Health care use and at-work productivity among employees with mental disorders

EAP 2.0: reimagining the role of the employee assistance program in the new workplace

Mental illness is a highly prevalent problem that affects millions of individuals. Like many other previous natural disasters and terrorist attacks, the recent Covid-19 pandemic has placed an enormous stress on the world and its workforce. In many ways the pandemic revealed gaps in the quality and availability of mental health resources, and, by magnifying the intense demand, it also spurred innovation. Telemedicine and virtual trauma-related services became examples of ways in which evaluation, treatment and counselling services could be delivered directly and efficiently to people who were confined to their dwellings and hospital beds. For many, the workplace has been a source of stress but also a vital component of one's self-worth, day-to-day purpose, and a resource for wellness programs and brief counselling services, not to mention, at least in many countries like the United States, a source for health insurance. The employee assistance program (EAP) is an example of a workplace-counselling and triage service that has enormous potential to meet the growing needs of individuals both in 'normal' times and during disasters. By better understanding the EAP's current structure alongside the advent of new technologies, it may be possible to develop a new and improved EAP model to meet a changing global landscape. For EAP to succeed and ultimately be scalable in an increasingly competitive and value-conscious marketplace, its processes of care will first require a bottom-up review with meaningful outcomes data. This will be necessary to drive continuous quality improvement and to demonstrate EAP 2.0's value to both employer and employee alike.

Public insurance expansions and mental health care availability

OBJECTIVE

To provide new evidence on the effects of large-scale public health insurance expansions, associated with the Affordable Care Act (ACA), on the availability of specialty mental health care treatment in the United States. We measure availability with the probability that a provider accepts Medicaid.

DATA SOURCE/STUDY SETTING

The National Mental Health Services Survey (N-MHSS) 2010-2018.

STUDY DESIGN

A quasi-experimental differences-in-differences design using observational data.

DATA COLLECTION

The N-MHSS provides administrative data on the universe of specialty mental health care providers in the United States. Response rates are above 90 percent in all years. Data cover 85 019 provider/year observations.

PRINCIPAL FINDINGS

ACA-Medicaid expansion increases the probability that a provider accepts Medicaid by 1.69 percentage points, 95 percent confidence interval: [0.0017,0.0321], which corresponds to an increase from 87.27 percent pre-expansion to 90.27 percent postexpansion in expansion states or a 1.94 percent increase. We observe spillovers to Medicare, although this finding is sensitive to specification.

CONCLUSIONS

This study provides evidence on the impact of ACA-Medicaid expansion on accepted forms of payment for specialty mental health care treatment. Findings suggest that expansion increases availability of providers who deliver valuable care for enrollees with severe mental illness. These findings may help policy makers reflecting on the future directions of the US health care delivery system.

Productivity Benefits of Medical Care: Evidence from US-Based Randomized Clinical Trials

BACKGROUND

One of the key recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine is to take a societal perspective when evaluating new technologies-including measuring the productivity benefits of new treatments. Yet relatively little is known about the impact that new treatments have on labor productivity.

OBJECTIVES

To examine the relationship between new drug treatments and gains in labor productivity across conditions in the United States and to evaluate which randomized clinical trials (RCTs) collected labor productivity data.

METHODS

We collected data on US-based RCTs with work-ability surveys from searches of Google Scholar, PubMed, Scopus, the Cochrane Central Registry of Clinical Trials, and ClinicalTrails.gov. Combining RCT data with survey data from the Medical Expenditure Panel Survey, we assessed productivity changes from new drug treatments.

RESULTS

During the last decade, some disease conditions have seen treatments that improve ability to work by as much as 60%. The annual increase in productivity gains attributable to new drug treatments was modest 1.1% (P = 0.53). Of the 5092 RCTs reviewed, ability-to-work measures were collected in 2% of trials. Work productivity surveys were more likely among prevalent medical conditions that affected individuals who worked, earned higher wages, and experienced larger reductions in hours worked as a consequence of disease diagnosis.

