Disability compensation and work among veterans with psychiatric and nonpsychiatric impairments

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.

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.

Chapter 7. Sickness absence and psychiatric disorders

There is limited scientific evidence that women have a higher frequency and incidence of sickness absence due to psychiatric diagnoses. Because of conflicting findings, there is insufficient evidence on gender differences in the duration of sickness absence. Because of conflicting findings, there is also insufficient evidence on the association between age and sickness absence with psychiatric diagnoses. There is insufficient evidence on the association of sickness absence due to psychiatric diagnoses with work-related factors, factors related to family and social networks outside of the job, and psychosocial factors in childhood and adolescence since none of the individual factors were investigated in more than a single study. The results were conflicting (insufficient evidence) in five studies that investigated whether individuals with psychiatric disorders were at greater risk for sickness absence and disability pension, irrespective of the diagnosis on the sickness certificate. The four studies that used alcohol diagnoses to identify alcohol problems found increased sickness absence irrespective of the diagnosis on the certificate (expressed as more sick-leave days or an increased risk for prolonged sickness absence in individuals with alcohol problems). Furthermore, two of the studies found an increased risk for disability pension in women diagnosed with alcohol problems. There is insufficient evidence because of too few studies. The results are conflicting with regard to the association between high alcohol consumption and sickness absence, irrespective of the diagnosis on the certificate (insufficient evidence).

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.

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.

Predicting the severity of everyday functional disability in people with schizophrenia: cognitive deficits, functional capacity, symptoms, and health status

Disability is pervasive in schizophrenia and is refractory to current medication treatments. Inability to function in everyday settings is responsible for the huge indirect costs of schizophrenia, which may be as much as three times larger than direct treatment costs for psychotic symptoms. Treatments for disability are therefore urgently needed. In order to effectively treat disability, its causes must be isolated and targeted; it seems likely that there are multiple causes with modest overlap. In this paper, we review the evidence regarding the prediction of everyday disability in schizophrenia. We suggest that cognition, deficits in functional capacity, certain clinical symptoms, and various environmental and societal factors are implicated. Further, we suggest that health status variables, recently recognized as pervasive in severe mental illness, may also contribute to disability in a manner independent from these other better-studied causes. We suggest that health status be considered in the overall prediction of real-world functioning and that interventions aimed at disability reduction targeting health status may be needed, in addition to cognitive enhancement, skills training, and public advocacy for better services.

Money management, mental health, and psychiatric disability: a recovery-oriented model for improving financial skills

TOPIC

Although money management skills are essential for independent functioning in the community, when viewed from the framework of psychosocial rehabilitation, there have been few systematic models for teaching money management skills to consumers with psychiatric disabilities based on a recovery orientation.

PURPOSE

For those diagnosed with psychiatric disabilities, better money management has consistently been shown to be associated with superior quality of life, fewer hospitalizations, and greater self-efficacy. Consumers frequently indicate that learning how to budget and staying out of debt are among their top goals for recovery with mental illness. The current paper reviews the issues of money management and mental health among people with psychiatric disabilities and proposes a recovery-oriented approach to increasing money management skills to increase community functioning among consumers.

SOURCES USED

Published literature, clinical cases, and financial literacy resources.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Improving money management can lead to a number of benefits by helping consumers with psychiatric disabilities: 1) gain more knowledge about disability benefits, 2) improve basic financial skills, and 3) reduce vulnerability to financial exploitation. Future work on incorporating this model into psychiatric rehabilitation programs would address skills consumers can use in living, working, and social environments in a way that enhances consumer choice and promotes recovery.

Performance-based measurement of functional disability in schizophrenia: a cross-national study in the United States and Sweden

OBJECTIVE

Recent advances in the assessment of disability in schizophrenia have separated the measurement of functional capacity from real-world functional outcomes. The authors examined the similarity of performance-based assessments of everyday functioning, real-world disability, and achievement of milestones in people with schizophrenia in the United States and Sweden.

METHOD

The UCSD Performance-Based Skills Assessment-Brief Version (UPSA-B) and a neuropsychological assessment were administered to schizophrenia patients living in rural areas in Sweden (N=146) and in the New York City area (N=244), and patients' functioning was rated by their case managers. Information from records and case managers was used to determine the frequency of living independently, working, and having ever experienced a stable romantic relationship.

RESULTS

Performance on the UPSA-B was essentially identical in the two samples (New York, mean score=13.84; Sweden, mean score=13.30), as were scores on the case manager ratings of everyday activities (New York, mean=49.0; Sweden, mean=48.8). The correlations between UPSA-B score, neuropsychological test performance, and case manager ratings did not differ across the two samples. The proportion of patients who had never had a close relationship and the rate of vocational disability were also nearly identical. However, while 80% of the Swedish patients were living independently, only 46% of the New York patients were.

CONCLUSIONS

While scores on performance-based measures of everyday living skills were similar in people with schizophrenia across cultures, real-world residential outcomes were very different. These data suggest that cultural and social support systems can lead to divergent real-world outcomes among individuals who show evidence of the same levels of ability and potential.

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.

Clinical symptomatology of posttraumatic stress disorder-diagnosed Australian and United States Vietnam combat veterans: an MMPI-2 comparison

The authors compared MMPI-2 scores of 95 Australian and 96 US Vietnam combat veterans diagnosed with posttraumatic stress disorder (PTSD) from structured PTSD clinical interviews. Groups were strikingly similar on the MMPI-2 clinical and validity scales but were different on two content scales, with higher scores on FRS (fears) and BIZ (bizarre mentation) for the US sample. Employment status was included as a factor, because it too discriminated groups, but it did not interact with the veteran group variable to produce scale differences. The roles of employment status and disability payments are considered in accounting for differences in the psychiatric presentations of the groups. Results suggest that American and Australian Vietnam combat PTSD samples are very similar to each other, with implications for the treatment outcome literature.

