Effects of disability compensation on participation in and outcomes of vocational rehabilitation

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.

Experiences of VA vocational and education training and assistance services: Facilitators and barriers reported by veterans with disabilities

OBJECTIVE

To understand the experiences of veterans with disabilities and caregiving needs who use Department of Veterans Affairs (VA) vocational and education services, including Supported Employment, the Post-9/11 GI Bill, and Vocational Rehabilitation and Employment.

METHOD

We conducted 26 joint semistructured interviews with post-9/11 veterans who had used at least one of three vocational and education services, and their family members who were enrolled in a VA Caregiver Support Program.

RESULTS

VA vocational and education services helped veterans with disabilities transition from the military into civilian life by providing skills and incremental exposure to engaging in everyday life tasks. Veteran motivation, caregiver support, and engaged staff at VA and academic institutions were key drivers of veteran success. Veterans who experienced challenges cited the following barriers: health problems, concerns about benefits loss if they became employed, and VA and academic programs that did not accommodate the needs of nontraditional veteran learners.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

There is a need to bolster VA vocational and educational services for veterans with disabilities in several domains, including modifying the roles of frontline staff and increasing communication between vocational counselors and health care teams to better accommodate the veteran's health-related limitations. Providing a vocational rehabilitation navigator to help veterans identify opportunities within VA and work/educational settings that are a good match for the veteran's goals and abilities could also be beneficial across vocational and educational services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Factors associated with employment and work perception in combat-exposed veterans

PURPOSE/OBJECTIVE

The purpose of this study was 2-fold: (a) to evaluate whether perception of work ability is associated with employment status in a sample of combat-exposed veterans, and (b) to determine whether the same sets of variables that are associated with employment status are also associated with perception of work ability. Research Method/Design: In this cross-sectional study, veterans (N = 83) underwent a neuropsychological assessment and completed questionnaires assessing demographic characteristics, combat-related experiences, and psychiatric and neurobehavioral/health-related symptoms. Primary outcomes of interest were employment status (unemployed vs. employed) and veterans' perception of whether their ability to work has declined due to an ongoing condition (yes vs. no).

RESULTS

A chi-square analysis revealed a significant relationship between perception of work ability and employment status. Additionally, psychiatric and neurobehavioral/health-related symptoms were associated with employment status and perception of work ability, whereas demographic characteristics (i.e., service-connected disability rating) and combat-related experiences (i.e., mTBI history) were only associated with perception of work ability. Objective cognitive functioning was not associated with employment status or perception of work ability.

CONCLUSIONS/IMPLICATIONS

Although preliminary, results suggest that perception of work ability is an important factor to consider when evaluating employment-related outcomes in veterans. Moreover, results indicate that while there is some overlap among the variables associated with employment status and perception of work ability, additional variables are linked with perception of work ability. Taken together, these findings suggest that perception of one's ability to work and factors that influence it may be particularly important treatment targets in the veteran population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

"I achieved being an adult": A Qualitative Exploration of Voluntary Transitions from Permanent Supportive Housing

This study examined how individuals voluntarily leaving permanent supportive housing (PSH) through a Moving On initiative experienced the transition from PSH services to mainstream housing. Participants (N = 25) were purposively sampled from five supportive housing agencies in a Moving On initiative. A modified grounded theory approach was used to analyze semi-structured, post-move interviews. Participants described the transition from PSH as a process that involved gaining freedom from negative aspects of the PSH environment and a stagnation in services, adjusting to a new environment and the loss of familiar supports, taking on new responsibilities of self-advocacy and managing new financial burdens, and feeling empowered to move on to next steps, which ultimately, led to achievement of independence. Various contextual conditions, including PSH- and postmove housing type, influenced participants' experience of this process. Findings can inform future Moving On initiatives, implementation of PSH programs, as well as the design of the larger homeless service system.

Negative Life Events (NLEs) Contributing to Psychological Distress, Pain, and Disability in a U.S. Military Sample

Introduction

The objective was to explore how negative life events (NLEs, e.g., litigation related to pain and disability, failing most recent physical fitness test, and financial difficulties) are related to pain coping and psychological adjustment to pain in active duty military personnel.

