Veterans seeking disability benefits for post-traumatic stress disorder: who applies and the self-reported meaning of disability compensation
Introduction
It is well documented that mental illness is associated with significant disability in multiple domains of social and occupational functioning (Dewa & Lin, 2000; Ormel et al., 1994; Zatzick et al., 1997), and has a deleterious effect on financial well-being. For example, the presence of mental illness is associated with lower income (Gresenz, Sturm, & Tang, 2001), decreased savings (Gresenz & Sturm, 2000) and decreased employment (Baron & Salzer, 2002; Stoddard, Jans, Ripple, & Kraus, 1998). The economic disadvantage associated with mental illness is likely due to both the direct effects of the illness (e.g., functional limitations) as well as to societal factors related to mental illness diagnosis (Baron & Salzer, 2002). For example, the stigma accompanying mental illness can have a profound impact on social perception, treatment initiation and adherence, income, and employment status (Givens & Tjia, 2002; Link, Struening, Rahav, Phelan, & Nuttbrock, 1997; Link, 1987; Sirey et al., 2001; Wright, Gronfein, & Owens, 2000).
Disability compensation programs can provide an economic safety net for people disabled by mental illness. The largest American disability programs are administered by the Federal government through the Social Security Administration and the Department of Veterans Affairs (VA). Currently, 8.5 million working-age adults receive Social Security Disability Insurance or Supplemental Security Income (National Academy of Social Insurance, 2001) and 2.3 million veterans receive VA disability compensation (Department of Veterans Affairs, 2001a). Mental disorders are the most common types of disabilities among recipients of Social Security Disability Insurance and Supplemental Security Income, with about one-third of beneficiaries of these programs carrying a mental disorder as a primary diagnosis (National Academy of Social Insurance, 2001). Almost 20% of veterans receiving VA disability compensation are compensated for a “mental disorder” (Department of Veterans Affairs, 2001c).
While there is general acknowledgement that disability compensation can greatly improve the lives of people with chronic mental illnesses who are unable to support themselves (Estroff, Patrick, Zimmer, & Lachicotte, 1997a; Estroff, Zimmer, Lachicotte, Benoit, & Patrick, 1997b; Rosenheck, Dausey, Frisman, & Kasprow, 2000), there are ongoing concerns that the provision of disability payments provides a disincentive for improvement (Drew et al., 2001; Mossman, 1996; Rohling, Binder, & Langhinrichsen-Rohling, 1995) and an incentive to exaggerate symptomatology and even malinger (e.g., Cambell & Tueth, 1997; Frueh, Hamner, Cahill, Gold, & Hamlin, 2000; Weighill, 1983). However, research suggests that both monetary and non-monetary factors contribute to participation in a disability system (Estroff, Patrick, Zimmer, & Lachicotte (1997a), Estroff, Zimmer, Lachicotte, Benoit, & Patrick (1997b); Kouzis & Eaton, 2000). For example, in a sample of recently discharged psychiatric inpatients, Estroff et al. (1997a), found that dysfunction, dependence, and a limited social network were independent predictors of application for Social Security Disability Insurance and Supplemental Security Income, while earned income and work were not. They conclude that obtaining disability income might help lessen an individual's actual or perceived dependence on others. However, it has also been hypothesized that the application for disability benefits may “spawn despair” because of the altered self-perception and stigma associated with the “disability” label (Estroff et al., 1997a, p. 521; Johnston, 1997). From these perspectives, disability status may have both advantages and disadvantages for the well-being of its recipients.
How do individuals claiming disability on the basis of a mental disorder perceive the advantages and the disadvantages of obtaining disability status? Do they enter a disability system because they determine that they could obtain greater advantage in terms of money, health care, shelter and food, through disability benefits than through competitive employment? Alternatively, are they looking for something besides or in addition to money through disability status? For instance, do they hope that disability income will lead to a more independent life-style, as suggested by Estroff et al. (1997b)? There are many assumptions made about the motivations of individuals engaged in a disability system (Reich (1986), Yelin (1992)). Disability policy as well as programs and interventions geared towards improving the functional status of disabled individuals, however, need to be informed by empirical evidence. It would be important to know what disability applicants hope to achieve through the obtainment of disability status, and then subsequently to determine whether those goals are better attained through participation in a disability program or through other means. Indeed, information about the reasons individuals seek a potentially stigmatizing identity could be useful in determining the needs of these individuals, the development of programs, policies or interventions to meet those needs, and measurement of their outcomes.
