Beyond service connection: what helps PTSD-disabled veterans get better?

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Project Summary/Abstract Project Background/ Rationale In a small sample of homeless, mentally ill veterans who applied for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) benefits, Rosenheck et al. showed that levels of illness and disability did not differ substantially among those who were and were not approved for benefits. However, once their benefits were approved, SSI/SSDI beneficiaries had substantially better life quality, less homelessness, and less reliance on welfare and food stamps to meet basic needs than veterans who were denied SSI/SSDI benefits. We recently extended this research to examine the long-term impacts of receiving or not receiving VA disability benefits for posttraumatic stress disorder (PTSD). PTSD is a uniquely disabling condition that affects veterans' mental health as well as their physical and social well-being. We estimate that 1.5 million veterans and military troops have been affected by PTSD symptoms. Of these, we estimate that almost 560,000 have applied for VA disability benefits for PTSD. Veterans who receive VA disability benefits are said to be "service connected." Approximately six years after enrolling a longitudinal panel of 3,337 nationally representative veterans who applied for PTSD disability benefits, findings showed that, on average, PTSD service connection reduced poverty and PTSD symptoms. However, the latter effect was small. PTSD service connection did not improve beneficiaries' work, role and social functioning overall. Notably, among both service connected (SC+) and non-service connected (SC-) veterans, substantial minorities had clinically relevant improvements in their PTSD symptoms. A smaller but still substantial minority in each group had clinically relevant deteriorations. Project Objectives 1) To identify factors associated with PTSD-disabled veterans getting clinically better or clinically worse, 2) To identify the strategies and lessons they learned that might help other PTSD-disabled veterans get better or, conversely, prevent them from getting worse, and 3) To use cross-case comparison to see if results differ by PTSD service-connected status, gender, or service era. A secondary aim is to see if objective survey measures of improvement/decrement correspond to veterans' self-perceptions of "being better" or "being worse." Project Methods This 3.5-year, observational study will use qualitative methods to take advantage of our pre-existing, well- characterized panel of former disability applicants. A mailed survey will identify the qualitative sample: veterans with clinically relevant improvements or decrements in PTSD symptom severity and in their work, role and social functioning since their last assessment. Survey respondents will be stratified according to 4 core characteristics: clinical status (got better or worse), PTSD service-connected status (SC+ or SC-), gender, and service era (served during or after the Vietnam Conflict). From eligible, mailed survey respondents, a total of 64 veterans will be randomly selected from these 4 strata for in-depth, qualitative interviews. The sample provides for 32 veterans per group for each planned 2-group, cross-case comparison and falls within usually recommended sample sizes for achieving thematic saturation. Because of the panel's geographic spread, interviews will be conducted by telephone. For the interviews, we will use inductive, open coding content analysis to identify themes across and within cases to address project objectives.