CONCLUSIONS

From our data, we estimated that drug innovation increased productivity by 4.8 million work days per year and $221 billion in wages per year. These labor-sector benefits should be taken into account when assessing the socially optimal cost for new drug innovation.

On-the-Job Productivity Losses Among Employees With Health Problems: The Role of Work Accommodations

OBJECTIVES

Debates about the productivity impact of work accommodations typically focus on employment and labor force participation outcomes. This study considers whether accommodations mediate on-the-job productivity losses among employees who report health problems.

METHODS

The study uses ordered logistic regression to predict employees' self-reported productivity losses as a function of health problems and experiences with needed work accommodations.

RESULTS

On average, the odds that an employee who did not get a needed accommodation reported higher levels of lost productivity are 5.11 times the odds for an employee who got a needed accommodation.

CONCLUSIONS

Although health problems make it difficult for many employees to perform well on the job, accommodations could reduce productivity losses in some cases. Nonetheless, more research on the impact of specific kinds of accommodations for different chronic conditions is warranted.

Neuropsychological Functioning in Veterans with Posttraumatic Stress Disorder: Associations with Performance Validity, Comorbidities, and Functional Outcomes

OBJECTIVES

Numerous studies have shown that individuals with posttraumatic stress disorder (PTSD) display reduced performances on neuropsychological tests, although most prior research has not adequately accounted for comorbidities or performance validity concerns that are common in this population and could partially account for the observed neurocognitive findings. Moreover, few studies have examined the functional implications of neuropsychological results in PTSD.

METHODS

We examined neuropsychological functioning in 44 veterans with PTSD and 40 veteran trauma comparison (TC) participants with combat exposure and no PTSD.

RESULTS

After excluding four veterans with PTSD for performance validity concerns, multivariate analyses of variance by neurocognitive domain revealed significantly worse performance by the PTSD group in the domains of speed of information processing (p=.035) and executive functions (p=.017), but no group differences in attention/working memory, verbal/language functioning, visuoconstruction, or episodic memory. Group differences by PTSD status were still present after covarying for depression, a history of head injuries, and substance use disorders. Executive functioning performance was associated with poorer self-reported occupational functioning and physical health-related quality of life, while speed of information processing performance was associated with poorer physical health-related quality of life.

DISCUSSION

These results are generally consistent with a fronto-limbic conceptualization of PTSD-associated neuropsychological dysfunction and show that cognitive functioning may be associated with critical functional outcomes. Taken together, results suggest that consideration of neurocognitive functioning may enhance the clinical management of individuals with PTSD.

The cost of generalized anxiety disorder in primary care settings: results of the ANCORA study

To assess the cost of illness of generalized anxiety disorder (GAD) in a primary healthcare setting in Spain. A cross-sectional, retrospective study was conducted. The sample comprised patients diagnosed with GAD according to ICD-10 criteria and a control group. Healthcare/non-healthcare resource utilization was recorded retrospectively for the 12 months prior to the study visit. Costs were estimated from a societal perspective. Two models have been produced to study the variables that influence the cost of the illness both, without and with controls. The study enrolled 456 patients [76.8 % women, 49.2 (17.0) years] with GAD and 74 controls without GAD [42.5 % women, 47.9 (16.7) years]. 67.8 % of subjects were on combination therapy (antidepressant + anxiolytic); 6 % were using 2 or more drugs to treat anxiety; and 23.4 % were on monotherapy. Total annual average costs were higher in the GAD group (€7,739 vs. €2,609), with mean costs attributable to GAD of €5,139 (healthcare costs: €1,329, indirect costs: 75 % of total cost, approximately). Age and health status measured by Hamilton Anxiety Rating Scale and clinical global impression were related to costs. The improvements in quality of life measured by EQ-5D index are associated to lower cost. GAD treated in Spanish primary healthcare settings generated considerable healthcare costs and, particularly, loss-of-productivity costs.

