To the Editor: Concerns about the influence on PTSD treatment of disability compensation for posttraumatic stress disorder (PTSD) through the Department of Veterans Affairs (VA) are well known. The main concern is that the compensation program may create an incentive for veterans to exaggerate symptoms or even malinger (1). Some have claimed that malingering is rampant and that those who engage in this behavior drop out of PTSD treatment once they are awarded benefits (2). However, we found no published studies of the impact of disability compensation for PTSD on the rate of use of VA mental health services.
We examined the effects of obtaining VA disability benefits for PTSD on participation in VA mental health treatment in a large Midwestern region. Using VA administrative data, we compared mental health service use before initiation of a disability claim with mental health service use soon after the claim was determined for all 452 VA users who applied for and obtained VA disability benefits on the basis of PTSD over a three-year period. We found that the rate of mental health service use increased after PTSD disability benefits were awarded (Z=7.35, p<.001). Over three-month periods, the mean±SD number of mental health appointments before claim initiation was 2.45±13.65, compared with 5.55± 16.61 after the award. The proportion of veterans using mental health services doubled after claim determination. Specifically, of the 452 veterans awarded compensation for PTSD, 112 veterans were using VA mental health services during the period before claim initiation, compared with 237 veterans during the period soon after claim determination (McNemar's test χ2=83.56, df=1, p<.001).
The VA assigns service-related conditions a disability rating ranging from 0 to 100 percent, with higher ratings indicating greater disability. We examined variation in service use as a function of the PTSD disability rating. In an analysis of variance of the rankings of mental health service use, a linear contrast was used to test for a linear association between the mean utilization rankings and the level of disability. The rate of mental health service use increased as disability level increased (t=3.56, df=448, p<.001). During the period just after award notification, veterans who received PTSD disability ratings of 70 and 100 percent used more mental health services than those who received lower ratings (χ2= 14.27, df=1, p<.001).
These findings suggest that VA disability awards for PTSD may provide an impetus for veterans to enter VA mental health treatment at an intensity level commensurate with their disability rating. Because veterans who receive VA disability benefits for nonpermanent conditions are reevaluated every two to five years, secondary-gain motivations must be considered. However, it seems unlikely that veterans would increase their service use so soon after receiving disability benefits in preparation for a reevaluation that will not occur for several years. In addition, the observed relationship between disability rating and service use is not readily explained as a secondary-gain effect. Instead, this increase in mental health service use is consistent with cross-sectional research demonstrating that veterans with VA disability benefits are more likely to use VA services (3). Further studies are needed to understand the effects of VA disability compensation on treatment.
The authors are affiliated with the Center for Chronic Disease Outcomes Research at the Veterans Affairs Medical Center in Minneapolis. Dr. Sayer and Dr. Spoont are also with the University of Minnesota, Twin Cities Campus.