Under-recognition of medically unexplained symptom conditions among US Veterans with Gulf War Illness

OBJECTIVE

Conditions defined by persistent "medically unexplained" physical symptoms and syndromes (MUS) are common and disabling. Veterans from the Gulf War (deployed 1990-1991) have notably high prevalence and disability from MUS conditions. Individuals with MUS report that providers do not recognize their MUS conditions. Our goal was to determine if Veterans with MUS receive an ICD-10 diagnosis for a MUS condition or receive disability benefits available to them for these conditions.

METHODS

A chart review was conducted with US Veterans who met case criteria for Gulf War Illness, a complex MUS condition (N = 204, M = 53 years-old, SD = 7). Three coders independently reviewed Veteran's medical records for MUS condition diagnosis or service-connection along with comorbid mental and physical health conditions. Service-connection refers to US Veterans Affairs disability benefits eligibility for conditions or injuries experienced during or exacerbated by military service.

RESULTS

Twenty-nine percent had a diagnosis of a MUS condition in their medical record, the most common were irritable colon/irritable bowel syndrome (16%) and fibromyalgia (11%). Slightly more Veterans were service-connected for a MUS condition (38%) as compared to diagnosed. There were high rates of diagnoses and service-connection for mental health (diagnoses 76% and service-connection 74%), musculoskeletal (diagnoses 86%, service-connection 79%), and illness-related conditions (diagnoses 98%, service-connection 49%).

CONCLUSION

Given that all participants were Gulf War Veterans who met criteria for a MUS condition, our results suggest that MUS conditions in Gulf War Veterans are under-recognized with regard to clinical diagnosis and service-connected disability. Veterans were more likely to be diagnosed and service-connected for musculoskeletal-related and mental health conditions than MUS conditions. Providers may need education and training to facilitate diagnosis of and service-connection for MUS conditions. We believe that greater acknowledgement and validation of MUS conditions would increase patient engagement with healthcare as well as provider and patient satisfaction with care.

Does filing a post-traumatic stress disorder disability claim promote mental health care participation among veterans?

This study examined the impact of participation in the Department of Veterans Affairs (VA) disability system on health care use by veterans filing disability claims on the basis of post-traumatic stress disorder (PTSD). VA administrative databases were used to examine health care use in 3-month intervals before, during, and after veterans' filing of PTSD disability claims. Subjects were all veterans using some VA health care who filed PTSD claims between 1997 and 1999 in a large Midwestern region. PTSD claimants used more medical and mental health services after filing a disability claim, compared with the preapplication period. Continuation of elevated mental health care use after claim determination occurred only for those veterans whose claims were approved. Use of VA mental health care before the disability examination was associated with an increased likelihood of claim approval. For veterans with PTSD, disability system participation may both promote and be promoted by receipt of mental health care.

The effects of reducing fear of falling on locomotion in older adults with a higher level gait disorder

Fear of falling (FOF) is one of the key clinical features affecting older adults with a higher-level gait disorder (HLGD), however, its effect on gait is not clear. Twenty-one HLGD patients walked under four conditions: 1) usual walking, 2) while holding a physical therapist's hand, 3) while using a walker, and 4) while being guarded. All three interventions reduced FOF, but guarding did not significantly affect any gait parameter (p > 0.10) and the walker only increased gait speed. In contrast, handholding improved gait speed and reduced gait variability, however, an altered gait pattern persisted even with handholding. Interventions such as handholding, guarding or use of a walker apparently may reduce FOF in HLGD patients, but the impact of this reduction on gait is limited. Thus, it appears that the gait disturbances in these patients are apparently not simply the consequence of FOF.

Dimensions multiples de la fatigue d’origine neurologique : différences entre l’accident vasculaire cérébral et la sclérose en plaques

INTRODUCTION

Fatigue is a complex, subjective experience, frequent in multiple sclerosis (MS) and stroke patients. The tiredness these patients experience can take on many features depending not only on the cerebral location of the lesions and mood aspects, but also on the pathophysiology of the disease. Thus, it is reasonable to expect that fatigue may have different implications in MS and stroke. The aim of the present work was to compare fatigue syndrome in these two populations. Patients were matched for handicap.