A case study for calculating employer costs for lost productive time in episodic migraine and chronic migraine: results of the American Migraine Prevalence and Prevention Study

OBJECTIVE

To model workplace lost productive time (LPT) from episodic migraine (EM) and chronic migraine (CM).

METHODS

We used published estimates of migraine epidemiology and related LPT to model the impact of migraine on two typical US workforce scenarios that differ by gender and age.

RESULTS

In a simulated service sector workforce of 10,000 individuals, the migraine-related LPT was $2.9 million annually compared with $2.1 million for a manufacturing workforce. Individuals with moderate frequency EM accounted for 42% of the cost. Individuals with high frequency EM and CM comprised 10% of all migraine sufferers and accounted for 22% of the LPT.

CONCLUSIONS

Lost productive time impact of migraine and other health problems depends on workforce demographics and the cost of labor. Employers can often estimate LPT costs to reveal priorities for optimizing use of health care.

Treating patients with fibromyalgia in primary care settings under routine medical practice: a claim database cost and burden of illness study

Introduction

The objective of this study was to analyze health care and non-health care resource utilization under routine medical practice in a primary care setting claims database and to estimate the incremental average cost per patient per year of fibromyalgia syndrome (FMS) compared with a reference population.

Methods

A 12-month cross-sectional and retrospective study was completed using computerized medical records from a health provider database. Analyses were conducted from the perspective of the provider and from the viewpoint of society. Health care and non-health care resource utilization included drugs, complementary tests, all types of medical visits, referrals, hospitalizations, sick leave, and early retirement because of disability due to FMS. Patients with a diagnosis of FMS in accordance with ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th revision) criteria were included in the analysis if they had at least one claim for FMS during the 12 months prior to the end of May 2007. A non-FMS comparison group was also created with the remaining subjects.

Results

Of the 63,526 patients recruited for the study, 1,081 (1.7%) (96.7% of whom were women, 54.2 [10.1] years old) met the criteria for FMS. After an adjustment for age and gender, FMS subjects used significantly more health care resources than the reference population and had more sick leave and the percentage of subjects with premature retirement was also significantly higher (P < 0.001 in all cases). As a result, FMS subjects showed an incremental adjusted per-patient per-year total cost of €5,010 (95% confidence interval [CI] 3,494 to 6,076, +153%, P < 0.001) on average compared with non-FMS subjects. Significantly higher differences were observed in both health care and non-health care adjusted costs: €614 (404 to 823, +66%) and €4,394 (3,373 to 5,420, +189%), respectively (P < 0.001 in both cases). Annual drug expenditure per patient on average was considerably higher in FMS patients, €230 (124 to 335, +64%, P < 0.001), than the reference group.

Conclusions

Under routine medical practice, patients with FMS were associated with considerably higher annual total costs in the primary care setting compared with the reference population.

Depressive symptoms and self-reported occupational injury in small and medium-sized companies

OBJECTIVES

This survey was designed to determine whether depressive symptoms had an effect on the risk of self-reported occupational injury in South Korea.

METHODS

We conducted a prospective follow-up survey of workers at 44 small- to medium-sized companies classified into manufacturing or service businesses; 1,350 questionnaires were used in the final analysis. The first survey requested information regarding personal characteristics, work characteristics, and depressive symptoms (CES-D); the second survey queried participants in the first survey about self-reported occupational injuries (including minor scratches or cuts) experienced in the previous 4 months. Risk ratios (RRs) were calculated through Poisson regression analysis. The number of occupational injuries during the previous 4 months served as the dependent variable, and depressive symptoms served as the independent variable.

RESULTS

After adjustment for demographic factors, the RRs were 1.75 (95% CI: 1.41-2.18) and 2.68 (95% CI: 1.98-3.64) in male and female, respectively. Additional adjustment for work-related variables did not alter the RR considerably in females (2.65; 95% CI: 1.95-3.59). Among the male workers, however, the RR was not significant (1.21; 95% CI: 0.95-1.55). On the other hand, when the analysis was limited to blue-collar workers, after adjustment for demographic and work-related factors, the RRs remained significant in both genders (male: 1.34; 95% CI: 1.03-1.74; female: 2.04; 95% CI: 1.41-2.95).