Materials and Methods

Data were gathered as part of the Evaluation of Suicidality, Cognitions, and Pain Experience study, a DoD-funded cross-sectional assessment of chronic pain and emotional coping among a cohort of military members. The investigators examined data from 147 respondents with complete survey and pain assessment data.

Results

The sample was active duty, male (62.6%), in a relationship or married (83.0%), and had children (68.7%). The majority of the sample endorsed zero NLEs (72.0%); 23.8% endorsed one NLE, 4.2% endorsed two NLEs, and no one endorsed all three NLEs. A significantly higher proportion of participants endorsing one or more NLEs reported suicidal ideation compared to those who reported no NLEs (χ2(2) = 8.61, p = 0.014). A higher number of endorsed NLEs coincided with higher symptom severity related to psychosocial distress (depression, thwarted belongingness, perceived burdensomeness, PTSD, and suicide cognitions) and poor pain coping (rumination, helplessness, and less acceptance of chronic pain).

Conclusions

Findings revealed that NLEs may impart a significant burden on military pain sufferers. Greater numbers of endorsed NLEs are associated with increased psychosocial distress and poor pain coping. Future longitudinal studies examining long-term psychosocial distress/poor pain coping as related to NLEs would help to elaborate the long-term consequences of NLEs on pain coping and psychosocial distress.

Managing absence and dropout in vocational rehabilitation - a mixed-methods analysis of practices and perspectives among vocational rehabilitation companies in Norway

Purpose: While absence and dropout represent challenges to the implementation of vocational rehabilitation programs in Norway, sanctions are rarely used in practice. The purpose of the article was to investigate the extent to which vocational rehabilitation managers and professionals experience that the absence regulations support a viable implementation of vocational rehabilitation programs.Methods: An open-ended question, asking vocational rehabilitation managers about their experiences in handling absence, was presented as part of an electronic questionnaire sent to all vocational rehabilitation companies in Norway. 72 managers (59%) responded to the open-ended question, and a qualitative content analysis was conducted. Insight from ten focus group interviews were included as part of the analyses.Results: Five thematic categories were created, which in their various ways demonstrate challenges associated with absence management in vocational rehabilitation programs: (i) failure of the Labour and welfare administration to react against unfounded absence; (ii) difficulties in distinguishing valid from nonvalid absence; (iii) uncertainty concerning the role of the general practitioner and medical documentation in the rehabilitation process; (iv) the prevalence of diffuse disorders and symptoms, and (v) lack of incentives and motivation among participants.Conclusions: Sound absence management requires a clarification of the role of the general practitioner in the vocational rehabilitation process and closer cooperation between general practitioners and vocational rehabilitation companies, to reduce unnecessary breaks in the process due to hasty issuing of sicknotes. Further, as absence management appears to be most difficult in relation to those with mental and social problems, a comprehensive view on disability and follow-up is needed, where physical, mental, social and contextual factors are seen together.IMPLICATIONS FOR REHABILITATIONAbsence and dropout represent challenges to the implementation of vocational rehabilitation programs in Norway,While a sound regulation of absence could impact positively on both the work-related and rehabilitation outcomes of vocational rehabilitation programs, evidence suggest that absence management is scarce, and that it becomes particularly difficult in relation to participants with mental health problems and social challenges.Clarification of the role of the general practitioner and the medical certificates they issue and strengthening the dialog between vocational rehabilitation companies and general practitioners to prevent unnecessary sick-listing and interruptions in the vocational rehabilitation process, could improve the follow-up of absence.Moreover, a flexible and sensible approach is needed, where absence management is seen in conjunction with the overall follow-up that is provided, and where awareness to individual challenges and needs should be in focus.

