Reversals in initially denied Department of Veterans Affairs' PTSD disability claims after 17 years: a cohort study of gender differences

BACKGROUND

In 2011, the Department of Veterans Affairs (VA) strengthened its disability claims processes for military sexual trauma, hoping to reduce gender differences in initial posttraumatic stress disorder (PTSD) disability awards. These process improvements should also have helped women reverse previously denied claims and, potentially, diminished gender discrepancies in appealed claims' outcomes. Our objectives were to examine gender differences in reversals of denied PTSD claims' outcomes after 2011, determine whether disability awards (also known as "service connection") for other disorders offset any PTSD gender discrepancy, and identify mediating confounders that could explain any persisting discrepancy.

METHODS

From a nationally representative cohort created in 1998, we examined service connection outcomes in 253 men and 663 women whose initial PTSD claims were denied. The primary outcome was PTSD service connection as of August 24, 2016. Secondary outcomes were service connection for any disorder and total disability rating. The total disability rating determines the generosity of Veterans' benefits.

RESULTS

51.4% of men and 31.3% of women were service connected for PTSD by study's end (p < 0.001). At inception, 54.2% of men and 63.2% of women had any service connection-i.e., service connection for disorders other than PTSD (p = 0.01) and similar total disability ratings (p = 0.50). However, by study's end, more men than women had any service connection (88.5% versus 83.5%, p = 0.05), and men's mean total disability rating was substantially greater than women's (77.1 ± 26.2 versus 66.8 ± 30.7, p < 0.001). History of military sexual assault had the largest effect modification on men's versus women's odds of PTSD service connection.

CONCLUSION

Even after 2011, cohort men were more likely than the women to reverse initially denied PTSD claims, and military sexual assault history accounted for much of this difference. Service connection for other disorders initially offset women's lower rate of PTSD service connection, but, ultimately, men's total disability ratings exceeded women's. Gender discrepancies in service connection should be monitored beyond the initial claims period.

Persistent Serious Mental Illness Among Former Applicants for VA PTSD Disability Benefits and Long-Term Outcomes: Symptoms, Functioning, and Employment

Millions of U.S. veterans have returned from military service with posttraumatic stress disorder (PTSD), for which a substantial number receive U.S. Department of Veterans Affairs (VA) disability benefits. Although PTSD is treatable, comorbid serious mental illness (defined here as schizophrenia, schizoaffective disorder, and bipolar spectrum disorders) could complicate these veterans' recovery. Using VA administrative data, we examined the burden of persistent serious mental illness in a nationally representative cohort of 1,067 men and 1,513 women who applied for VA PTSD disability benefits between 1994 and 1998 and served during or after the Vietnam conflict. Self-reported outcomes were restricted to the 713 men and 1,015 women who returned surveys at each of 3 collection points. More than 10.0% of men and 20.0% of women had persistent serious mental illness; of these, more than 80.0% also had persistent PTSD. On repeated measures modeling, those with persistent serious mental illness consistently reported more severe PTSD symptoms and poorer functioning in comparison to other participants (ps < .001); their employment rate did not exceed 21.0%. Interactions between persistent serious mental illness and PTSD were significant only for employment (p = .002). Persistent serious mental illness in this population was almost 2 to 19 times higher than in the general U.S.

POPULATION

The implications of these findings are discussed.

Heat-loss response to a thermal challenge in seasonal affective disorder

This study extends earlier findings of poorly facilitated postexercise heat loss during the winter in seasonal affective disorder (SAD). While depressed in the winter, 19 SAD subjects exhibited a significantly impaired postexercise heat loss relative to 10 control subjects. During the summer while euthymic, SAD subjects did not significantly differ from control subjects in postexercise heat loss. Since thermoregulatory heat loss is a highly dopamine-dependent process, these results support earlier findings of poorly facilitated dopamine availability in SAD during the winter and suggest a centrally mediated effect of light in SAD.

Modulatory role of serotonin in neural information processing: implications for human psychopathology

Investigation of the role of 5-hydroxytryptophan (5-HT), which functions as a modulator in the central nervous system, across behavioral contexts suggests that a general principle of transmitter function may be derived that is independent of specific behaviors and specific neural loci. A functional principle of 5-HT action in neural information processing in the central nervous system is proposed. Extremes deviations in 5-HT activity result in biases in information processing that may have direct effects on behavior. Such biases may predispose to pathological conditions such as violent suicide and aggression.