CONCLUSIONS

We found that the risk of self-reported occupational injury experience was higher in workers who reported depressive symptoms. Additional study using objective data is required to confirm our results.

Medical and productivity costs of anxiety disorders: case control study

This retrospective case-control study examines the medical and productivity costs associated with a diagnosis of anxiety. The study used a data set from a large employer database that collected medical, pharmaceutical, absenteeism, short-term disability, and worker compensation records during 2000 from 6 major employers. Patients diagnosed with anxiety disorders (n= 1917) were matched at a 1:1 ratio to patients not diagnosed with anxiety disorders (n= 1917) based on age, sex, metropolitan statistical area, and type of insurance coverage. Paired-difference t tests, McNemer's test, and analyses of covariance were used to compare the anxiety population with the control group. Employees diagnosed with anxiety disorders were significantly more likely to have additional diagnoses, use more services, require hospitalization, or visit the emergency room compared with the control group. Furthermore, after controlling for differences in comorbidities, employees diagnosed with anxiety disorders had significantly higher medical costs [$1555; 95% confidence interval (CI) $1066-2043], productivity costs ($1366; 95% CI $708-2023), and total costs ($2920; 95% CI $2035-3805) compared with the control group. Results indicate that anxiety disorders are associated with significant medical and productivity costs.

Health-Related Lost Productive Time (LPT): Recall Interval and Bias in LPT Estimates

We examined the effect of interview characteristics (ie, recall interval, interview version) on estimates of health-related lost productive work time (LPT). Three versions of a telephone interview were administered using 7-day and 4-week recall periods. In a population-based survey, 7674 workers randomly were assigned to one of six interviews at contact; 615 participants received a follow-up interview. We found strong evidence of under-reporting using a 4-week recall period and a not significant trend in over-reporting LPT using a 7-day recall period. Of the three interviews, version 3 could be administered most quickly, on average, and yielded the most discriminating estimates of LPT by health condition (ie, headache, allergic rhinitis, and cold/flu). Our data suggest that variation in relatively short recall periods influences estimates of health-related LPT. A 2-week recall period may be optimal for minimizing overall reporting error but requires additional research to verify.

Lost productive work time costs from health conditions in the United States: results from the American Productivity Audit

The American Productivity Audit (APA) is a telephone survey of a random sample of 28,902 U.S. workers designed to quantify the impact of health conditions on work. Lost productive time (LPT) was measured for personal and family health reasons and expressed in hours and dollars. Health-related LPT cost employers 225.8 billion US dollars/year (1685 US dollars/employee per year); 71% is explained by reduced performance at work. Personal health LPT was 30% higher in females and twice as high in smokers (> or =1 pack/day) versus nonsmokers. Workers in high-demand, low-control jobs had the lowest average LPT/week versus the highest LPT for those in low-demand, high-control jobs. Family health-related work absence accounted for 6% of all health-related LPT. Health-related LPT costs are substantial but largely invisible to employers. Costs vary significantly by worker characteristics, suggesting that intervention needs vary by specific subgroups.

A review of self-report instruments measuring health-related work productivity: a patient-reported outcomes perspective