Consideration of substance use in compensation and pension examinations of veterans filing PTSD claims

Veterans filing claims that service-induced PTSD impairs them worry that claims examiners may attribute their difficulties to conditions other than PTSD, such as substance use. Substance use commonly co-occurs with PTSD and complicates establishing a PTSD diagnosis because symptoms may be explained by PTSD alone, PTSD-induced substance use, or by a substance use condition independent of PTSD. These alternative explanations of symptoms lead to different conclusions about whether a PTSD diagnosis can be made. How substance use impacts an examiner’s diagnosis of PTSD in a Veteran’s service-connection claim has not been previously studied. In this study, we tested the hypothesis that mention of risky substance use in the Compensation & Pension (C&P) examination would result in a lower likelihood of service-connection award, presumably because substance use reflected an alternative explanation for symptoms. Data were analyzed from 208 Veterans’ C&P examinations, medical records, and confidentially-collected research assessments. In this sample, 165/208 (79%) Veterans’ claims were approved for a mental health condition; 70/83 (84%) with risky substance use mentioned and 95/125 (76%) without risky use mentioned (p = .02). Contrary to the a priori hypothesis, Veterans with risky substance use were more likely to get a service-connection award, even after controlling for baseline PTSD severity and other potential confounds. They had almost twice the odds of receiving any mental health award and 2.4 times greater odds of receiving an award for PTSD specifically. These data contradict assertions of bias against Veterans with risky substance use when their claims are reviewed. The data are more consistent with substance use often being judged as a symptom of PTSD. The more liberal granting of awards is consistent with literature concerning comorbid PTSD and substance use, and with claims procedures that make it more likely that substance use will be attributed to trauma exposure than to other causes.

Supported employment and education in comprehensive, integrated care for first episode psychosis: Effects on work, school, and disability income

BACKGROUND

Participation in work and school are central objectives for first episode psychosis (FEP) programs, but evidence effectiveness has been mixed in studies not focused exclusively on supported employment and education (SEE). Requirements for current motivation to work or go to school limit the generalizability of such studies.

METHODS

FEP participants (N=404) at thirty-four community treatment clinics participated in a cluster randomized trial that compared usual Community Care (CC) to NAVIGATE, a comprehensive, team-based treatment program that included ≥5h of SEE services per week, , grounded in many of the principles of the Individual Placement and Support model of supported employment combined with supported education services. All study participants were offered SEE regardless of their initial interest in work or school. Monthly assessments over 24months recorded days of employment and attendance at school, days of participation in SEE, and both employment and public support income (including disability income). General Estimation Equation models were used to compare CC and NAVIGATE on work and school participation, employment and public support income, and the mediating effect of receiving ≥3 SEE visits on these outcomes.

RESULTS

NAVIGATE treatment was associated with a greater increase in participation in work or school (p=0.0486) and this difference appeared to be mediated by SEE. No group differences were observed in earnings or public support payments.

CONCLUSION

A comprehensive, team-based FEP treatment approach was associated with greater improvement in work or school participation, and this effect appears to be mediated, in part, by participation in SEE.

Predictors of Return to Work for People With Psychiatric Disabilities

This investigation was a baseline study to determine if the speed of return to work could be predicted for people with psychiatric disabilities in a private sector setting. Participants with psychiatric disability claims who returned to work ( N = 300) were obtained from a nationwide Fortune 500 insurance company. The authors compared the speed of return to work for the participants, as measured by days on claim, among the levels of demographic and vocational variables. Hierarchical regression analysis indicated that several vocational variables were significant predictors. Participants who were not self-employed were found to have significantly ( p < .01) fewer days on claim than participants who were self-employed. Predisability occupational experience and age at return to work were significant ( p < .05) predictors of return to work. The low R2 value does constrain how these results may be generalized to this particular population. Surprisingly, many of the factors that were predictive of return to work in populations studied in the public sector were not significant in the present investigation. Implications for disability insurers, rehabilitation counselors, and people with psychiatric disabilities are discussed.

Rural and Urban Differences in Vocational Rehabilitation Case Mix, Delivery Practices, and Employment Outcomes

Purpose: To examine rural and urban differences in Vocational Rehabilitation (VR) case mix, delivery practices, and employment outcomes.