MATERIALS AND METHODS

Seventy-nine stroke and 39 MS outpatients were included with the following inclusion criteria: i) patients with possible or relapsing-remitting MS with an Expanded Disability Status Scale (EDSS) score<2.5, disease duration<6 years, and stable medical condition for at least 6 weeks; ii) stroke patients with mild neurological impairment, i.e. scoring<3 at the National Institute of Health Stroke Scale (NIHSS) one year after stroke; iii) absence of functional impairment (Barthel index=100) and similar negligible handicap (Rankin scale<2 for both groups); no or mild cognitive deficit; iv) neither DSMIV criteria of depression, nor significant anxious/depressive symptoms (Hospital Anxiety and Depression scale; HAD; score<8) in both groups. The Fatigue Assessing Instrument (FAI) was used to assess fatigue.

RESULTS

Twenty-nine percent of stroke and 46 p. cent of MS patients had a significant score on the FAI (p<0.05). Multiple regression analysis using groups, gender and age as factors showed a group effect in 3 out of 4 subscales: MS patients scored higher than stroke patients mainly for psychic impact (4.86 vs. 3.28), but also for severity (mean 3.86 vs. 2.97) and specificity (4.36 vs. 3.32). Response to rest (5.36 vs. 6.06) only tended to be better in the stroke group. In the subpopulation with significant fatigue scores, psychic impact was more elevated in the MS group. The functional consequence of fatigue in physical, professional and social activities were similar.

DISCUSSION

Fatigue was more severe in MS than stroke patients, independently of disability. The most significant factor in the MS group was the psychic impact, reflecting impaired motivation, concentration and irritability, despite the absence of depression. However, subjective consequences of fatigue on work, family and leisure activities were comparable in both groups.

Use of mental health treatment among veterans filing claims for posttraumatic stress disorder

This study examines predictors of current mental health service use in a sample of 154 veterans filing claims for Veterans Affairs (VA) disability benefits based on Posttraumatic Stress Disorder (PTSD). Our conceptual framework was the behavioral model that classifies predictors of service utilization into predisposing (background), enabling (e.g., insurance) and need (e.g., symptoms) factors. Slightly more than half of the PTSD claimants were receiving mental health treatment at the time of claim initiation. Mean symptom levels were clinically significant in both users and nonusers of mental health treatment. In a multivariate logistic regression analysis, mental health treatment use was associated with younger age, marriage, and dependence on public insurance. Implications for future research are discussed.

The psychological risks of Vietnam for U.S. veterans: a revisit with new data and methods

In 1988, the National Vietnam Veterans Readjustment Study (NVVRS) of a representative sample of 1200 veterans estimated that 30.9% had developed posttraumatic stress disorder (PTSD) during their lifetimes and that 15.2% were currently suffering from PTSD. The study also found a strong dose-response relationship: As retrospective reports of combat exposure increased, PTSD occurrence increased. Skeptics have argued that these results are inflated by recall bias and other flaws. We used military records to construct a new exposure measure and to cross-check exposure reports in diagnoses of 260 NVVRS veterans. We found little evidence of falsification, an even stronger dose-response relationship, and psychological costs that were lower than previously estimated but still substantial. According to our fully adjusted PTSD rates, 18.7% of the veterans had developed war-related PTSD during their lifetimes and 9.1% were currently suffering from PTSD 11 to 12 years after the war; current PTSD was typically associated with moderate impairment.

Post-traumatic stress disorder claims from the viewpoint of veterans service officers

OBJECTIVE

To situate veterans' experience of the Department of Veterans Affairs claims process in a broader context, this study explored the beliefs of veterans service officers (VSOs) about the Department of Veterans Affairs disability claims process for post-traumatic stress disorder (PTSD).

METHODS

A mail survey of the county and national VSOs working in Minnesota was performed. Questionnaires included a modified version of the Disability Application Appraisal Inventory.

RESULTS

Most VSOs believe thatveterans value the Department of Veterans Affairs disability status for PTSD to obtain validation for what they experienced in the military and that veterans have negative reactions to the claims process for PTSD. VSOs' satisfaction with the claims process was associated with beliefs about its fairness.

