial effects and the ability to treat these medical conditions while minimizing risks for misuse and diversion.

Posttraumatic Stress Disorder Among Low-Income Adolescents Experiencing Family-Neighborhood Income Disparities

Certain neighborhood factors may increase the risk of exposure to trauma, therefore increasing the risk of posttraumatic stress disorder (PTSD). Other aspects of neighborhoods can be protective, such as neighborhood-based social relationships, which provide social support that buffers the risk of developing PTSD. The strength of these social relationships may not be as dependent on neighborhood conditions as much as they are contingent on socioeconomic similarities between neighborhood residents. Using a nationally representative sample of hospital emergency department admissions in the United States (N = 13,669,251), this study hypothesized that an interaction between family-level income and neighborhood-level income would be associated with adolescent PTSD. The results show that female adolescents who resided in the highest income areas were 1.39 times more likely, 95% CI [1.09, 1.77], to be diagnosed with PTSD than those who lived in the lowest income areas. This association was not statistically significant for male adolescents. Additionally, low-income female youth were nearly one-third more likely than their non-low-income counterparts to be diagnosed, odds ratio (OR) = 1.29, 95% CI [1.12, 1.48], whereas low-income male youth were nearly twice as likely than their non-low-income counterparts to be diagnosed, OR = 1.95, 95% CI [1.62, 2.34]. Furthermore, there was an interaction among both male and female adolescents such that lower-income adolescents living in higher-income areas had higher odds of a PTSD diagnosis compared to their higher-income peers in areas that were in the same median household income quartile.

Chromosomes to Social Contexts: Sex and Gender Differences in PTSD

PURPOSE OF REVIEW

This review highlights recent research on sex- and gender-related factors in the prevalence, symptom expression, and treatment of PTSD. Further discoveries about the underlying mechanisms of sex and gender effects have the potential to shape innovative directions for research.

RECENT FINDINGS

The prevalence of PTSD is substantially higher among women, but women show a modest advantage with respect to treatment response. There is evidence of greater heritability among females. Women are more likely to experience sexual and intimate violence, childhood trauma exposure, and repeated trauma exposures. Specific characteristics of social contexts act as gender-linked risks for PTSD. Among individuals diagnosed with PTSD, men and women are similar in phenotypic expression. Though research has yet to fully account for the factors that explain sex- and gender- related effects on PTSD, emerging research suggests these effects occur across multiple levels. Shared risk factors for trauma exposure and PTSD merit further investigation. Both social and biological contexts merit investigation to understand sex-linked differences in heritability.

Effect of Evidence-Based Supported Employment vs Transitional Work on Achieving Steady Work Among Veterans With Posttraumatic Stress Disorder: A Randomized Clinical Trial

IMPORTANCE

Posttraumatic stress disorder (PTSD) often interferes with a person's ability to obtain or sustain employment, which leads to premature exit from the labor force and reduced income.

OBJECTIVE

To determine whether individual placement and support (IPS)-supported employment is more effective than stepwise vocational rehabilitation involving transitional work assignments at helping veterans with PTSD attain steady, competitive employment.

DESIGN, SETTING, AND PARTICIPANTS

The Veterans Individual Placement and Support Toward Advancing Recovery (VIP-STAR) study was a prospective, multisite, randomized clinical trial that included 541 unemployed veterans with PTSD at 12 Veterans Affairs medical centers. Data were collected from December 23, 2013, to May 3, 2017. Intent-to-treat analysis was performed.

INTERVENTIONS

Individual placement and support is a supported employment intervention that rapidly engages people with disabilities in community job development to obtain work based on their individual job preferences. Transitional work is a stepwise vocational rehabilitation intervention that assigns people temporarily to noncompetitive jobs as preparation for competitive employment in the community.

MAIN OUTCOMES AND MEASURES

A priori hypotheses were that, compared with those in transitional work, more participants in the IPS group would become steady workers (primary) and earn more income from competitive jobs (secondary) over 18 months. Steady worker was defined as holding a competitive job for at least 50% of the 18-month follow-up period.

RESULTS

A total of 541 participants (n = 271 IPS; n = 270 transitional work) were randomized. Mean (SD) age was 42.2 (11) years; 99 (18.3%) were women, 274 (50.6%) were white, 225 (41.6%) were African American, and 90 (16.6%) were of Hispanic, Spanish, or Latino ethnicity. More participants in the IPS group achieved steady employment than in the transitional work group (105 [38.7%] vs 63 [23.3%]; odds ratio, 2.14; 95% CI, 1.46-3.14). A higher proportion of IPS participants attained any competitive job (186 [68.6%] vs 154 [57.0%]; P = .005) and had higher cumulative earnings from competitive jobs (median [interquartile range] $7290 [$23 174] in IPS vs $1886 [$17 167] in transitional work; P = .004).

CONCLUSIONS AND RELEVANCE

This multisite trial demonstrated significantly greater effectiveness of IPS-supported employment over stepwise transitional work vocational rehabilitation for veterans living with chronic PTSD. The results provide supporting evidence for increasing access to IPS for veterans living with PTSD.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01817712.