Methods: Rehabilitation Services Administration 911 (RSA-911) case data do not include location indicators that allow for rural analyses. We compiled RSA-911 data with county and ZIP code information from 47 VR agencies matched with additional sources to control for geographic and economic variations. Rural analyses included cross tabulations and logistic regression.

Results: Findings indicate that urban, large rural, small rural, and isolated rural outcomes and case mixes are significantly different based on education, age, minority status, receipt of Social Security Disability Insurance and Supplemental Security Income, and disability type (p ≤ .001).

Conclusion: Geographic indicators allow for differences to be explored and considered when making programmatic changes within the VR system.

Work outcomes after benefits counseling among veterans applying for service connection for a psychiatric condition

OBJECTIVE

This study's objective was to determine the efficacy of benefits counseling in a clinical trial. There has been concern that disability payments for psychiatric disorders reduce incentives for employment and rehabilitation. Benefits counseling, with education about opportunities to work and the financial implications of work on receipt of disability benefits, may counter these disincentives.

METHODS

This single-blind, six-month randomized clinical trial enrolled 84 veterans who had applied for service-connected compensation for a psychiatric condition. Veterans were randomly assigned to either four sessions of benefits counseling or of a control condition involving orientation to the U.S Department of Veterans Affairs health care system and services. Days of paid work and work-related activities were assessed at follow-up visits by using a timeline follow-back calendar.

RESULTS

Veterans assigned to benefits counseling worked for pay for significantly more days than did veterans in the control group (effect size=.69, p<.05), reflecting an average of three more days of paid employment during the 28 days preceding the six-month follow-up. Benefits counseling was associated with increased use of mental health services, but this correlation did not mediate the effect of benefits counseling on working.

CONCLUSIONS

Barriers to employment associated with disability payments are remediable with basic counseling. More research is needed to understand the active ingredient of this counseling and to strengthen the intervention.

Financial motivation to work among people with psychiatric disorders

BACKGROUND

Supported employment is an effective intervention for people with serious mental illnesses (SMI) but is underutilized. Clients' desire to work might be heightened by programs that provide counseling about managing one's funds, since money management helps people become more aware of the advantages of having money.

AIM

To analyze the thoughts of recently homeless or hospitalized persons with SMI concerning their personal finances and employment.

METHODS

We interviewed 49 people with SMI about their finances, reviewed transcripts and analyzed their baseline characteristics.

RESULTS

Twenty of the 49 participants spontaneously expressed a desire to work in order to earn more money. Those who expressed a desire to work managed their money significantly better than those who did not.

CONCLUSION

Discussion of finances, such as that fostered by money management programs, may promote engagement in vocational rehabilitation and working for pay.

Veterans' attitudes toward work and disability compensation: associations with substance abuse

INTRODUCTION

Veterans deemed disabled for conditions resulting from, or aggravated by, their service in the military are eligible for service-connected disability payments. Despite many positive effects of disability payments, one concern is that Veterans with psychiatric conditions who receive disability payments are less likely to be employed compared to those who are denied benefits. Little is known about the attitudes of substance using Veterans, for whom work is a particularly important part of recovery, toward work and disability compensation.

METHODS

This study compared the responses of Veterans with (n=33) and without substance use problems (n=51) to questions about work's significance and its relationship to disability payments. T- and chi-square tests were conducted to determine if Veterans with substance use problems differed from the others on work-related attitudes and perceptions of the relation between work and Veterans' benefits.

RESULTS

Veterans endorsed high levels of agreement with statements that working would lead to loss of benefits. Veterans with substance use agreed more strongly that they would rather turn down a job offer than lose financial benefits.

CONCLUSIONS

The greater preference for disability payments among substance-using Veterans may reflect a realistic concern that they are particularly likely to have difficulty maintaining employment. The widespread concern among Veterans that work will lead to loss of VA disability payments is striking given the ambiguity about how likely loss of benefits actually is, and should be addressed during the service-connection application process.