CONCLUSIONS

In general, VSOs' beliefs about the reasons veterans value service connection for PTSD parallel those veterans report. More work is needed to determine how VSOs influence veterans, to determine whether PTSD claimants have special or unique needs as they undergo the claims process, and to explore fairness concerns.

The effect of standardized, computer-guided templates on quality of VA disability exams

BACKGROUND

The costs and limitations of clinical encounter documentation using dictation/transcription have provided impetus for increased use of computerized structured data entry to enforce standardization and improve quality. The purpose of the present study is to compare exam report quality of Veterans Affairs (VA) disability exams documented by computerized protocol-guided templates with exams documented in the usual fashion (dictation).

METHODS

Exam report quality for 17,490 VA compensation and pension (C&P) disability exams reviewed in 2005 was compared for exam reports completed by template and exam reports completed in routine fashion (dictation). An additional set of 2,903 exams reviewed for quality the last three months of 2004 were used for baseline comparison.

RESULTS

Mean template quality scores of 91 (95% CI 89, 92) showed significant improvement over routine exams conducted during the study period 78 (95% CI 77, 78) and at baseline 73 (95% CI 72, 75). The quality difference among examination types is presented.

DISCUSSION

The results of the present study suggest that use of the standardized, guided documentation templates in VA disability exams produces significant improvement in quality compared with routinely completed exams (dictation). The templates demonstrate the opportunity and capacity for informatics tools to enhance delivery of care when operating in a health system with a sophisticated electronic medical record.

PTSD and Treatment Adherence: the role of health beliefs

Health beliefs have been shown to influence a myriad of medical treatment decisions. More recently, the impact of health beliefs on treatment decisions for mental illness has become a focus of study. This study examines the health beliefs and treatment behavior of veterans with posttraumatic stress disorder (PTSD). Using standard survey methodology, we assessed beliefs about the cause of PTSD, expected duration and controllability of symptoms, and life consequences of having PTSD. Treatment participation and medication compliance were assessed, as were common treatment correlates, such as patient-provider relationships, dosing frequency, side effect severity, number of prescribed medications, and use of drugs or alcohol to control PTSD symptoms. Explanatory models of PTSD, perceived controllability, and use of benzodiazepines were found to predict psychiatric medication use. Negative life consequences of PTSD were associated with participation in psychotherapy. Assessment of health beliefs may help providers to understand their patients' treatment behavior and to facilitate treatment engagement.

Mitigating effect of Department of Veterans Affairs disability benefits for post-traumatic stress disorder on low income

OBJECTIVE

The goal was to assess the impact of Veterans Affairs (VA) disability benefits for post-traumatic stress disorder (PTSD) on veterans' odds of poverty. Women and African American veterans were of special interest, because they are less likely than other groups to receive PTSD disability benefits.

METHODS

A cross-sectional survey of 4,918 veterans who applied for VA disability benefits for PTSD between 1994 and 1998 was performed. Responses were linked to administrative data.

RESULTS

Overall, 42% reported low income (defined as household income less than or equal to 20,000 dollars per year). Men's and women's odds of reporting poverty were similar, but receipt of PTSD disability benefits mediated African American veterans' odds of poverty. Veterans' odds of impoverishment were reduced considerably if they received VA PTSD disability benefits and identified themselves as disabled.

CONCLUSIONS

VA disability benefits for PTSD reduced odds of impoverishment for psychiatrically ill veterans. This effect appeared to be especially important for African American veterans and for veterans self-identifying as disabled.

Spontaneous reports of emotional upset and health care utilization among veterans with posttraumatic stress disorder after receiving a potentially upsetting survey

This study assessed the effects of a potentially distressing mailed survey on the emotional well-being and health care utilization (HCU) of 4,918 male and female veterans who applied for posttraumatic stress disorder disability benefits. Content analysis of spontaneous comments, in combination with analysis of subjects' HCU before and after receipt of the survey, suggested that spontaneously disclosed episodes of emotional upset were rare. In general, surveyed veterans' HCU decreased after receipt of the survey.

