Changes in psychiatric status and service use associated with continued compensation seeking after claim determinations for posttraumatic stress disorder

Compensation and Pension Exams for Military Sexual Trauma-Related Posttraumatic Stress Disorder: Examiner Perspectives, Clinical Impacts on Veterans, and Strategies

BACKGROUND

It is estimated that in one in three women veterans experience military sexual trauma (MST), which is strongly associated with posttraumatic stress disorder (PTSD). A 2018 report indicated the Veterans Benefits Administration (VBA) processed approximately 12,000 disability claims annually for PTSD related to MST, most of which are filed by women. Part of the VBA adjudication process involves reviewing information from a Compensation and Pension (C&P) exam, a forensic diagnostic evaluation that helps determine the relationship among military service, diagnoses, and current psychosocial functioning. The quality and outcome of these exams may affect veteran well-being and use of Veterans Health Administration (VHA) mental health care, but no work has looked at examiner perspectives of MST C&P exams and their potential clinical impacts on veteran claimants.

METHODS

Thirteen clinicians ("examiners") who conduct MST C&P exams through VHA were interviewed. Data were analyzed using rapid qualitative methods.

RESULTS

Examiners described MST exams as more clinically and diagnostically complex than non-MST PTSD exams. Examiners noted that assessing "markers" of MST (indication that MST occurred) could make veterans feel disbelieved; others raised concerns related to malingered PTSD symptoms. Examiners identified unique challenges for veterans who underreport MST (e.g., men and lesbian, gay, bisexual, transgender, and queer [LGBTQ+] veterans), and saw evaluations as a conduit to psychotherapy referrals and utilization of VHA mental health care. Last, examiners used strategies to convey respect and minimize retraumatization, including a standardized process and validating the difficulty of the process.

CONCLUSIONS

Examiners' responses offer insight into a process entered by thousands of veterans annually with PTSD. Strengthening the MST C&P process is a unique opportunity to enhance trust in the VBA claims process and increase likelihood of using VHA mental health care, especially for women veterans.

Sociodemographic Factors in Combat Compensation Seekers for Delayed-Onset PTSD

INTRODUCTION

Sociodemographic factors can sometimes be more contributory in relation to war-related stress-induced disorder treatment and compensation-seeking than health-related factors. However, their impact is often overlooked. This study explores a relationship between sociodemographic factors and diagnoses of combat-related stress-induced disorders in combat compensation seekers for delayed-onset PTSD (DOPTSD).

MATERIALS AND METHODS

Between June 2002 and August 2004, at the Regional Centre for Psychotrauma Zagreb, University Hospital Dubrava, the expert team evaluated subjects to diagnose DOPTSD and other comorbid illnesses. The study included 831 war veterans who experienced combat stress during the 1991-1995 Croatian war. They were subjects of psychiatric treatments before applying for compensation. The researchers derived results from data collected during the expert evaluation for compensation seeking, which included a structured diagnostic procedure. The diagnostic procedure included structured clinical interviews that also provided sociodemographic (age, sex, education, employment, marital status, number of children, and place of residence) and other data (heredity, medical history of physical and mental disorders, history of social functioning, combat-related and post-traumatic experiences, symptoms, their duration, intensity, and treatment). After the interview, the Clinical Global Impression Scale, the Clinician-Administrated PTSD Scale, and the Mississippi Scale for Combat-Related PTSD were applied. Final diagnoses of a lifetime or current PTSD and stress-related disorders according to the ICD-10 were established after fulfilling psychiatric and psychometric criteria. Multiple logistic regression determined independent contributions of sociodemographic characteristics (e.g., age, gender, education, employment and marital status, and parental status), war (duty duration and physical disabilities from combat injuries), and post-war experiences (outpatient treatment duration and the number of hospitalizations) in predicting compensation eligibility.

RESULTS

Better-educated combat compensation seekers were 2.23 times more likely to have eligible psychiatric diagnoses. Furthermore, married veterans were 2.22 times more likely to have eligible diagnoses than single compensation seekers. Likewise, hospitalization status was a risk factor concerning post-war experiences for eligible psychiatric diagnoses.

CONCLUSION

Marriage and higher education are accounted for longer DOPTSD in the group of combat compensation seekers with diagnoses eligible for compensation as a protective factor. A higher number of hospitalizations was also predictive because of more severe PTSD symptomatology as a risk factor. Higher education, marriage, and the higher number of the hospitalizations contributing to war-related DOPTSD diagnoses eligible for compensation.