Dimensional measurement of seasonal variation in mood and behavior

Recent epidemiologic studies have found that the behaviors that characterize seasonal affective disorder (SAD) show seasonal variation in 92%-95% of the general population, suggesting that seasonal variation in behavior and mood is a continuous, dimensional variable extending throughout the general population, defined at the upper extreme by SAD. Research into population seasonality will require a dimensional measure of seasonal variation in mood and behavior that produces a broad, finely graded distribution of seasonality scores sensitive to individual differences throughout the entire range of scores. Accordingly, the Inventory of Seasonal Variation (ISV) was developed as such a measure. This study demonstrated that the ISV has high internal structural validity and is highly sensitive to individual differences in seasonality across its entire range of scores in the normal population. This latter characteristic is not shared by other existing measures of seasonality. Initial external validity of the ISV was supported in that the mean of ISV scores of a SAD sample was found to lie at the 97th percentile of the normal population of scores. Analysis of ISV scores revealed that a winter pattern of seasonality was reported by over 95% of subjects, a pattern that was more pronounced in women than men, while a summer type of seasonality was reported by only 0.6% of the general population.

Seasonal and mood independence of low basal prolactin secretion in premenopausal women with seasonal affective disorder

To test hypotheses of opposing roles of dopamine and serotonin in prolactin secretion in seasonal affective disorder, the authors determined basal serum prolactin concentrations for premenopausal women, eight with and 14 without seasonal affective disorder, in late afternoon during the follicular phase of the menstrual cycle (and a subgroup during the luteal phase) in winter and summer. Despite their significantly higher Hamilton depression scale scores in winter than in summer, the patients had significantly lower prolactin concentrations than the control subjects in both seasons. These results suggest that low prolactin secretion may be a trait characteristic in seasonal affective disorder.

Thermoregulatory response to thermal challenge in seasonal affective disorder: a preliminary report

It has recently been proposed that alterations in central dopamine (DA) functional activity may, in part, account for certain behavioral changes observed in seasonal affective disorder (SAD) during the winter. To explore this possibility, a preliminary study of thermoregulatory heat loss to an endogenous heat challenge--a strongly DA-dependent process--was undertaken in groups of four SAD woman and four nonpsychiatric control women across three conditions (winter, after successful phototherapy, and summer). Homeostatic heat loss during recovery from heat challenge in SAD, but not in control, subjects was found to be a significant function of light condition and of clinical state. Thermoregulatory heat loss in SAD subjects was significantly blunted in winter during depression, was similar in efficiency to control subjects after a successful antidepressant response to phototherapy, and tended to be more efficient than controls in summer during a euthymic state. Results raise the possibility that a common effect of phototherapy and summer light conditions is a facilitation of central DA activity in SAD.

General behavior inventory identification of unipolar and bipolar affective conditions in a nonclinical university population

Validated the General Behavior Inventory (GBI), revised to identify unipolar as well as bipolar affective conditions, in a nonclinical sample (n = 201) against naive, interview-derived diagnoses. For bipolar and unipolar conditions, respectively, the GBI had high positive (.94, .87) and negative (.99, .93) predictive power with the effect of prevalence considered, adequate sensitivity (.78, .76), high specificity (.99, .99), and adequate selection ratios for sampling of affective and nonaffective subjects from nonclinical populations for research purposes. The utility of the GBI in several different research contexts is discussed.

General Behavior Inventory identification of unipolar and bipolar affective conditions in a nonclinical university population

Validated the General Behavior Inventory (GBI), revised to identify unipolar as well as bipolar affective conditions, in a nonclinical sample (n = 201) against naive, interview-derived diagnoses. For bipolar and unipolar conditions, respectively, the GBI had high positive (.94, .87) and negative (.99, .93) predictive power with the effect of prevalence considered, adequate sensitivity (.78, .76), high specificity (.99, .99), and adequate selection ratios for sampling of affective and nonaffective subjects from nonclinical populations for research purposes. The utility of the GBI in several different research contexts is discussed.