[Posttraumatic stress disorder (PTSD)]

The diagnosis of posttraumatic stress disorder (PTSD) has been introduced in 1980. The diagnosis, as construct raises several political, moral, legal, and compensation issues. PTSD is considered as a multisystemic dysregulation, involving the hypothalamic- pituitary - adrenal axis, adrenergic hypersensibility, and serotonergic dysfunction. The prevalence of PTSD is 1-9% in the general population, but substantially higher among victims of traumatic events: 19-70%. Placebo controlled studies provide a body of evidence concerning efficacy of selective serotonin reuptake inhibitors in the treatment of PTSD both in the acute and maintenance treatments. Studies with balanced male-female ratio suggest no gender-related differences in the clinical response, furthermore both civilians and veterans improved significantly for selective serotonin reuptake inhibitor treatment.

Service utilization among compensation-seeking veterans

To examine the relationship between compensation-seeking status, symptom reporting, and health care utilization among combat veterans presenting for a Posttraumatic Stress disorder (PTSD) evaluation. Archival data for 68 veterans was drawn from electronic medical records for which compensation-seeking status was available. Consistent with previous findings, self-reports of distress and validity scale indices on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) were higher among compensation-seeking (CS) veterans than noncompensation-seeking (NCS) veterans despite a lack of difference in actual PTSD diagnoses. However, no significant differences emerged between these two groups on healthcare utilization indices. Although exploratory analyses did not yield significant group differences on various healthcare indices, there was a trend for CS veterans to use PTSD services more, suggesting the need to further explore utilization patterns among these groups.

A model for improving the quality and timeliness of compensation and pension examinations in VA facilities

In response to external and internal customer dissatisfaction and in anticipation of markedly higher volumes of examination requests, the Department of Veterans Affairs (VA) produced an eight-month facilitated quality-improvement project designed to improve the quality and timeliness of compensation examination processing. To determine whether participation in the project was associated with better outcomes and to identify team characteristics that were associated with high performance, we obtained centrally collected facility-level performance measures on quality and timeliness of the examinations. To determine factors associated with team success, we compared measures of leadership support reported by teams with high and low performance outcomes. Thirty teams representing 34 VA medical centers and 22 Veterans Benefits Administration's regional offices participated in the project. Monthly volumes were significantly higher for participating teams, and volumes increased significantly over time for both groups. At the beginning of the project, examination timeliness was substantially worse for participating teams (34.1 versus 29.9 days, p = .03); by the end, participants had better performance (28.5 versus 30.3 days, p = .00). Quality measures were maintained. By the end of the project, high performers reported improved leadership, frontline support, resource availability, alignment with strategic goals, and leadership mandate when compared to performance at the beginning of the project; low performers reported the opposite. These results suggest that the principles of clinical improvement can be applied successfully to teach teams how to achieve process improvements within a large healthcare organization. Visible, ongoing support by leadership and alignment of project objectives with strategic goals are associated with improved project outcomes.

Clinical symptomatology of posttraumatic stress disorder-diagnosed Australian and United States Vietnam combat veterans: an MMPI-2 comparison

The authors compared MMPI-2 scores of 95 Australian and 96 US Vietnam combat veterans diagnosed with posttraumatic stress disorder (PTSD) from structured PTSD clinical interviews. Groups were strikingly similar on the MMPI-2 clinical and validity scales but were different on two content scales, with higher scores on FRS (fears) and BIZ (bizarre mentation) for the US sample. Employment status was included as a factor, because it too discriminated groups, but it did not interact with the veteran group variable to produce scale differences. The roles of employment status and disability payments are considered in accounting for differences in the psychiatric presentations of the groups. Results suggest that American and Australian Vietnam combat PTSD samples are very similar to each other, with implications for the treatment outcome literature.

