Examining bias in the award of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder in women veterans: Analysis of evaluation reports and VA decisions.

Studies have raised concerns about possible inequities in the U.S. Department of Veterans Affairs (VA)'s awards of disability for posttraumatic stress disorder (PTSD) to women. However, the diagnoses and opinions made by disability examiners have not been studied. A sample of 270 initial PTSD examination reports and corresponding VA decisions were studied. Compared to men, women veterans were as likely to be diagnosed with a service-related mental disorder, χ2(1, N = 270) = 2.31, p = .129, odds ratio (OR) = 1.79, 95% CI [0.84, 3.80], and be granted service-connection, χ2(1, N = 270) = 0.49, p = .483, OR = 1.28, 95% CI [0.65, 2.51]. Women veterans were considered to have more psychiatric symptoms, Z = -2.05, p = .041, r = .16, and more psychiatric impairment, Z = -2.48, p = .013, r = .20, but the percentage of disability awarded by the VA did not differ, χ2(1, N = 270) = 0.49, p = .483; OR = 1.28, 95% CI [0.65, 2.51]. Secondary analyses implicate the role of military sexual trauma and premilitary trauma in explaining sex differences in symptoms and impairment. The findings indicate that neither opinions by examiners nor corresponding decisions by the VA regarding service connection reflect a negative bias toward women veterans. Results indicate that unbiased examinations lead to equitable VA claims decisions for women veterans. Future studies of the VA PTSD disability program nationally, including examination procedures and VA policies and implementation, will promote equity for women veterans in the PTSD claims process.

Military sexual trauma-related posttraumatic stress disorder service-connection: Characteristics of claimants and award denial across gender, race, and compared to combat trauma.

The current study characterizes a cohort of veteran claims filed with the Veterans Benefits Administration for posttraumatic stress disorder secondary to experiencing military sexual trauma, compares posttraumatic stress disorder service-connection award denial for military sexual trauma-related claims versus combat-related claims, and examines military sexual trauma -related award denial across gender and race. We conducted analyses on a retrospective national cohort of veteran claims submitted and rated between October 2017-May 2022, including 102,409 combat-related claims and 31,803 military sexual trauma-related claims. Descriptive statistics were calculated, logistic regressions assessed denial of service-connection across stressor type and demographics, and odds ratios were calculated as effect sizes. Military sexual trauma-related claims were submitted primarily by White women Army veterans, and had higher odds of being denied than combat claims (27.6% vs 18.2%). When controlling for age, race, and gender, men veterans had a 1.78 times higher odds of having military sexual trauma-related claims denied compared to women veterans (36.6% vs. 25.4%), and Black veterans had a 1.39 times higher odds of having military sexual trauma-related claims denied compared to White veterans (32.4% vs. 25.3%). Three-fourths of military sexual trauma-related claims were awarded in this cohort. However, there were disparities in awarding of claims for men and Black veterans, which suggest the possibility of systemic barriers for veterans from underserved backgrounds and/or veterans who may underreport military sexual trauma.

Functional Disability in US Military Veterans: The Importance of Integrated Whole Health Initiatives.

Objective: To examine the prevalence and sociodemographic, medical, and psychiatric correlates of disability in activities of daily living (ADLs) and instrumental ADLs (IADLs) in the US veteran population.Methods: Data were analyzed from 4,069 US veterans who participated in the 2019-2020 National Health and Resilience in Veterans Study (NHRVS). Multivariable and relative importance analyses (RIAs) were conducted to identify independent and strongest correlates of ADL and IADL disability.Results: A total of 5.2% (95% CI, 4.4%-6.2%) and 14.2% (95% CI, 12.8%-15.7%) of veterans reported ADL and IADL disability, respectively. Older age, male sex, Black race, lower income, and deployment-related injuries were associated with ADL and IADL disabilities, as were certain medical and cognitive conditions. Results of RIAs revealed that sleep disorders, diabetes, posttraumatic stress disorder (PTSD), older age, and cognitive disorders were most strongly associated with ADL disability, while chronic pain, PTSD, lower income, and sleep and cognitive disorders were most strongly associated with IADL disability.Conclusions: Results of this study provide an up-to-date estimate of the prevalence and sociodemographic, military, and health correlates of functional disability in US veterans. Improved identification and integrated clinical management of these risk factors may help mitigate disability risk and promote the maintenance of functional capacity in this population.Prim Care Companion CNS Disord. 2023;25(4)22m03461. Author affiliations are listed at the end of this article.

Compensation and Pension Exams for Military Sexual Trauma-Related Posttraumatic Stress Disorder: Examiner Perspectives, Clinical Impacts on Veterans, and Strategies.