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.

Leveraging institutional support for family caregivers to meet the health and vocational needs of persons with disabilities

BACKGROUND

Family caregivers might enhance veteran engagement in health and nonhealth services (i.e., vocational/educational assistance).

PURPOSE

To describe how veterans with disabilities perceive their recovery needs, identify types of social support from caregivers that help veterans engage in Veterans Affairs (VA) health and nonhealth services, and explore participant views of VA institutional support for caregivers to help veterans engage in these services.

METHODS

Joint in-depth qualitative interviews with U.S. veterans and family caregivers (n = 26).

FINDINGS

Caregivers performed social support functions that helped veterans engage in health and vocational/educational services and institutional support from VA enhanced caregivers' capacity.

DISCUSSION

Caregivers are well positioned to align health and nonhealth services with patient needs to enhance recovery. Staffing a point person for caregivers within the health system is key to help families develop a coordinated plan of treatment and services to improve patient success across health and nonhealth domains. Nurses are well suited to perform this role.

Veterans' compensation claims beliefs predict timing of PTSD treatment use relative to compensation and pension exam

Introduction

In this study we developed the Disability Beliefs Scale to assess Veterans’ beliefs that engaging in treatment, as well as other behaviors, would affect the likelihood of a Veteran’s being awarded disability-related benefits. We posited that Veterans with stronger beliefs that attending mental health treatment would facilitate a service-connection award would be more likely to attend PTSD treatment before their compensation and pension examinations for PTSD.

Methods

Electronic health records for 307 post-9/11-era Veterans applying for compensation and pension for service-connected PTSD and engaging in a clinical trial of a treatment-referral intervention were analyzed for PTSD-specific and more general mental health treatment use around the time of their compensation examinations. All participants completed the Disability Beliefs Scale and other baseline assessments. Multilevel models assessed change in treatment use as a function of time relative to the C&P exam, compensation examination status (before or after), and the interaction between examination status and beliefs about treatment benefits.

Results

No main effects of time or examination status were observed. As hypothesized, beliefs about treatment benefits moderated the effect of examination status on PTSD treatment use. Veterans believing more strongly that mental health treatment would help a claim differentially attended PTSD treatment before the examination than after. The effect was not observed for general mental health treatment use.

Conclusion

The association between Veterans’ use of PTSD treatment and their service-connection examination status was moderated by beliefs that receiving treatment affects the service-connection decision. This suggests that factors reported to motivate seeking service-connection—finances, validation of Veterans’ experiences, and the involvement of significant others—might also help motivate Veterans’ use of effective PTSD treatments. However, the results reflect correlations that could be explained in other ways, and service-connection was one of many factors impacting PTSD treatment engagement.

Mental Health Service Utilization before and after Receipt of a Service-Connected Disability Award for PTSD: Findings from a National Sample

OBJECTIVE

To determine patterns of mental health service use before and after VA disability compensation awards for posttraumatic stress disorder (PTSD).

DATA SOURCES

A 10 percent random sample of VHA-enrolled Veterans with new or increased PTSD service connection between 2012 and 2014 (n = 22,249).

STUDY DESIGN

We used latent trajectory analysis to identify utilization patterns and multinomial logistic regression to assess associations between Veteran characteristics and trajectory membership.

DATA EXTRACTION METHODS

We assessed receipt of VHA mental health encounters in each of the 52 weeks prior to and following PTSD disability rating or rating increase.

PRINCIPAL FINDINGS

The best fitting model had five groups: No Use (36.6 percent), Low Use (37.7 percent), Increasing Use (9.4 percent), Decreasing Use (11.2 percent), and High Use (5.1 percent). Adjusting for demographic characteristics and compared with the No Use group, Veterans in the other groups were more likely to reside closer to a VHA facility, receive a higher PTSD disability rating, and screen positive for military sexual trauma.

CONCLUSIONS

Service use remained stable (80 percent) or increased (9 percent) for the vast majority of Veterans. Service utilization declined for only 11 percent. Data did not indicate substantial service discontinuation following rating. Low VHA service utilization suggests opportunities to enhance outreach for Veterans with PTSD-related disability benefits.

Relationship between substance use and attitudes towards seeking professional psychological help among veterans filing PTSD claims

INTRODUCTION

Veterans in distress often do not seek mental health treatment, even when such services are available. Substance use may further undermine treatment-seeking, given its association with negative treatment views. This study examined attitudes towards seeking psychological help in a sample of veterans diagnosed with posttraumatic stress disorder (PTSD), with and without co-occurring substance use disorders (SUD).

