Does Filing a Post-Traumatic Stress Disorder Disability Claim Promote Mental Health Care Participation among Veterans?

Military Medicine, Jun 2007 by Spoont, Michele R, Sayer, Nina A, Nelson, David B, Nugent, Sean

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 posttraumatic 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.

Introduction

Military-related post-traumatic stress disorder (PTSD) is often a chronic debilitating condition that increases the individual's risk for suicide,1 chronic health problems,2 and unemployment.3 It is estimated that 2.4 to 3.8% of the >25 million veterans (between 600,000 and 957,000} suffer from PTSD.4,5 Therefore, it is not surprising that, since the Vietnam War era, PTSD has been the most common mental disorder for which veterans receive disability compensation.6

The relationship between PTSD treatment and disability status has become an issue of national importance, because the Department of Veterans Affairs (VA) spends more than $250 million dollars annually for specialized PTSD treatment services7 but annual disability compensation payments for PTSD are >4 times that amount.6 Because of concerns regarding the increasing number of veterans receiving compensation for military-related PTSD, the Institute of Medicine of the National Academies was recently charged with evaluating the VA PTSD disability examination process, to better understand the relationship between disability compensation for and recovery from PTSD in veterans.8 Although there are a large number of veterans receiving disability benefits for PTSD, those receiving benefits represent less than one-half of the population of veterans with military-related PTSD (~220,000).4,6 Similarly, only slightly more than one-half of the 250,000 veterans who receive mental health services for PTSD through the VA system also receive disability benefits for PTSD.6,7

The relationship between VA mental health care and disability benefits for PTSD is complex. Many assume that veterans may use VA mental health care to improve their chances of obtaining PTSD disability benefits.9,10 This concern received indirect support from several studies that reported that veterans with PTSD who were determined to be "compensation seeking" produced psychological test profiles suggesting symptom exaggeration.10-14 Because disability system participation often follows years of employment failures15 and the benefits associated with VA disability status can be considerable (e.g., tax-free monthly payments, eligibility for VA medical and pharmacy services at reduced or no cost, and educational, home loan, and other benefits16,17), the concern about misuse of mental health services has remained despite the lack of direct supporting evidence.

Although there are clear incentives for some veterans to misuse mental health services to support their disability claims, disability system participation may promote the use of mental health services for reasons other than secondary gain. In a previous study by our group, it was found that award of VA PTSD disability status was associated with an increased use of VA mental health services.18 Moreover, the most disabled veterans (those whose disability ratings were highest) were most likely to be high utilizers of mental health services.

To better understand the relationship between disability system participation and health care use, it would be helpful to know whether the rate of health care use changes before notification of claim outcome (i.e., before a change in eligibility for services). Although there is limited research examining the effects of the PTSD claim determination on service use,18,19 there is no published research examining changes in service use over the course of the claims application process. From the applicant's perspective, there are three major steps in the disability claims process.20,21 The first step involves filling out an application form and submitting supportive evidence (e.g., medical records). The second step is a medical or psychiatric disability examination for the claimed condition, usually with a VA clinician. The final step is the receipt of written notification of the claim determination (awarded or denied).

Mental health service use might increase as a result of participation in the disability system for several reasons. First, for veterans filing claims for PTSD, participation in the VA disability system puts them in contact with mental health professionals via the disability examination.20,21 This contact may affect treatment engagement through either referral or encouragement. second, claimants may attempt to "prove" that they are disabled by seeking mental health care, so as to better document their disability.14 Third, the process of disability system participation may promote problem recognition or enhance distress, both of which may lead some claimants to pursue mental health care as a result of changes in perceived treatment need.22-24