Work reintegration for veterans with mental disorders: a systematic literature review to inform research

Disparities in program enrollment and employment outcomes for veterans with psychiatric and co-occurring substance use disorders referred or enrolled for VHA vocational rehabilitation

Introduction

The purpose of the study was to investigate factors that influence vocational rehabilitation program enrollment and employment at discharge of veterans with psychiatric and co-occurring alcohol and other substance use disorders enrolled at a veteran health administration (VHA) medical center.

Methods

A sample of 2,550 veteran patients referred for VHA vocational rehabilitation between 2016 and 2021 were examined for the current study. The current study was classified as quality improvement/assurance, thus resulting in exempt research by the U.S. Department of Veteran Affairs Institutional Review Board.

Results

Veterans with active alcohol use disorders (AUDs) and co-occurring depression, anxiety, post-traumatic stress disorder, or bipolar disorders were less likely to be enrolled for vocational rehabilitation program services compared to those without these co-occurring diagnoses. Veterans with AUD (active & in-remission status combined into one category) and a diagnosis of anxiety were less likely to be employed at discharge compared to veterans with AUDs and no anxiety diagnosis (anxiety diagnosis - 3.5% vs. no anxiety diagnosis - 5.8%).

Discussion

VHA vocational rehabilitation can be an effective intervention to assist veterans in reintegrating back into the community. Yet, there appears to be some disparities in the program enrollment and employment at discharge, depending on the nature of the psychiatric diagnosis. Investigating the factors contributing (mediating or moderating) to these discrepancies are needed. Although it appears access is not the issue in being referred for vocational rehabilitation services, other factors are likely contributing to program entry.

Military to civilian transition challenges, caregiving activities, and well-being among spouses of newly released Canadian Armed Forces Veterans

Introduction: Transition to civilian life may not only be highly challenging for service members, but also for their spouses, especially following a medical release. Often, the families of ill or injured service members must confront unexpected responsibilities related to caring for the member, while having to adjust to civilian life. This study was conducted to examine military to civilian transition challenges and engagement in caregiving among spouses of newly released Canadian Armed Forces (CAF) Veterans and their associations with spousal well-being. Methods: The Canadian Armed Forces Transition and Well-Being Survey (CAFTWS) was administered to spouses of CAF Veterans released in 2016 ( N = 595). The survey assessed spouses’ experiences with a range of military to civilian transition challenges and engagement in caregiving, as well as various indicators of their well-being (e.g., daily stress and psychological distress). Regression analyses were conducted to assess the associations of transition challenges and caregiving with well-being. Results: Results revealed that challenges related to finding educational opportunities and health care providers, and loss of military identity, as well as more frequent engagement in caregiving, were significantly associated with elevated levels of daily stress and psychological distress among spouses of Veterans. Discussion: This study is among the first to examine transition experiences, caregiving and well-being in a representative sample of Veterans’ spouses. Findings outline key challenges experienced and underline important predictors of well-being. Recommendations on services that could help facilitate or improve the experiences of families during the transition process are discussed.

Labour market outcomes of Veterans

Introduction: Employment is important to health, well-being, and adjustment from military to civilian life. Given the importance of employment, we examine Veteran labour force outcomes in Canada. Methods: We examined labour market indicators from the 2010 and 2013 Life After Service Studies cross-sectional Survey on Transition to Civilian Life, along with the 2013 Income Study for Canadian Regular Force Veterans (released since 1998). Results: In Canada, most Regular Force Veterans surveyed were employed after release and satisfied with their work – both employment and satisfaction rates grew over time. The unemployment rate did not differ from that of the general Canadian population. However, Veterans were more likely than the general Canadian population to experience activity limitations at work. Variations in outcomes were found across diverse groups of the population. For example, unemployed Veterans were younger at release, had the fewest years of service, and were more likely to have served in the Army than employed Veterans. Veterans who were not in the labour force were older and had more years of service, and many were experiencing barriers to work. Employment rates were lower among female Veterans and among medically released Veterans. Discussion: Labour market outcomes vary across sub-groups of the Veteran population, suggesting targeted approaches to improve labour market outcomes. Findings suggest that the prevention of work disability is important for improving outcomes. Best practices in preventing work disability include restructuring compensation to recognize varying degrees of earnings capacity and to encourage labour market engagement and supported employment programs.