BACKGROUND: It is estimated that in one in three women veterans experience military sexual trauma (MST), which is strongly associated with posttraumatic stress disorder (PTSD). A 2018 report indicated the Veterans Benefits Administration (VBA) processed approximately 12,000 disability claims annually for PTSD related to MST, most of which are filed by women. Part of the VBA adjudication process involves reviewing information from a Compensation and Pension (C&P) exam, a forensic diagnostic evaluation that helps determine the relationship among military service, diagnoses, and current psychosocial functioning. The quality and outcome of these exams may affect veteran well-being and use of Veterans Health Administration (VHA) mental health care, but no work has looked at examiner perspectives of MST C&P exams and their potential clinical impacts on veteran claimants. METHODS: Thirteen clinicians ("examiners") who conduct MST C&P exams through VHA were interviewed. Data were analyzed using rapid qualitative methods. RESULTS: Examiners described MST exams as more clinically and diagnostically complex than non-MST PTSD exams. Examiners noted that assessing "markers" of MST (indication that MST occurred) could make veterans feel disbelieved; others raised concerns related to malingered PTSD symptoms. Examiners identified unique challenges for veterans who underreport MST (e.g., men and lesbian, gay, bisexual, transgender, and queer [LGBTQ+] veterans), and saw evaluations as a conduit to psychotherapy referrals and utilization of VHA mental health care. Last, examiners used strategies to convey respect and minimize retraumatization, including a standardized process and validating the difficulty of the process. CONCLUSIONS: Examiners' responses offer insight into a process entered by thousands of veterans annually with PTSD. Strengthening the MST C&P process is a unique opportunity to enhance trust in the VBA claims process and increase likelihood of using VHA mental health care, especially for women veterans.

Proposed Changes to the Department of Veterans Affairs Disability Rating Rubric for Mental Disorders.

OBJECTIVE: The U.S. Department of Veterans Affairs (VA) provides disability benefits for general medical and mental health conditions related to military service. Despite advances in conceptualization, assessment, and diagnosis of mental disorders, the current rating rubric used to determine the award amounts received by veterans with posttraumatic stress disorder and other mental disorders has not been substantively revised since 1996. The VA recently proposed sweeping changes to the rating rubric for mental disorders, shifting the focus from a symptom-based algorithm to one based on functional impairment and bringing the rubric more in line with existing disability systems and guidelines. METHODS: The authors examined the VA's current symptom-based rating rubric and reviewed and analyzed the proposed changes, including a comparison with other rating systems used for mental disorders. Research on the relationship between psychiatric symptoms and functional impairment is also discussed. RESULTS: Bringing examination procedures in line with the new function-based rating schedule will require significant changes to current standard practice for both examiners and Veterans Benefits Administration raters. The new rubric requires more specific definitions, anchors, and operationalization of the domains of function in the rating schedule to improve reliability and validity. CONCLUSIONS: The new system reflects an overdue shift away from a symptom-based formula toward real-world functioning. Concept study data suggest that the system may increase ratings for veterans awarded compensation, but the actual impact remains unknown. The authors discuss the implications of the new method for disability determination and offer suggestions for maximizing effective and fair implementation of the new rubric.

PTSD Disability Examination Reports: A Comparison of Veterans Health Administration and Contract Examiners.

Background: An enormous increase in disability claims for posttraumatic stress disorder (PTSD) has occurred over the past decade. To meet the demand for examinations required to determine diagnosis, causation, and impairment, the US Department of Veterans Affairs Veterans Health Administration (VHA) has increasingly relied on contract examiners. Despite anecdotal reports of poor-quality examinations by contractors, no systematic study comparing VA and contract examinations has been reported. Methods: Data from 113 initial PTSD examination reports were coded and rated on variables related to content and quality. Administrative disability decisions rendered by VHA were identified and coded independently. Results: Contract examinations reported more symptoms and a greater degree of impairment, resulting in higher VHA disability ratings compared with VHA examiner reports. Contractor examinations were rated as having poorer quality than were VHA examinations on 2 of 3 metrics and included several examination reports that contained no relevant history or discussion required to support opinions about diagnosis or impairment. Conclusions: The findings provide the first systematic evidence of greater symptom/impairment reporting and poorer overall quality in contract examinations for PTSD disability claims compared with those conducted by VHA examiners, with resulting differential outcomes in VHA disability ratings. The findings have implications for the quality, integrity, and reliability of the VHA PTSD disability claims process and support the need for program oversight, examiner training, and quality assurance.