Health impairment often leads to work impairment in the form of both absenteeism and presenteeism (i.e. reduced productivity while at work). Several self-report productivity instruments have been designed over the past few years to measure the impact of illness on productivity at work and/or in non-work activities. In a review of the literature we identified six generic subjective instruments - the Endicott Work Productivity Scale, Health and Labor Questionnaire, Health and Work Questionnaire, Health and Work Performance Questionnaire, Work Limitations Questionnaire (WLQ) and the Work Productivity and Activity Impairment Questionnaire (WPAI) - that could theoretically be used in any working population. These instruments were usually validated against other subjective measures (such as health-related QOL). Each productivity instrument has benefits in certain research settings, but the psychometric properties of the WPAI have been assessed most extensively. It was the most frequently used instrument and has also been modified to measure productivity reductions associated with specific diseases (e.g. allergic rhinitis, gastro-oesophageal reflux disease, chronic hand dermatitis). The WLQ has also been tested extensively to measure the general health impact and impact of specific conditions. Two migraine-specific subjective instruments were also identified: the Migraine Disability Assessment questionnaire and the Migraine Work and Productivity Loss Questionnaire, of which the latter was found to have better psychometric properties. Productivity outcomes are useful in that they characterise the impact of an illness in the workplace and show the effect of treatment on productivity. Evidence of psychometric properties and generalisability of different instruments was found to a varying degree. Thus, further research is needed to assess the accuracy and usefulness of individual instruments in certain research settings. Health-related productivity has been increasingly recognised as an important component of the burden of illness associated with a given disease; without it, one cannot reliably assess this burden.

Validation of the work and health interview

BACKGROUND

Instruments that measure the impact of illness on work do not usually provide a measure that can be directly translated into lost hours or costs. We describe the validation of the Work and Health Interview (WHI), a questionnaire that provides a measure of lost productive time (LPT) from work absence and reduced performance at work.

METHOD

A sample (n = 67) of inbound phone call agents was recruited for the study. Validity of the WHI was assessed over a 2-week period in reference to workplace data (i.e. absence time, time away from call station and electronic continuous performance) and repeated electronic diary data (n = 48) obtained approximately eight times a day to estimate time not working (i.e. a component of reduced performance).

RESULTS

The mean (median) missed work time estimate for any reason was 11 (8.0) and 12.9 (8.0) hours in a 2-week period from the WHI and workplace data, respectively, with a Pearson's (Spearman's) correlation of 0.84 (0.76). The diary-based mean (median) estimate of time not working while at work was 3.9 (2.8) hours compared with the WHI estimate of 5.7 (3.2) hours with a Pearson's (Spearman's) correlation of 0.19 (0.33). The 2-week estimate of total productive time from the diary was 67.2 hours compared with 67.8 hours from the WHI, with a Pearson's (Spearman's) correlation of 0.50 (0.46).

CONCLUSION

At a population level, the WHI provides an accurate estimate of missed time from work and total productive time when compared with workplace and diary estimates. At an individual level, the WHI measure of total missed time, but not reduced performance time, is moderately accurate.

Impact of a Collaborative Care Model on Depression in a Primary Care Setting: A Randomized Controlled Trial

To measure the effects of a collaborative care model that emphasized the role of clinical pharmacists in providing drug therapy management and treatment follow-up to patients with depression, we conducted a randomized controlled trial at a staff model health maintenance organization. We compared the outcomes of subjects treated in this collaborative care model (75 patients, intervention group) with subjects receiving usual care (50 patients, control group). After 6 months, the intervention group demonstrated a significantly higher drug adherence rate than that of the control group (67% vs 48%, odds ratio 2.17, 95% confidence interval 1.04-4.51, p=0.038). Patient satisfaction was significantly greater among members randomly assigned to pharmacists' services than among controls, and provider satisfaction surveys revealed high approval rates as well. Changes in resource utilization were favorable for the intervention group, but differences from the control group did not achieve statistical significance. Clinical improvement was noted in both groups, but the difference was not significant. Clinical pharmacists had a favorable effect on multiple aspects of patient care. Future studies of this model in other health care settings appear warranted.