Veteran income and employment policies in Canada

Introduction: This article examines the history of Veteran financial benefits provided by Veterans Affairs Canada (VAC) since the First World War. Methods: The history of financial benefits is described using policy documents held at VAC. Data from the Life After Service Studies (LASS), covering Veterans released since 1998, were used to describe income and employment among Veterans today. Results: For wartime-era Veterans, benefits supported those with service-related disability and their employment, along with those experiencing poverty. Post–Korean War Veteran benefits were limited to service-related disability benefits. Studies during 1997–2003 suggested that the needs of Veterans and their families were inadequately addressed by existing VAC programs. Consequently, the Government of Canada announced plans to modernize its programs, and the New Veterans Charter (NVC) was launched in 2006. Subsequently, NVC financial benefits have been expanded numerous times. The incomes of Regular Force Veterans declined after release but recovered, surpassing pre-release income, and low-income rates were half that of Canadians. Most Regular Force Veterans were employed after release and satisfied with their work. Lower rates of difficult adjustment were found among employed Veterans, who were satisfied with their finances and jobs. Higher rates of difficult adjustment were found among Veterans who were not employed; who were not satisfied with their job, main activity, or finances; or who were experiencing low income. Discussion: Wartime-era Veterans’ financial benefits and employment supports were guided by the idea of opportunity with security. After 2006, policy returned to a focus on employment supports to enhance Veteran well-being while continuing to provide financial benefits for Veterans experiencing service-related disability.

Predictors of Postdeployment Functioning in Combat-Exposed U.S. Military Veterans

Posttraumatic stress disorder (PTSD) and sequelae of mild traumatic brain injury (mTBI) are presumed to contribute to reintegration difficulties in combat-exposed veterans. Yet their relative impacts on postdeployment functioning are not well understood. The current study used structural equation modeling (SEM) to clarify the extent to which symptoms of internalizing disorders (e.g., depression, anxiety), mTBI symptoms, and cognitive performance are associated with functional impairment in 295 combat-exposed veterans. SEM results showed that internalizing symptoms most significantly predicted functional impairment (r = 0.72). Blast mTBI and cognitive performance were associated with internalizing (r = 0.24 and -0.25, respectively), but functional impairment was only modestly related to cognition (r = -0.17) and unrelated to mTBI. These results indicate that internalizing symptoms are the strongest predictor of functioning in trauma-exposed veterans, exceeding the effects of mTBI and cognitive performance. This evidence supports prioritizing interventions that target internalizing psychopathology to improve functioning in cases of co-occurring PTSD and mTBI.

Job Offers to Individuals With Severe Mental Illness After Participation in Virtual Reality Job Interview Training

OBJECTIVE

Individuals with severe mental illness have low employment rates, and the job interview presents a critical barrier for them to obtain competitive employment. Prior randomized controlled trials (RCTs) indicated that virtual reality job interview training (VR-JIT) improved job interviewing skills among trainees. This study assessed whether VR-JIT participation was associated with greater odds of receiving job offers in the six-months after completion of training.

METHODS

To assess the efficacy of VR-JIT, trainees (N=39) in the method and a comparison group (N=12) completed a brief survey approximately six months after participating in the RCTs. Primary vocational outcome measures included receiving a job offer and number of weeks searching for employment.