Achieving excellence in veterans healthcare--a balanced scorecard approach

This article provides healthcare administrators and managers with a framework and model for developing a balanced scorecard and demonstrates the remarkable success of this process, which brings focus to leadership decisions about the allocation of resources. This scorecard was developed as a top management tool designed to structure multiple priorities of a large, complex, integrated healthcare system and to establish benchmarks to measure success in achieving targets for performance in identified areas. Significant benefits and positive results were derived from the implementation of the balanced scorecard, based upon benchmarks considered to be critical success factors. The network's chief executive officer and top leadership team set and articulated the network's primary operating principles: quality and efficiency in the provision of comprehensive healthcare and support services. Under the weighted benchmarks of the balanced scorecard, the facilities in the network were mandated to adhere to one non-negotiable tenet: providing care that is second to none. The balanced scorecard approach to leadership continuously ensures that this is the primary goal and focal point for all activity within the network. To that end, systems are always in place to ensure that the network is fully successful on all performance measures relating to quality.

Immunological responses are not abnormal in symptomatic Gulf War veterans

The underlying etiology and pathogenesis of Gulf War veterans' illnesses continue to be under intense investigation. Reports have suggested the basis for these illnesses may be an altered immune system, but compelling evidence is lacking. We sought to determine whether in vitro immune responses were abnormal in symptomatic Gulf War veterans relative to matched controls. A randomized case-control study was conducted by blinded comparison of laboratory measures of in vitro immune responses in blood samples obtained from veterans in an outpatient facility of a Veterans Affairs medical center. Symptomatic Gulf War veterans with otherwise undefined illnesses (52 symptomatic subjects), asymptomatic Gulf War veterans (31 asymptomatic controls), and veterans who had applied for disability compensation and had not participated in the Gulf War (21 disability controls) represented the volunteer sample. In vitro cellular and humoral immune responses were measured to detect functional abnormalities in antigen presenting cells (autologous mixed leukocyte reactions and expression of interleukin (IL)-1beta, IL-6, IL-10, and tumor necrosis factor-alpha); T cells (lymphocyte proliferation using the polyclonal T-cell activators phytohemagglutinin and Concanavalin A; primary immune responses in allogeneic mixed leukocyte reactions; secondary immune response using the recall antigens tetanus toxoid, Candida albicans, and anthrax vaccine; and soluble IL-2 receptor expression); type-1 T-helper cells (gamma interferon expression); type-2 T-helper cells (IL-4 and IL-10 expression); and B cells (polyclonal B-cell activator pokeweed mitogen-induced immunoglobulin production). In general, immune response measures did not differ significantly between groups. Heightened responses observed in the disability control group (sporadically greater responses to one mitogen and two antigens) and the Gulf War participation control group (greater recall responses to anthrax vaccine) did not suggest impaired immune cell function in symptomatic veterans when compared with controls. We conclude that in vitro immunological responses are not abnormal in symptomatic Gulf War veterans.

Evolution of disability in late 19th century America: Civil War pensions for Union Army veterans with musculoskeletal conditions

This article examines the evolution of musculoskeletal (MSK) disability and its impact on mortality and work patterns in the late 19th century in America, in the context of the Civil War disability policy scheme. The study was conducted on 17,702 Union Army (UA) Civil War veterans. Of these, 10,789 were examined and diagnosed with major MSK conditions, rheumatism, sciatica, and spinal curvature, between 1862 and 1907. Analyses examine MSK (i) prevalence rates by birth cohort and age group; (ii) fatality rates as compared with other disabilities; (iii) risk rates by occupation type; and (iv) lifespan for MSK patients. MSK conditions are commonly claimed disabilities within the Civil War data set, with prevalence rates increasing with age. Regression studies show that working in clerical and professional (relative to manual labor) occupations decreases the likelihood of being examined for and diagnosed with MSK conditions. MSK patients examined at older ages tended to have longer lifespan than those examined at younger ages. The findings suggest that changes in age, environmental, and occupational conditions during the late 19th century affected MSK condition prevalence and the average lifespan of MSK patients. Implications for contemporary disability policy are discussed.

The longitudinal course of posttraumatic stress disorder symptoms among aging military veterans

This study examined the longitudinal course of posttraumatic stress disorder (PTSD) among two samples of Dutch aging military veterans: 576 veterans with a military disability pension and 198 community sample veterans, who fought in World War II, the former Dutch East Indies, and Korea. Both samples were investigated in 1992 and in 1998 with a standardized and validated instrument measuring PTSD symptoms. In 1992, 27% of the veterans with a military disability pension met the criteria for a PTSD diagnosis; in 1998, this was 29%. Of the community sample veterans, 9% reported a PTSD diagnosis in 1992, in 1998 this was 8%. The results provide strong support for the long-term persistence of PTSD symptoms. In addition, PTSD caseness at one time point was associated with significantly elevated PTSD symptom severity at the time of no PTSD diagnosis. No evidence was found for an aggravation of PTSD due to stressors associated with aging.