While information is available about the characteristics of individuals with mental disorders who seek social security benefits (Bilder & Mechanic, 2003; Estroff, Patrick, Zimmer, & Lachicotte (1997a), Estroff, Zimmer, Lachicotte, Benoit, & Patrick (1997b); Kouzis & Eaton, 2000; Okpaku, 1985; Reich, 1986; Rosenheck et al., 2000; Segal & Choi, 1991), much less is known about veterans seeking VA disability status. Veterans are eligible for VA disability compensation for conditions that were either caused or aggravated by their military service (Principles Related to Service Connection, 2002). The VA disability program, therefore, differs from the social security disability system in that eligibility is not based on income and an inability to work. Consequently, individuals seeking VA disability status may come from a more varied economic background than those seeking Social Security Disability Insurance or Supplemental Security Income. Additionally, because veterans with low income are eligible for many VA medical services free of charge (Department of Veterans Affairs, 2002), they may have different patterns of medical and mental health care utilization than their non-veteran counterparts. Determination of the life circumstances of those seeking VA disability status is important to the development of appropriate outreach and other programs to help meet the VA's strategic goal to “restore the capacity of disabled veterans to the greatest extent possible and improve the quality of their lives and that of their families” (Department of Veterans Affairs, 2001b).
The VA disability application process is known to be complicated, time-consuming and stressful (Eldridge, 1991; Hyer, O’Leary, Elkins, & Arena, 1985; Leyland & Lundberg, 1998; Pitman, Sparr, Saunders, & Mc Farlane, 1996). To file a claim, a veteran must submit a completed compensation and pension application that includes a description of the claimed condition, along with supporting material. When the application is sufficiently developed, the veteran is usually medically evaluated for the claimed condition. After the evaluation, a rating specialist makes a rating decision and the veteran receives notification of the outcome in writing (Oboler, 2000). The entire process can take longer than 1 year from start to finish (Department of Veterans Affairs, 2001a). If the claim is granted, the veteran is said to have service connection for the condition and the disability is said to be “service connected”. Since the inclusion of post-traumatic stress disorder (PTSD) in the DSM III in 1980 (American Psychiatric Association, 1980), PTSD has become the fifth most common disability for which veterans are awarded service connection and the most prevalent service connected mental disorder (Department of Veterans Affairs, 2001c).
There is reason to believe that the disability application process on the basis of PTSD may be particularly stressful. This is because, in addition to the paper work, uncertainty, and waiting involved in processing any disability claim, individuals seeking disability status on the basis of PTSD must discuss trauma in the non-therapeutic context of the disability evaluation. There is no physical marker or other objective indicator of PTSD. Instead, the diagnosis is based largely on the examinee's self-report of psychological symptoms in connection with a claimed stressor (Resnick, 1997). Because PTSD, by definition, involves avoidance of trauma-related material (American Psychiatric Association, 1994), one must wonder whether the discussion of trauma during the disability evaluation is particularly difficult for veterans who actually have PTSD (Pitman, Sparr, Saunders, & Mc Farlane, 1996). Veterans who apply for service connection for PTSD must be sufficiently motivated not only to undergo the steps involved in the compensation application process, but also to describe their trauma histories to virtual strangers.
In this study, we describe the characteristics of veterans seeking VA disability benefits for PTSD and their self-reported reasons for valuing such benefits. This study is based on a patient-centered perspective in which the patient's point of view and values are given priority (Sullivan, 2003). Implications for research and practice involving individuals seeking disability status are discussed.
Section snippets
Data collection
To obtain our sample of PTSD disability claimants, we established a collaboration with the regional office of the branch of the VA responsible for processing VA compensation claims, the Veterans Benefits Administration, in a large Midwestern region, the veteran population of which is predominantly comprised of White males (Department of Veterans Affairs, 2003). After obtaining Institutional Review Board approvals, we extracted identifying information, including addresses, for all veterans
Characteristics of claimants
Table 1 lists demographic characteristics of veterans seeking VA disability benefits for PTSD in this Midwestern region of the United States. The modal claimant is a married White male veteran from the Vietnam era with at least a high school education who owns his own home, receives medical care at a VA Medical Center and has at least two other people in his social network whom he feels he can count on. However, this generalization masks the diversity of individuals seeking disability benefits.
Discussion
Many individuals applying for disability compensation on the basis of PTSD in this region lacked adequate economic resources. However, almost a quarter of the veterans applying for compensation for PTSD reported annual household incomes greater than $40,000. This suggests that poverty may serve as more of a motivator for some applicants than for others. The presence of higher income applicants distinguishes VA compensation claimants from claimants of disability programs with income thresholds
Acknowledgements
This study is based upon work funded by a Department of Veterans Affairs Health Services Research and Development Grant (IIR 98-057-2). We would like to thank the Department of Veterans Affairs Center for Chronic Disease Outcomes Research at the Minneapolis Veterans Affairs Medical Center for its support of this project.
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