RESULTS

A larger proportion of trainees than comparison participants received a job offer (51% versus 25%, respectively). Trainees were more likely to receive a job offer than comparison participants (odds ratio=9.64, p=.02) after analyses accounted for cognition, recency of last job, and diagnosis. Trainees had greater odds of receiving a job offer for each completed VR-JIT trial (odds ratio=1.41, p=.04), and a greater number of completed VR-JIT trials predicted fewer weeks of searching for employment (β=-.74, p=.02).

CONCLUSIONS

Results provide preliminary support that VR-JIT is a promising intervention associated with enhanced vocational outcomes among individuals with severe mental illness. Given that participants had minimal access to standardized vocational services, future research could evaluate the effectiveness of VR-JIT among individuals with and without access to standardized vocational services as well as evaluate strategies to implement VR-JIT within a large community mental health service provider.

Determinants of chronic physical health conditions in Canadian Veterans

Introduction: Limited information is available about the determinants of chronic health conditions of Veterans despite the increasingly perilous nature of military engagements in recent decades. Methods: Econometric analysis, using probit and negative binomial models, was conducted on the basis of data from a cross-sectional self-reported health survey of Canadian Veterans to investigate the determinants of musculoskeletal, respiratory, gastrointestinal, and cardiovascular health conditions; pain; and diabetes. Results: The results stress the role of military service–related factors in the increased likelihood of chronic physical health conditions in Canadian Veterans. Army Veterans had an increased probability of musculoskeletal (0.08, p ≤ 0.001) and gastrointestinal (0.05, p ≤ 0.001) conditions and pain (0.07, p ≤ 0.01). Veterans who were deployed had an increased risk of musculoskeletal conditions (0.08, p ≤ 0.001) and pain (0.06, p ≤ 0.001). In terms of non–service-related factors, the results confirm the role of obesity as a statistically significant determinant of chronic musculoskeletal, respiratory, and cardiovascular conditions; pain; and diabetes. Female Veterans were also at higher risk of respiratory and gastrointestinal conditions. Low-income Veterans have increased probability of musculoskeletal, gastrointestinal, pain, and cardiovascular conditions, and the risk decreased with rising income level. Finally, Veterans with mental health conditions had increased odds of musculoskeletal (OR = 2.79, p ≤ 0.001), respiratory (OR = 2.40, p ≤ 0.001), gastrointestinal (3.66, p ≤ 0.001), pain (OR = 2.61, p ≤ 0.001), and cardiovascular (OR = 1.45, p ≤ 0.01) conditions and diabetes (OR = 1.37, p ≤ 0.05). Discussion: The findings have important clinical and health resource use implications as Veterans seek treatment in community settings once they transition from military to civilian life. They also serve to advance the research agenda on the health of Veterans, an understudied population in Canada.

Veterans' attitudes toward work and disability compensation: associations with substance abuse

INTRODUCTION

Veterans deemed disabled for conditions resulting from, or aggravated by, their service in the military are eligible for service-connected disability payments. Despite many positive effects of disability payments, one concern is that Veterans with psychiatric conditions who receive disability payments are less likely to be employed compared to those who are denied benefits. Little is known about the attitudes of substance using Veterans, for whom work is a particularly important part of recovery, toward work and disability compensation.

METHODS

This study compared the responses of Veterans with (n=33) and without substance use problems (n=51) to questions about work's significance and its relationship to disability payments. T- and chi-square tests were conducted to determine if Veterans with substance use problems differed from the others on work-related attitudes and perceptions of the relation between work and Veterans' benefits.

RESULTS

Veterans endorsed high levels of agreement with statements that working would lead to loss of benefits. Veterans with substance use agreed more strongly that they would rather turn down a job offer than lose financial benefits.

CONCLUSIONS

The greater preference for disability payments among substance-using Veterans may reflect a realistic concern that they are particularly likely to have difficulty maintaining employment. The widespread concern among Veterans that work will lead to loss of VA disability payments is striking given the ambiguity about how likely loss of benefits actually is, and should be addressed during the service-connection application process.