Zonisamide as an Adjunctive Treatment to Cognitive Processing Therapy for Veterans With Posttraumatic Stress Disorder and Comorbid Alcohol Use Disorder: A Pilot Study.

BACKGROUND AND OBJECTIVES: There are high rates of comorbid alcohol use disorder (AUD) among those who have posttraumatic stress disorder (PTSD). Ideally, treatment for comorbidity should address both disorders simultaneously. Zonisamide, an anticonvulsant, may be effective in decreasing alcohol use and may attenuate symptoms of PTSD. Treatment strategies can include medication in combination with a proven evidence-based psychotherapy designed to treat PTSD, such as cognitive processing therapy (CPT). METHODS: This 12-week pilot study was designed to test feasibility, acceptability, and preliminary efficacy of zonisamide (400 mg) as an adjunct to CPT for veterans with PTSD and comorbid AUD. Veterans (n = 24) with PTSD and current alcohol dependence were randomized in a 3:1 ratio to receive zonisamide or placebo in a double-blind fashion. All subjects received CPT enhanced to include sessions addressing drinking behavior. RESULTS: Subjects overall reported a significant decrease in drinking outcomes, craving, and symptoms of PTSD. Zonisamide was well-tolerated and easily administered with CPT, which was also well-tolerated. Exploratory analysis of comparison of groups suggests there was no advantage of zonisamide vs placebo in drinking or PTSD outcomes. There was a numeric but nonsignificant higher rate of abstinence with zonisamide (50%) vs placebo (33%). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: The interpretation of the results is limited by the pilot nature of this study. The combination of psychosocial treatment with medication management mimics real-world treatment. In order to isolate the individual contributions of medication vs psychotherapy a much larger study would need to be conducted. (Am J Addict 2020;29:515-524).

Quality of life in veterans with alcohol dependence and co-occurring mental illness.

Quality of life is negatively impacted by diagnosis of mental illness. Those with mental illness report problems in physical, psychological, cognitive, social, and occupational functioning. This study was designed to examine changes in quality of life in veterans with dual diagnoses. All veterans participated in a treatment study designed to treat alcohol dependence with naltrexone, disulfiram, and the combination of naltrexone/disulfiram or placebo for 12 weeks. Quality of life was assessed before treatment and at the end of treatment. Quality of life improved for all veterans and the improvement was more significant for those who abstained from alcohol throughout treatment. Severity of psychiatric symptom was associated with worse quality of life. This study demonstrates the importance of addressing social functioning in veterans with dual diagnosis.

Treatment for comorbid borderline personality disorder and alcohol use disorders: a review of the evidence and future recommendations.

There is a high degree of comorbidity between borderline personality disorder (BPD) and alcohol use disorders (AUDs). There is some evidence that this pattern of comorbidity may be associated with poorer prognosis. Although there are many different psychotherapeutic and pharmacological treatments for BPD and AUDs when they occur alone, there are very few treatment options when they occur together. The objective of this article was to review the existing treatment options-both psychotherapeutic and pharmacological-for patients with dual diagnoses of BPD and AUDs and to explore alternative treatment options that warrant further study. There have been a number of studies that have examined the efficacy of specific psychotherapies targeting drinking among patients with comorbid BPD; however, their efficacy in reducing BPD symptoms is unknown. There are also three psychotherapies that were specifically developed for patients with BPD and substance use disorders (SUDs), but only one of these (Dynamic Deconstructive Psychotherapy) has been tested among patients with dual diagnoses of BPD and AUDs. Research on pharmacotherapy for dual diagnoses of BPD and AUD is scarce, and no study has yet explored medication options that can concurrently manage symptoms of BPD and decrease alcohol consumption. Interestingly, there is growing evidence that anticonvulsants and second generation antipsychotics, the recent medications of choice for the management of BPD symptoms, may also reduce alcohol craving and consumption. Although premature, these findings are encouraging especially for this population of patients for whom treatment options are very limited.

The interpersonal problems of the socially avoidant: self and peer shared variance.

We demonstrate a means of conservatively combining self and peer data regarding personality pathology and interpersonal behavior through structural equation modeling, focusing on avoidant personality disorder traits as well as those of two comparison personality disorders (dependent and narcissistic). Assessment of the relationship between personality disorder traits and interpersonal problems based on either self or peer data alone would result in counterintuitive findings regarding avoidant personality disorder. In contrast, analysis of the variance shared between self and peer leads to results that are more in keeping with hypothetical relationships between avoidant traits and interpersonal problems. Similar results were found for both dependent personality disorder traits and narcissistic personality disorder traits, exceeding our expectations for this method.