Assessment of post-traumatic stress disorder and comorbidity

The symptoms of lifetime post-traumatic stress disorder (PTSD) and comorbid diagnoses were compared among 502 combat-experienced soldiers under examination for compensation-related purposes to confirm or deny the diagnosis of PTSD and 196 soldiers with combat experience without any psychiatric disorder. The two groups were matched with regard to duration of combat experience, time between combat experience and the study, age, marital status, and education. PTSD was diagnosed by psychiatrists with a structured clinical interview according to the research version of the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders. The psychologists applied the Mississippi Scale for Combat-Related PTSD, Watson's criteria for PTSD, the Minnesota Multiphasic Personality Inventory version 201, and the Trauma Questionnaire. Also, a very detailed heteroanemnestic questionnaire was completed by social workers. Medical documentation and data from the combat services were provided during the examination for compensation-related purposes. After psychiatric and psychological assessment, 20% of the combat-experienced soldiers under examination for compensation-related purposes were diagnosed with lifetime PTSD, 47% were diagnosed with PTSD and comorbid disorders, 6% were diagnosed with PTSD and enduring personality change, and 5% were diagnosed with adjustment disorder. Twelve percent did not fulfill any diagnostic psychiatric criteria, and 10% fulfilled diagnostic criteria for other psychiatric disorders, although they had previous medical documentation confirming PTSD diagnoses. Correlation coefficients between psychiatric and psychological assessment were significant, indicating their complementarity in reaching the final diagnosis. It is necessary to include many different assessment methods in the examination for forensic or compensation-related purposes to obtain a more objective assessment.

Is it time to limit the role of the judiciary in compensation matters?

The current use of expert medical opinion in both adversarial and inquisitorial legal matters has been criticised and a number of alternatives have been suggested. These alternatives include pre-trial (non-adversarial) consensus reports by panels of experts, College-appointed panels of experts, or expert assessors to sit with and advise the judge. A further model that deserves consideration is that of the Repatriation Medical Authority (RMA). This has an established role in the compensation system for Australian Veterans and specified Defence Force personnel. The RMA provides Statements of Principles which state the causes, within the bounds of the Veterans' Entitlements Act, of a specified disease, injury or death on the basis of the available 'sound medical scientific evidence'. The RMA is an example of the uses of epidemiology in providing compensation-based social services. This model has emerged as one which has clear implications for other compensation environments as well as in other evidence-based social policy decision making arenas. A description of the development and function of the RMA is outlined and the essential features for its operation are detailed. Fundamentally, this model promotes consistency and equity by the use of impartial and evidence-based decision making.

Schedule for rating disabilities; diseases of the ear and other sense organs. Department of Veterans Affairs. Final rule

This document amends that portion of the Department of Veterans Affairs (VA) Schedule for Rating Disabilities that addresses the ear and other sense organs. The intended effect of this action is to update this portion of the rating schedule to ensure that it uses current medical terminology and unambiguous criteria, and that it reflects medical advances that have occurred since the last review.

[The war invalid laws of 1920 on support for disabled soldiers and their surviving relatives in the provinces of southern Jutland, and the disabled soldiers' board of Sønderborg]

After the reunion between Denmark and Southern Jutland in 1920, the Danish state took over the obligations towards disabled soldiers and surviving relatives to dead soldiers from this province, serving in the German army during World War I. In 1920, the regulations were fixed by law, giving rise to Invalide-noevnet (disabled soldiers' board) in Sonderborg. The board dealt with altogether 6400 applications for invalidity pension and 4000 applications from surviving relatives. In Sonderborg an institution for disabled soldiers (Krigsinvalideskolen) was founded, including a hospital department and workshops for training and rehabilitation as well as production of bandages. A survey is given of these activities. The author next uncovers the story behind one of 9 names on a war memorial tablet, representing soldiers from the parish of Lebol, Sydals, who died in German war service during World War I. The medical record for this dead soldier is given and the family's fruitless efforts for 18 years to obtain pension are reported in details.