Validation of the Health-Related Productivity Questionnaire Diary (HRPQ-D) on a sample of patients with infectious mononucleosis: results from a phase 1 multicenter clinical trial

The objective of this work was to assess the performance of the newly developed Health-Related Productivity Questionniare-Diary (HRPQ-D). Patients completed the HRPQ-D daily for 1-week periods during weeks 1, 2, 4, and 8 of a clinical trial for infectious mononucleosis. Productivity data were collected on a daily basis in terms of absenteeism, presenteeism, and combined lost productivity for three work venues (work outside home, housework, and classes/homework). These were then correlated with patient symptom scores. Symptom scores were positively correlated with lost work hours because of absenteeism and combined lost productivity scores. However, negative correlations were observed between symptom scores and the lost work hours due to presenteeism. The HRPQ-D demonstrated good construct validity, making it a useful tool for determining productivity levels across different work venues within clinical trial or survey research applications.

Relationship of employee-reported work limitations to work productivity

BACKGROUND

Work limitation rates are crucial indicators of the health status of working people. If related to work productivity, work limitation rates may also supply important information about the economic burden of illness.

OBJECTIVE

Our objective was to assess the productivity impact of on-the-job work limitations due to employees' physical or mental health problems.

RESEARCH DESIGN

Subjects were asked to complete a self-administered survey on the job during 3 consecutive months. Using robust regression analysis, we tested the relationship of objectively-measured work productivity to employee-reported work limitations.

SUBJECTS

We attempted to survey employees of a large firm within 3 different jobs. The survey response rate was 2245 (85.9%). Full survey and productivity data were available for 1827 respondents.

MEASURES

Each survey included a validated self-report instrument, the Work Limitations Questionnaire (WLQ). The firm provided objective, employee-level work productivity data.

RESULTS

In adjusted regression analyses (n = 1827), employee work productivity (measured as the log of units produced/hour) was significantly associated with 3 dimensions of work limitations: limitations handling the job's time and scheduling demands (P = 0.003), physical job demands (P = 0.001), and output demands (P = 0.006). For every 10% increase in on-the-job work limitations reported on each of the 3 WLQ scales, work productivity declined approximately 4 to 5%.

CONCLUSION

Employee work limitations have a negative impact on work productivity. Employee assessments of their work limitations supply important proxies for the economic burden of health problems.

Depression-related short-term disability in an employed population

There has been a growing realization that the number of workplace disability claims for mental and nervous disorders is increasing. Yet, little is known about the working population disabled by these disorders. Absence of basic information describing this population makes it virtually impossible to plan effective workplace programs. Using administrative data collected from three major Canadian financial/insurance sector employers, we focus on one group of disorders--depression. In this study, we report the prevalence of short-term disability due to depression and describe the characteristics of workers affected and their disability outcomes. We observed that compared with other nervous and mental disorders, depression-related short-term disability generally affected more employees, lasted longer, and had a higher rate of recurrence. In addition, at the end of their episodes more than three quarters of workers returned to work. These estimates suggest that the potential magnitude of the impact of short-term disability should be a concern for employers. This study helps identify the main characteristics of workers who develop depression-related disability. It also helps clarify what happens to those on short-term disability.

Considerations in the treatment of anxiety disorders: a pharmacoeconomic review

Anxiety disorders are a group of common mental disorders that impose a significant economic burden on the healthcare system and society. For this review of published literature on the pharmacoeconomics of treating anxiety disorders, various studies of the cost, resource use and the economic outcomes of pharmacological treatment were examined. Numerous studies have been published that document how the excessive costs associated with anxiety disorders, especially panic disorder, result from a combination of factors including under-recognition and misdiagnosis of the problem by primary healthcare providers, high medical resource utilisation including unnecessary or inappropriate diagnostic tests and high levels of medical help-seeking behaviour by patients. Little information has been available on the economic effects of pharmacotherapy for anxiety disorders but recent studies have shown that selective serotonin re-uptake inhibitors (SSRIs) are associated with a shift in medical resource utilisation (lower rates of emergency department and laboratory visits) which can potentially result in decreased healthcare expenditures. Facilitating an increased awareness among primary healthcare providers of the anxiety disorders and utilising appropriate diagnostic and treatment strategies can benefit patients while providing more efficient and effective healthcare spending leading to an overall reduction in the burden of disease.

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.