Perceptions of the C&P Process for PTSD: Symptoms and Service Utilization
Nina A. Sayer PhD
VA Medical Center
Minneapolis, MN
Funding Period: October 1999 - January 2004

BACKGROUND/RATIONALE:
The VA disability system touches the lives of millions of veterans and their families. In FY 2000, 2.3 million veterans were receiving service-connected disability compensation, and the VA spent more than 14 billion dollars in disability benefits. These numbers are growing steadily as each year the VA received more than 100,000 new claims for disability compensation. However, we know little about the health status, health outcomes, and health care needs of veterans engaged in the VA disability system.

Almost half a million veterans are service connected for mental disorders, and PTSD is the most common mental health condition for which veterans file new claims. It is also the condition for which filing a claim may be the most stressful. Filing for disability benefits for PTSD is unique in that it requires veterans to reveal very personal and troubling experiences, namely trauma, in a nontherapeutic context. This may be particularly difficult for individuals with PTSD because, as delineated in the DSM IV criteria for PTSD, the disorder involves active avoidance of trauma-related memories. The objective of this study is to examine the clinical impact of pursuing VA disability benefit on the basis of PTSD and to identify factors that may mediate any such effects. Such information is needed for the development of interventions to minimize any negative health outcomes associated with the compensation and pension (C&P) process for PTSD.

OBJECTIVE(S):
Primary objectives include to: 1) develop a reliable and valid instrument to examine veterans' knowledge and beliefs about the VA disability system for PTSD; 2) examine the association between veteran knowledge and beliefs at baseline and variations in symptoms and service utilization as veterans undergo the C&P process for PTSD; and 3) determine whether social support moderates any of these associations.

METHODS:
This is a four-year project with two phases. Participants are male and female veterans seeking disability benefits for PTSD for the first time. In phase 1, we examined the psychometric properties (test-retest reliability, internal consistency, factor structure and predictive validity) of an inventory to assess knowledge and beliefs about the C&P process for PTSD, the C&P Appraisal Inventory (AI). Phase 2 is a prospective study of PTSD disability claimants. We are examining changes in symptoms and VA service utilization associated with key events (including the PTSD C&P exam) in the C&P process and factors that predict these changes, including AI scores, as well as the buffering effect of social support.

FINDINGS/RESULTS:
Phase 1: The DAAI scales are internally consistent and largely uncorrelated. Test-retest correlations are high for Negative Expectations and Importance scales. Factor analysis offered evidence of the DAAI structural validity. Evidence of the DAAI construct validity was offered by results from multiple regression analyses predicting MMPI-2 indicators of distress. These and related findings are presented in two separate publications. Phase 2: PTSD symptoms increased around the time of the disability examination for PTSD relative to the baseline period. Controlling for demographic variables, there was a positive association between DAAI Negative Expectations and this increase in PTSD symptoms. The more negative a veterans view of the disability application process at the time of claim initiation, the greater the increase in PTSD symptoms within 24-hours of the disability examination. Mental health service utilization also increased around the exam period relative to a pre-claim baseline period. Controlling for demographic variables, Negative Expectations and Knowledge had independent positive associations with the rate of mental health service utilization around the time of the PTSD disability examination. Importance scores were not associated with a change in PTSD symptoms or with mental health service utilization. There was no moderating effect of social support. Manuscripts are in preparation.

IMPACT:
The DAAI has utility as a research tool to measure claim-related beliefs, the impact of those beliefs on reactions to the claims process and changes in beliefs pursuant to interventions. Interventions are needed to reduce the effect of the disability examination on veterans seeking VA disability benefits for PTSD. Results are being disseminated through presentations at national conferences and to stakeholders such as Veterans Service Officers and PTSD providers, as well as publications.

PUBLICATIONS:

Journal Articles

1. Sayer NA, Spoont M, Nelson DB, Clothier B, Murdoch M. Changes in psychiatric status and service use associated with continued compensation seeking after claim determinations for posttraumatic stress disorder. Journal of Traumatic Stress. 2008; 21(1): 40-8.
2. Spoont MR, Sayer NA, Nelson DB, Clothier B, Murdoch M, Nugent S. Does clinical status change in anticipation of a PTSD disability examination? Psychological services. 2008; 5(1): 49-59.
3. Sayer NA, Murdoch M, Carlson KF. Compensation and PTSD: Consequences for Symptoms and Treatment. PTSD Research Quarterly. 2007; 18(4): 1-3.
4. Spoont MR, Sayer NA, Nelson DB, Nugent S. Does filing a post-traumatic stress disorder disability claim promote mental health care participation among veterans? Military Medicine. 2007; 172(6): 572-5.
5. Sayer NA, Clothier B, Spoont M, Nelson DB. Use of mental health treatment among veterans filing claims for posttraumatic stress disorder. Journal of Traumatic Stress. 2007; 20(1): 15-25.
6. Sayer NA, Spoont M, Nelson DB. Post-traumatic stress disorder claims from the viewpoint of veterans service officers. Military Medicine. 2005; 170(10): 867-70.
7. Sayer NA, Spoont M, Nelson D. Veterans seeking disability benefits for post-traumatic stress disorder: who applies and the self-reported meaning of disability compensation. Social Science and Medicine. 2004; 58(11): 2133-43.
8. Sayer NA, Spoont M, Nelson DB, Nugent S. Development and psychometric properties of the disability application appraisal inventory. Psychological Assessment. 2004; 16(2): 192-6.
9. Sayer N, Spoont M, Murdoch M. The Department of Veterans Affairs Disability Compensation Program: What providers should know. Federal Practitioner. 2004; 21(5): 15-20.
10. Sayer NA, Spoont M, Murdoch M. The VA disability compensation program: what providers should know. Federal Practitioner. 2004; 21(5): 15-20.
11. Sayer NA, Spoont M, Nelson DB. Disability compensation for PTSD and use of VA mental health care. Psychiatric Services. 2004; 55(5): 589.
12. Sayer NA, Thuras P. The influence of patients' compensation-seeking status on the perceptions of veterans affairs clinicians. Psychiatric Services. 2002; 53(2): 210-2.

DRA: Health Services and Systems, Military and Environmental Exposures
DRE: Communication and Decision Making
Keywords: PTSD, Deployment (Pre Gulf War I), Gulf War I
MeSH Terms: Pensions, Health Services Research