The pathology of primary blast overpressure injury

Primary blast injury occurs in civilian and military detonations and from the firing of weapon systems. The pathology of primary blast injury has been reported for the last 70 years and has primarily been limited to descriptions of gross pathology and histology. Commonly accepted tenets have not been confirmed as blast overpressure experiments in enclosures and with multiple detonations have been conducted. Organ systems other than the ear and the lung are playing a greater role in injury definition and research importance. This paper is an overview and update of the current understanding of the pathology of primary blast injury.

The VA health care system: an unrecognized national safety net

The dominance of local health care markets in conjunction with variable public funding results in a national patchwork of "safety nets" and beneficiaries in the United States rather than a uniform system. This DataWatch describes how the recently reorganized Department of Veterans Affairs serves as a coordinated, national safety-net provider and characterizes the veterans who are not supported by the market-based system.

Compensation and pension evaluations: psychotic, neurotic, and post-traumatic stress disorder Millon Clinical Multiaxial Inventory II profiles

The purpose of the present work was to provide an examination of the three major VA adjudication classifications (post-traumatic stress disorder [PTSD], psychotic, and neurotic) through objective psychological testing. During routine follow-up compensation and pension evaluations, 143 patients were given the Millon Clinical Multiaxial Inventory II (MCMI-II). Additionally, their current disability diagnoses as well as their current percentage of disability were coded. Discriminant function analysis revealed that the pivotal discriminatory variables were alcohol abuse for the PTSD patients, thought disorder for the psychotics, and anxiety for the neurotics. This is remarkably consistent with general clinical expectations. This should allow for more specific use of the MCMI-II in compensation and pension examinations by Department of Veterans' Affairs psychologists.

[Implication of compensation in recovery from combat-induced post-traumatic stress disorder]

The effect of compensation payment on long-term adjustment of soldiers with war-induced psychic trauma was studied. 2 groups of combat stress reaction casualties of the 1982 Lebanon War were examined: 109 casualties had been recognized by the Ministry of Defence as eligible for benefits, while 111 casualties had not applied for compensation benefits. Data were collected from their IDF medical charts and computerized personal records, from clinical data collected by IDF clinicians, and by mail and telephone surveys. Results indicated that the groups were quite similar in social functioning before the war. However, in those compensated there was more distress and impaired functioning following the war and at follow-up. The role of compensation in recovery from war-induced psychic trauma is discussed.

Compensation and psychic trauma: a study of Israeli combat veterans

The precursors and outcomes of compensation-seeking in Israeli war psychiatric casualties were examined. Findings suggest that compensation was sought by veterans who had experienced the most severe traumas and had subsequently developed the most severe symptoms and functional limitations. Reported range and severity of symptoms and functional limitations did not diminish with compensation.

[The determination of the cause-effect relationship in the loss of health and work capacity by former servicemen leaving military service]

A cause-and -effect criterion was applied to analyze the interconnection of disorders, diseases, wound, contusions and traumata with active duty status. On the basis of this analysis the authors come to a conclusion about the necessity to improve the relevant legislation. First of all it is the notion "duty status" that must be substituted by the notion "military service duty status". Taking into account the latter, it is necessary to establish within the terms of law a post of an official, a group of officials, or and organ that would have the rights to determine the circumstances of serviceman's incapacitation or invalidity and to draw up a relevant document for that matter. In the author's opinion the solution of these questions could considerably improve the socio-legislative protection of servicemen.

Expanded delivery system needed for post-traumatic stress

For many Vietnam combat veterans, the war never ended. They fight it over and over again in their minds. Their condition is called post-traumatic stress disorder. The Department of Veterans Affairs has made significant strides in treating these vets, but the VA is able to meet only a small part of the veterans' demand for treatment. A need exists at the community level, particularly in rural areas, where many veterans do not have access to the specialized treatment they need without traveling great distances and navigating red tape.