Examination of Veterans Affairs disability compensation as a disincentive for employment in a population-based sample of Veterans under age 65

PURPOSE

Concerns that disability benefits may create disincentives for employment may be especially relevant for young American military veterans, particularly veterans of the recent wars in Iraq and Afghanistan who are facing a current economic recession and turning in large numbers to the Department of Veterans Affairs (VA) for disability compensation. This study describes the rate of employment and VA disability compensation among a nationally representative sample of veterans under the age of 65 and examines the association between levels of VA disability compensation and employment, adjusting for sociodemographics and health status.

METHODS

Data on a total of 4,787 veterans from the 2010 National Survey of Veterans were analyzed using multinomial logistic regressions to compare employed veterans with two groups that were not employed.

RESULTS

Two-thirds of veterans under the age of 65 were employed, although only 36 % of veterans with a VA service-connected disability rating of 50 % or higher were employed. Veterans who received no VA disability compensation or who were service-connected 50 % or more were more likely to be unemployed and not looking for employment than veterans who were not service-connected or were service-connected less than 50 %, suggesting high but not all levels of VA disability compensation create disincentives for employment. Results were similar when analyses were limited to veterans who served in Iraq and Afghanistan.

CONCLUSIONS

Education and vocational rehabilitation interventions, as well as economic work incentives, may be needed to maximize employment among veterans with disabilities.

Work reintegration for veterans with mental disorders: a systematic literature review to inform research

BACKGROUND

Some veterans, and especially those with mental disorders, have difficulty reintegrating into the civilian workforce.

PURPOSE

The objectives of this study were to describe the scope of the existing literature on mental disorders and unemployment and to identify factors potentially associated with reintegration of workers with mental disorders into the workforce.

DATA SOURCES

The following databases were searched from their respective inception dates: MEDLINE, EMBASE, Cumulative Index Nursing Allied Health (CINAHL), and PsycINFO.

STUDY SELECTION

In-scope studies had quantitative measures of employment and study populations with well-described mental disorders (eg, anxiety, depression, posttraumatic stress disorder, substance-use disorders).

DATA EXTRACTION

A systematic and comprehensive search of the relevant published literature up to July 2009 was conducted that identified a total of 5,195 articles. From that list, 81 in-scope studies were identified. An update to July 2012 identified 1,267 new articles, resulting in an additional 16 in-scope articles.

DATA SYNTHESIS

Three major categories emerged from the in-scope articles: return to work, supported employment, and reintegration. The literature on return to work and supported employment is well summarized by existing reviews. The reintegration literature included 32 in-scope articles; only 10 of these were conducted in populations of veterans.

LIMITATIONS

Studies of reintegration to work were not similar enough to synthesize, and it was inappropriate to pool results for this category of literature.

CONCLUSIONS

Comprehensive literature review found limited knowledge about how to integrate people with mental disorders into a new workplace after a prolonged absence (>1 year). Even more limited knowledge was found for veterans. The results informed the next steps for our research team to enhance successful reintegration of veterans with mental disorders into the civilian workplace.

Compensation and treatment: disability benefits and outcomes of U.S. veterans receiving residential PTSD treatment

The U.S. Department of Veterans Affairs (VA) provides specialized intensive posttraumatic stress disorder (PTSD) programs to treat trauma-related symptoms in addition to providing service-connected disability to compensate veterans for injury sustained while serving in the military. Given the percentage of veterans who are receiving treatment for PTSD, in addition to seeking compensation for PTSD, a debate has emerged about the impact of compensation on symptom recovery. This study examined the associations among status of compensation, treatment expectations, military cohort, length of stay, and outcomes for 776 veterans who were enrolled in 5 VA residential PTSD programs between the years of 2005 and 2010. Mixed model longitudinal analyses, with age, gender, and baseline symptoms nested within treatment site in the model, found that treatment expectations were modestly predictive of treatment outcomes. Veterans seeking increased compensation reported marginally lower treatment expectations (d = .008), and did not experience poorer outcomes compared to veterans not seeking increased compensation with the effect of baseline symptoms partialled out. Veterans from the era of the Iraq and Afghanistan conflicts reported lower treatment expectations (d = .020) and slightly higher symptoms at intake (d = .021), but had outcomes at discharge equivalent to veterans from other eras with baseline symptoms partialled out. These findings help further inform the debate concerning disability benefits and symptom changes across time.