METHODS

Altogether, 143 male OEF/OIF veterans filing service-connected benefits claims for PTSD completed the Attitudes Towards Seeking Professional Psychological Help-Short Form (ATSPPH-SF) and other baseline assessments. Treatment attitudes were compared among veterans with (n=34) and without (n=109) SUD using ANCOVA, controlling for demographic covariates. Post-hoc ANCOVA compared means on the two ATSPPH-SF subscales: Openness to Seeking Treatment, and Value/Need in Seeking Treatment.

RESULTS

Overall, ATSPPH-SF scores were similar to those reported in other samples of young men. Controlling for demographic covariates, veterans with co-occurring SUD held significantly less favorable attitudes towards seeking help than veterans without comorbid SUD. In subscale analyses, valuation of treatment was significantly lower among veterans with SUDs, but openness towards treatment was not.

CONCLUSIONS

Substance-using veterans' lower valuation of treatment may reflect opinions that problems resolve on their own, psychotherapy is ineffective, or concerns that SUDs complicate treatment. Thus an approach towards engaging these veterans in treatment that addresses a general skepticism towards the value of psychological help is warranted.

The Health and Social Isolation of American Veterans Denied Veterans Affairs Disability Compensation

Authors comparatively analyzed health and social isolation between U.S. military veterans denied Veterans Affairs (VA) disability compensation and veterans awarded VA disability compensation. The 2001 National Survey of Veterans was used to create a sample of 4,522 veterans denied or awarded VA disability compensation. Using the Andersen health services utilization model as a conceptual framework, multivariate logistic regression was applied to assess relationships between VA disability compensation award status, three separate domains of health, and correlates of social isolation. Results indicate that denied applicants were more likely than those awarded to have poor overall health (odds ratio [OR] = 1.45, 95% confidence interval [CI]: 1.23, 1.70), and limitations in activities of daily living (OR = 1.12, 95% CI: 1.03, 1.21). Denied applicants' physical functioning (40.3) and mental functioning (41.2) composite summary scores were not clinically different from those of awarded applicants (39.0 and 40.1, respectively), indicating that both were comparably impaired. Veterans denied VA disability compensation had poor health and functional impairments. They also experienced poverty and isolation, suggesting that they may be in need of additional supportive services. Connecting veterans to community resources could be a vital service to provide to all veterans applying for disability compensation.

Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future

Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.

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.

Patients with combat-related and war-related posttraumatic stress disorder 10 years after diagnosis

AIM

To establish how many patients diagnosed with posttraumatic stress disorder (PTSD) in 1996 used psychiatric facilities and had psychiatric symptoms 10 years later, and assess their sociodemographic characteristics, comorbid disorders, and type of treatment.

METHODS

Medical records of patients diagnosed with PTSD in 1996 were reviewed in the period 2007-2009 and the patients who contacted a psychiatrist in that period (n=85) and those who did not (n=158) were compared.

RESULTS

There were 36.7% of men and 20% of women diagnosed with PTSD in 1996 who contacted a psychiatrist in the period 2007-2009. Patients who contacted a psychiatrist and those who did not did not differ in sex, age, the number of visits and hospitalizations in 1996, and employment status. The majority of patients still had PTSD and/or were enduring personality change in the period 2007-2009, and 54.8% had some comorbidity (mostly depression, alcohol-related disorders, and personality disorders). Patients were most often treated with anxiolytics and antidepressants.

CONCLUSION

Ten years after the traumatic experience, one third of patients with PTSD received psychiatric help, regardless of their sex, age, and employment status. Half of them had comorbid disorders and the majority of them were treated with anxiolytics and antidepressants.

Giving context to post-deployment post-concussive-like symptoms: blast-related potential mild traumatic brain injury and comorbidities

In the military and Veterans Administration systems, individuals with potential MTBI are presenting with symptoms in excess of what would be expected based on initial injury characteristics and/or at unexpected time periods based on current research findings. This article investigates factors that might account for the discrepancy between current research expectations and some occurrences in clinical practice. The physics of blast waves, as well as animal and human research, relevant to explosions are reviewed. Additional factors that occur within the military blast exposure milieu are also explored because the context in which an injury occurs can potentially impact symptom severity and course of recovery. Differential diagnoses, iatrogenic illness, diagnosis threat, and symptom embellishment are also considered.