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.

The civilian labor market experiences of Vietnam-era veterans: the influence of psychiatric disorders

BACKGROUND: Most research on the civilian labor market experiences of veterans has focused on the extent to which the skills and experience acquired in the military are rewarded in the civilian employment sector. While studies have been mindful of the need to analyze this question in a multivariate framework, controlling for other factors that might independently affect labor market outcomes, they have met this goal with limited success. As a result, an important element of the employment and wage determination process - psychiatric health - has been absent from this literature. AIMS OF THE STUDY: Using a nationally representative survey of Vietnam-era veterans, this study analyzes the contribution of psychiatric health toward explaining differences in the post-service civilian wages, hours worked, and employment probabilities among male veterans. METHODS: The analysis is based on data from the National Survey of the Vietnam Generation, a survey, completed in the late 1980s, of persons who were on active duty during the years of the Vietnam War, 1964-1975. Three outcome variables are studied - the hourly wage rate, usual hours worked per week, and a 0-1 indicator for whether the respondent is currently working. Lifetime diagnoses of four categories of mental disorders - major depression, anxiety disorders, substance abuse/dependence, and combat-related posttraumatic stress disorder (PTSD) - were constructed from the US NIMH Diagnostic Interview Schedule, administered by the survey. The employment probability equation was estimated using probit; the hourly earnings and hours worked equations via ordinary least squares conditioned on being employed. RESULTS: The study finds that PTSD significantly lowered the likelihood of working and, for those veterans who were working, their hourly wages. On average, a veteran with a lifetime diagnosis of PTSD was 8.5 percentage points less likely to be currently working than was a veteran who did not meet diagnostic criteria. Among those who were employed, veterans with PTSD earned, on average, $2.38 less per hour ($3.61 in 1999 U.S. dollars). Anxiety disorders and major depression had nearly as large an effect on employment rates, as did PTSD. Major depression was also found to have lowered hourly wages by an average of $6.77 per hour ($10.17 in 1999 US dollars). However, psychiatric health did not affect typical hours worked per week. DISCUSSION: This study contributes new information to several literatures. Previous research on the extent to which PTSD interferes with readjustment to civilian life has focused on quality-of-life outcomes such as overall well-being, physical health, and homelessness. Previous research on mental health and earnings has focused on annual earnings. This study makes hourly wage comparisons, a closer measure of productivity differences since they represent differences in pay for the same input of time. Finally, this study demonstrates that the effects of psychiatric health are as important as the influence of non-health characteristics that are thought to signal earnings potential in the civilian labor market (education and experience). These findings, however, may not apply generally. The importance of PTSD may be specific to veterans of the Vietnam War and may not pertain to persons suffering non-combat-related PTSD. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE AND HEALTH POLICY FORMULATION: The magnitude of our estimates implies potentially large benefits from developing effective treatments for PTSD and from insuring access to these treatments. IMPLICATIONS FOR FURTHER RESEARCH: Future research should examine the relationship between work and PTSD in the general population and should explore the indirect effects of mental health, such as its effects on the post-service educational attainment and occupational choices of veterans.

Designing work experiences for persons with serious mental disorders

Persons with serious mental disorders need to participate in productive activities, including mainstream, competitive employment, during the course of their treatment and recovery.

Effects of compensation-seeking on treatment outcomes among veterans with posttraumatic stress disorder

The desire to acquire or increase financial compensation for a psychiatric disability is widely believed to introduce a response bias into patients' reports of their symptoms and their work performance. The hypothesized effects of compensation-seeking in inhibiting improvement from treatment are examined. Data from outpatient (N = 455) and inpatient (N = 553) programs for the treatment of posttraumatic stress disorder and associated disorders in the Department of Veterans Affairs were used to compare outcomes for veterans who were and were not seeking compensation. Outcome was measured as pre/post improvement in symptoms and work performance over the course of 1 year after the initiation of treatment. No compensation-seeking effect was observed among outpatients, but a significant effect was found for some inpatients. The effect for inpatients was manifested essentially by patients in a program type which was designed to have an extremely long length of stay, thus triggering a virtually automatic increase in payments. Like outpatients, inpatients in programs with a moderate length of stay did not manifest a compensation-seeking effect on improvement. Although not permitting a definitive explanation, the preponderance of the evidence favors the overstatement of symptoms rather than either the severity or the chronicity of the disorder as the most likely explanation for the compensation-seeking effect that was observed. For patients treated in standard outpatient and short-stay inpatient programs, compensation does not seem to affect clinical outcomes adversely.

Misplaced rewards: Veterans' Administration system and symptom magnification

The process of disability determination in the Veterans' Administration system and the maladaptive patterns of behavior that may develop in veterans attempting to qualify for disability benefits have been subjects of considerable interest to those who care for these individuals. The potential misuse of disability payments by veterans, especially for purposes of financing drug and alcohol dependence, is a related issue of concern. The quest for disability status is frequently an all consuming process, as the veteran attempts to document the presence and severity of his or her disorder to the degree necessary to obtain approval for compensation. Veterans' Administration patients may engage in symptom magnification as a means of convincing healthcare workers of the veracity of their complaints and to establish the necessary paper trail for their disability claims. It is clear when dealing with this challenging patient population that it is exceedingly difficult to know when a patient has a prominent psychologic overlay to his or her condition, is embellishing existing symptoms, or is prevaricating in an effort to obtain disability payments. Although it is essential to focus on the objective signs of disease while attempting to evaluate the subjective correlates, it is also important to determine the motivation of the patient. Rewarding individuals for pain and disability, particularly on a long term basis, can have numerous negative consequences and ultimately may be a disservice to the patient.