Early intervention services for psychosis and time until application for disability income support: a survival analysis

Ensuring the financial security of individuals recovering from first episode psychosis is imperative, but disability income programs can be powerful disincentives to employment, compromising the social and occupational aspects of recovery. Survival analysis and Cox regression analysis were used to examine the rate at which individuals served by early intervention for psychosis (EIP) services apply for government disability income benefits and factors that predict rate of application. Health records for 558 individuals served by EIP programs were reviewed. Within the first year of receiving services 30% will make application for disability income; 60% will do so by 5 years. Rate of application is predicted by rate of hospital admission, financial status and engagement in productivity roles at the time of entry to EIP service. The findings suggest the need to examine the extent to which the recovery goals of EI services are undermined by early application for government income support. They also suggest the need to develop best practice guidelines related to ensuring the economic security of individuals served.

Disability and employee benefits receipt: evidence from the U.S. Vocational Rehabilitation Services Program

Studies indicate positive effects of the U.S. Vocational Rehabilitation Services (VRS) in assisting people with disabilities to find independent employment. Underemployment continues to impact access to adequate health care and other benefits. Workers with disabilities receive fewer benefits, overall. With data from the Longitudinal Study of Vocational Rehabilitation Services Program (LSVRSP), the authors compare the rates of receipt of 6 types of benefits for people with physical, mental, and sensory impairments. Although those with physical disabilities are most likely to receive benefits, all groups lack adequate access to health care, sick leave, and vacation. The authors discuss implications for services provision in the current job market.

Frequency of subsyndromal symptoms and employment status in patients with bipolar disorder

OBJECTIVE

This study investigated the frequency of episodes and subsyndromal symptoms based on employment status in patients with bipolar disorder.

METHODS

Patients with bipolar disorder (n = 281) provided daily self-reported mood ratings for 5 months, returning 46,292 days of data. Data were analyzed using three employment status groups: disabled (n = 75), full-time employee or full-time student (n = 135), and other (n = 71). Demographic characteristics were compared by employment status. A univariate general linear model with employment status and other demographic variables as fixed factors and covariates was used to analyze the percent of days in episodes and percent of days with subsyndromal symptoms.

RESULTS

While there was no significant difference in the percent of days in episodes among the employment groups, disabled patients suffered subsyndromal symptoms of depression twice as frequently as those in the full-time group. Disabled patients spent 15% more days either in episodes or with subsyndromal symptoms than those in the full-time group, equivalent to about 45 extra sick days a year.

CONCLUSION

Frequent subsyndromal symptoms, especially depressive, may preclude full-time responsibilities outside the home and contribute to disability in bipolar disorder. Additional treatments to reduce the frequency of subsyndromal symptoms are needed.

Application for disability pension and change in use of prescribed drugs. A regional Danish cohort study

AIM

To investigate if a pending application for disability pension had an influence on the applicant's purchase of medical drugs, with a particular focus on musculoskeletal disorders and the use of painkillers.

METHODS

We performed a registry-based follow-up study including 12,020 applicants for disability pension in a Danish county from 1995 to 2000 and linked this information to a database of drug prescriptions. Purchase of drug was calculated for the 6-month period just before the decision and for the 6-month period 2 years later. Changes in a 2-year time period were estimated by differences in purchase rates. Furthermore, the proportion of applicants with an increased purchase of drugs and the proportion of applicants who ceased buying drugs were estimated. The results were stratified by diagnosis and result of application (awarded/rejected). The analyses were furthermore restricted to musculoskeletal disorders and the use of painkillers.

RESULTS AND CONCLUSIONS

At baseline 81% had a purchase and after the 2-year time period 11% ceased buying prescribed drugs. Half of all applicants increased the purchase of drugs. For musculoskeletal disorders one third had an increased purchase rate of painkillers while one fourth ceased purchase of drugs with variations in different diagnostic subgroups. The major changes of drug purchase after a pending application for disability pension are probably ascribed to characteristics of the diseases underlying the disability.

