Development and psychometric properties of the disability application appraisal inventory

Comparison of attitudes towards the service connection claims process among veterans filing for PTSD and veterans filing for musculoskeletal disorders

ABSTRACT

Many veterans have negative views about the service connection claims process for posttraumatic stress disorder (PTSD), which likely impacts willingness to file service connection claims, re-file claims, and use Veterans Healthcare Administration care. Nevertheless, veterans have reported that PTSD claims are important to them for the financial benefits, validation of prior experience and harm, and self-other issues such as pleasing a significant other. It is unknown if reported attitudes are specific to PTSD claimants or if they would be similar to those submitting claims for other disorders, such as musculoskeletal disorders. Therefore, the purpose of this study was to compare attitudes and beliefs about service connection processes between veterans submitting service connection claims for PTSD and musculoskeletal disorders.Participants were Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans filing service connection claims for PTSD (n = 218) or musculoskeletal disorder (n = 257) who completed a modified Disability Application Appraisal Inventory. This secondary data analysis using multiple regression models tested the effect of demographics, clinical characteristics, and claim type on 5 Disability Application Appraisal Inventory subscales: Knowledge about service connection claims, Negative Expectations about the process, and importance of Financial Benefits, importance of Validation of veteran's experience/condition, and importance of Self-Other attitudes.The PTSD group assigned significantly less importance to financial benefits than the musculoskeletal disorder group. In addition, the subset of the PTSD group without depression had significantly more Negative Expectations than musculoskeletal disorder claimants without depression. Negative Expectations did not differ between the PTSD and musculoskeletal disorder groups with depression. Depression was significantly positively associated with Negative Expectations, importance of Financial Benefits, and importance of Validation.Most perceptions around seeking service connection are not specific to PTSD claimants. Depression is associated with having negative expectations about service connection claims and motivations to file claims. Addressing depression and negative expectations during the compensation and pension process might help veterans at this important point of contact with Veterans Healthcare Administration services.

Changes in Post-traumatic Stress Disorder Service Connection Among Veterans Under Age 55: An 18-Year Ecological Cohort Study

INTRODUCTION

Mandatory, age-based re-evaluations for post-traumatic stress disorder (PTSD) service connection contribute substantially to the Veterans Benefits Administration's work load, accounting for almost 43% of the 168,013 assessments for PTSD disability done in Fiscal Year 2017 alone. The impact of these re-evaluations on Veterans' disability benefits has not been described.

MATERIALS AND METHODS

The study is an 18-year, ecological, ambispective cohort of 620 men and 970 women receiving Department of Veterans Affairs PTSD disability benefits. Veterans were representatively sampled within gender; all were eligible for PTSD disability re-evaluations at least once because of age. Outcomes included the percentage whose PTSD service connection was discontinued, reduced, re-instated, or restored. We also examined total disability ratings among those with discontinued or reduced PTSD service connection. Subgroup analyses examined potential predictors of discontinued PTSD service connection, including service era, race/ethnicity, trauma exposure type, and chart diagnoses of PTSD or serious mental illness. Our institution's Internal Review Board reviewed and approved the study.

RESULTS

Over the 18 years, 32 (5.2%) men and 180 (18.6%) women had their PTSD service connection discontinued; among them, the reinstatement rate was 50% for men and 34.3% for women. Six men (1%) and 23 (2.4%) women had their PTSD disability ratings reduced; ratings were restored for 50.0% of men and 57.1% of women. Overall, Veterans who lost their PTSD service connection tended to maintain or increase their total disability rating. Predictors of discontinued PTSD service connection for men were service after the Vietnam Conflict and not having a Veterans Health Administration chart diagnosis of PTSD; for women, predictors were African American or black race, Hispanic ethnicity, no combat or military sexual assault history, no chart diagnosis of PTSD, and persistent serious mental illness. However, compared to other women who lost their PTSD service connection, African American and Hispanic women, women with no combat or military sexual assault history, and women with persistent serious illness had higher mean total disability ratings. For both men and women who lost their PTSD service connection, those without a PTSD chart diagnosis had lower mean total disability ratings than did their counterparts.

CONCLUSIONS

Particularly for men, discontinuing or reducing PTSD service connection in this cohort was rare and often reversed. Regardless of gender, most Veterans with discontinued PTSD service connection did not experience reductions in their overall, total disability rating. Cost-benefit analyses could help determine if mandated, age-based re-evaluations of PTSD service connection are cost-effective.

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.

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.

Racial differences in veterans' satisfaction with examination of disability from posttraumatic stress disorder

OBJECTIVE

The examination that determines if a veteran has service-connected posttraumatic stress disorder (PTSD) affects veterans' lives for years. This study examined factors potentially associated with veterans' perception of their examination's quality.

METHODS

Veterans (N=384) being evaluated for an initial PTSD service-connection claim were randomly assigned to receive either a semistructured interview or the examiner's usual interview. Immediately after the interview, veterans completed confidential ratings of the examinations' quality and of their examiners' interpersonal qualities and competence. Extensive data characterizing the veterans, the 33 participating examiners, and the examinations themselves were collected.

RESULTS

Forty-seven percent of Caucasian veterans and 34% of African-American veterans rated their examination quality as excellent. African Americans were less likely than Caucasians to assign a higher quality rating (odds ratio=.61, 95% confidence interval=.38-.99, p=.047). Compared with Caucasians, African Americans rated their examiners as having significantly worse interpersonal qualities but not lower competence. Ratings were not significantly related to the veterans' age, gender, marital status, eventual diagnosis of PTSD, Global Assessment of Functioning score, the examiner's perception of the prevalence of malingering, or the presence of a third party during the examination.

CONCLUSIONS

Ratings of disability examinations were generally high, although ratings were less favorable among African-American veterans than among Caucasian veterans.