US Department of Veterans Affairs disability policies for posttraumatic stress disorder: administrative trends and implications for treatment, rehabilitation, and research

An accumulating body of empirical data suggests that current Department of Veterans Affairs (VA) psychiatric disability and rehabilitation policies for combat-related posttraumatic stress disorder (PTSD) are problematic. In combination, recent administrative trends and data from epidemiological and clinical studies suggest theses policies are countertherapeutic and hinder research efforts to advance our knowledge regarding PTSD. Current VA disability policies require fundamental reform to bring them into line with modern science and medicine, including current empirically supported concepts of resilience and psychiatric rehabilitation.

Changing to an outcome-focused program improves return to work outcomes

OBJECTIVES

The purposes of this study were to: (1) evaluate the effectiveness of changing a Return to Work (RTW) program's focus to one that was "outcome-focused", and (2) to determine which factors collected in the facility's database were most predictive of RTW.

METHODS

A total of 13,428 client files were extracted from Millard Health's database which included data on two cohorts of subjects: those in the program before and after the change in focus had been made. This was to determine whether significant improvements in outcomes were achieved. Variables that were hypothesized to be predictive of RTW were selected based on previous published literature. Analyses included ANOVA's, logistic regression analysis and Pearson correlation.

RESULTS

Statistically significant improvements in RTW, total temporary disability claims, client satisfaction, efficiency of services and scores on the Perceived Disability Index (PDI), Short Form-36 (SF-36) and Visual Analogue Scale (VAS) for perceived pain were found. Variables that were predictive of RTW included: more efficient services, completion of a worksite visit, having the worker participate in the visit, availability of modified duties from the employer, fewer absences from the program and better scores on the PDI, SF-36 and VAS. The most predictive variable of RTW was sores on the PDI indicating lower levels of perceived disability.

CONCLUSIONS

Changing to an outcome-focused program improved various outcomes in this RTW program. Several factors predict the outcome of RTW and these should be considered in treatment planning.

Disability benefits and clinical outcomes among homeless veterans with psychiatric and substance abuse problems

This study examined the relationship between disability payment status and clinical outcomes among 305 homeless veterans entering VA treatment. Disability status and clinical outcomes were characterized using self-report data at program entry, and quarterly for 2 years thereafter. Seeking or already receiving disability benefits at program entry was not associated with any of the 8 clinical outcomes examined. Those seeking or receiving disability benefits during the 2 years that followed showed more serious mental health problems and lower levels of mental health functioning, but no greater risk of substance use or not being employed nor worse housing outcomes than those who remained uninterested in applying for disability benefits. This study does not, therefore, support the notion that disability orientation results in poorer clinical outcomes, at least not among homeless veterans.

Employment and mental health service utilization in Washington State

This study examined employment among individuals utilizing publicly funded mental health services in Washington State during a 2-year period through the analysis of archival administrative data. The mean income found in this study was higher than that reported in the supported employment literature. This difference likely reflects the inclusion of individuals with less severe mental illness and ongoing employment who are typically excluded from studies of supported employment. Individuals in this study were employed in all industrial sectors in a distribution similar to the general population, although somewhat over-represented in service industries. Employment rates varied from 15% to 21% over a 3-year period and did not appear to increase after treatment. Employment rates tended to decline after the receipt of public support. Among individuals who lost employment, service utilization was found to increase prior to the loss of employment. Policy implications are discussed.

Effect of financial compensation on vocational rehabilitation

OBJECTIVE

To examine how financial compensation affects the outcome of vocational rehabilitation.

DESIGN

A registry-based follow-up study.

SUBJECTS

A total of 1397 rehabilitees discharged from the 5 local rehabilitation agencies in Aarhus County, Denmark from 1 July 2000 to 31 December 2001.

METHODS

At submission demographic data was obtained as well as data on financial compensation, i.e. compensation for industrial injury, indemnity for off-duty injury and application for disability pension. Rehabilitation outcomes were recorded at discharge. Renouncing further attempts at rehabilitation was defined as a negative outcome; education, further rehabilitation or return-to-work on normal or less demanding terms were defined as a positive outcome. Rehabilitees with and without financial compensation were compared.

RESULTS

Rehabilitees with involvement of financial compensation had an increased risk of a negative outcome compared with those without involvement of financial compensation. Adjustment for potential confounders did not change the association between financial compensation and negative outcome. The risk of a negative outcome rose with increasing age, with less than 1 year of labour market experience and with rented housing. Previous occupation as a skilled worker reduced the risk.

CONCLUSION

Financial compensation was associated with an increased risk of a negative vocational rehabilitation outcome.

Employment outcomes and PTSD symptom severity

A diagnosis of chronic war-related posttraumatic stress disorder (PTSD) has been linked consistently to poor employment outcomes. This study investigates the relation further, analyzing how symptom severity correlates with work status, occupation type, and earnings. Study participants were male Vietnam veterans with severe or very severe PTSD who received treatment in the Department of Veterans Affairs system (N = 325). Veterans with more severe symptoms were more likely to work part-time or not at all. Among workers, more severe symptoms were weakly associated with having a sales or clerical position. Conditional on employment and occupation category, there was no significant relation between PTSD symptom level and earnings. Alternative PTSD symptom measures produced similar results. Our findings suggest that even modest reductions in PTSD symptoms may lead to employment gains, even if the overall symptom level remains severe.

Employment outcomes in Massachusetts Clubhouses

Employment outcomes of individuals participating in 17 Massachusetts Clubhouses certified by the International Center for Clubhouse Development were examined through an annual survey. Major components of employment programs in contemporary clubhouses are identified and individual employment outcomes are described. Within contemporary practice in ICCD clubhouses in this sample, clubhouses provided a three-pronged approach to employment. Between 1998-2001, 1702 individuals worked in 2714 separate job placements, employed in Transitional (TE), Supported (SE), and Independent Employment (IE). Forty percent of members with more than one job (N = 385) participated in at least one TE. Individuals with longer memberships tended to work longer and had higher job earnings.

Veterans seeking disability benefits for post-traumatic stress disorder: who applies and the self-reported meaning of disability compensation

Assumptions about the characteristics and motivations of individuals pursuing disability status are well known. However, policy, programming and interventions need to be based on information about the actual sociodemographic characteristics of disabled individuals, as well as their goals in seeking disability status. In this study, we focus on veterans seeking disability compensation for post-traumatic stress disorder (PTSD) from the United States Department of Veterans Affairs. We present information on their life circumstances and their self-reported reasons for valuing the obtainment of veterans' disability status on the basis of PTSD. There was considerable variability in the background of veterans seeking disability status on the basis of PTSD. Of concern, only about half of these individuals were receiving any mental health treatment at the time of application. Most claimants reported seeking disability compensation for symbolic reasons, especially for acknowledgement, validation and relief from self-blame. Reasons having to do with improved finances were less frequently endorsed, although the importance of obtaining improved solvency through disability status decreased as income increased. The sense of investment in obtaining a sense of self-acceptance and acceptance from others through disability status varied by sociodemographic variables. Overall, findings suggest that individuals seeking disability benefits may have unmet mental health care needs, and that policy makers, investigators and providers should consider material benefit as one of many possible reasons for engaging in a disability compensation system.

Impact of public support payments, intensive psychiatric community care, and program fidelity on employment outcomes for people with severe mental illness

This study explored the relationship of public support payments, intensive psychiatric community care (IPCC), and fidelity of implementation to 1-year employment outcomes for 520 veterans with severe mental illness (SMI) in a clinical trial of IPCC. At study entry, 455 (87.5%) participants received public support. At 1 year, 46 (8.8%) participants met criteria to be classified as workers. A multivariate analysis indicated that baseline public support was significantly associated with a lower likelihood of employment, and baseline work was positively associated with employment at 1 year. IPCC patients were three times more likely to be working than control subjects, and a significant interaction favored well-implemented IPCC programs over others. This study points out not only the inhibiting effect of public support payment on employment but also the value of IPCC and the special importance of fidelity to program models for employment for people with SMI.