Federal Policy and the Rise in Disability Enrollment: Evidence for the VA's Disability Compensation Program

The U.S. Department of Veterans' Affairs (VA) currently provides disability benefits to 2.72 million veterans of U.S. military service through the Disability Compensation (DC) program. Until recently, the medical eligibility criteria for this program were the same across service eras, with the key condition being that the disability was caused or aggravated by military service. But in July of 2001, the VA relaxed the eligibility criteria for Vietnam veterans by including diabetes in the list of conditions covered by DC. This change was motivated by an Institute of Medicine report, which linked exposure to Agent Orange and other herbicides used by the U.S. military in Vietnam, to the onset of diabetes. In this paper, we investigate the impact of this policy change on DC enrollment, expenditures, and the sensitivity of the program to economic conditions. Our findings demonstrate that the Agent Orange decision increased DC enrollment by 7.6 percentage points among Vietnam veterans and that an additional 3.3 percent enjoyed an increase in their DC benefits. Our estimates further suggest that the policy change increased program expenditures by $2.69 billion during the 2006 fiscal year and by$45 billion in present value terms. After the policy took effect, we find that the sensitivity of the program to local economic conditions increased substantially. Taken together, our results suggest that even relatively narrow changes in the medical eligibility criteria for federal disability programs can have a powerful effect on program enrollment and expenditures.

Correlates of Improvement in Substance Abuse Among Dually Diagnosed Veterans with Post-Traumatic Stress Disorder in Specialized Intensive VA Treatment

Substantial rates of substance use comorbidity have been observed among veterans with PTSD highlighting the need to identify patient and program characteristics associated with improved outcomes for substance abuse. Data were drawn from 12,270 dually diagnosed veterans who sought treatment from specialized intensive Veterans Health Administration PTSD programs between 1993 and 2011. The magnitude of the improvement in Addiction Severity Index (ASI) alcohol and drug use composite scores from baseline was moderate, with effect sizes (ES) of -.269 and -.287, respectively. Multivariate analyses revealed that treatment in longer-term programs, being prescribed psychiatric medication, and planned participation in reunions were all associated with slightly improved outcomes. Reductions in substance use measures were associated with robust improvements in PTSD symptoms and violent behavior. These findings suggest not only synergistic treatment effects linking improvement in PTSD symptoms with substance use disorders among dually diagnosed veterans with PTSD but also to improvement in violent behavior. Furthermore, the findings indicate that proper discharge planning in addition to intensity and duration of treatment for dually diagnosed veterans with severe PTSD may result in better outcomes. Further dissemination of evidence-based substance abuse treatment may benefit this population

Program Design and Clinical Operation of Two National VA Initiatives for Homeless Mentally Ill Veterans

In 1987, in response to reports of large numbers of veterans among America\u27s homeless, the Department of Veterans Affairs established two new national health care initiatives, which have seen over 40,000 homeless veterans since their inception. We present here evaluation and treatment data on a sample of 14,000 of them. Because of differences in their design, the two programs vary in the degree to which they emphasize community outreach, homelessness prevention, and the provision of aftercare services to patients discharged from other VA programs. In spite of these differences, veterans treated in the two programs have similar health care problems and show similar degrees of improvement at the conclusion of residential treatment. About one third of those admitted complete residential treatment successfully; one third are known to be in stable community housing at the time of discharge; and more than one third are employed. These modest success rates reflect both the severity of psychiatric disorder and social dysfunction in this population, and the limited ability of health care programs to address the full range of problems faced by the homeless mentally ill, even when services are specifically tailored to meet their needs. In designing programs for the homeless, it is particularly important to link health care efforts directly with sustained vocational rehabilitation services, housing subsidies, and income supports. New VA initiatives in all three of these areas have been undertaken and are described

Is Shared Housing a Way to Reduce Homelessness?

Most single adults share housing with other adults, and living alone is considerably more expensive than living with someone else. Yet policies that discourage shared housing for formerly homeless people or people at risk of becoming homeless are common, and those that encourage it are rare. This would be understandable if such housing adversely affected its users in some way. We ask whether shared housing produces adverse effects. Our provisional answer is no. Indeed, shared housing is associated with reduced psychotic symptomology and it appears that this relationship is causal over some time frames, although the latter result is not robust. We use data from ACCESS, a 5-year, 18 site demonstration project with over 6,000 formerly homeless individuals as participants

Making Homelessness Programs Accountable to Consumers, Funders and the Public

This paper discusses how different types of performance measurement can be used to improve the accountability of homeless programs to consumers, funders and to the public. A distinction is made between the kinds of data used in formal research projects and data that can be practically obtained in a practice setting. Consumer outcomes are discussed in terms of accountability to consumers, program outcomes in terms of accountability to funders, and systems outcomes in terms of accountability to the public. Cost-benefit analyses are also discussed as providing another critical dimension of accountability to funders and the public

Association of child maltreatment and psychiatric diagnosis in Brazilian children and adolescents

OBJECTIVES: The objective of this study was to evaluate the association between different types of child maltreatment and the presence of psychiatric disorders in highly vulnerable children and adolescents served by a multidisciplinary program. METHODS: In total, 351 patients with a mean age of 12.47, of whom 68.7% were male and 82.1% lived in shelters, underwent psychiatric evaluations based on the Kiddie-Sads-Present and Lifetime Version. Two different methods were used to evaluate maltreatment: medical records were reviewed to identify previous diagnoses related to socioeconomic and psychosocial circumstances, and the Childhood Trauma Questionnaire was used to obtain a structured history of trauma. Bivariate associations were evaluated between psychiatric disorders and evidence of each type and the frequency of abuse. RESULTS: The most frequent psychiatric diagnoses were substance use disorders, affective disorders and specific disorders of early childhood, whereas 13.67% of the sample had no psychiatric diagnosis. All patients suffered neglect, and 58.4% experienced physical or sexual abuse. The presence of a history of multiple traumas was only associated with a diagnosis of substance use disorder. Mental retardation showed a strong positive association with reported physical abuse and emotional neglect. However, a negative correlation was found when we analyzed the presence of a history of multiple traumas and mental retardation. CONCLUSION: All children living in adverse conditions deserve careful assistance, but we found that physical abuse and emotional neglect were most strongly associated with mental retardation and multiple traumas with substance abuse

The impact of psychiatric diagnosis on treatment adherence and duration among victimized children and adolescents in São Paulo, Brazil

OBJECTIVE: Despite the high prevalence of substance abuse and mood disorders among victimized children and adolescents, few studies have investigated the association of these disorders with treatment adherence, represented by numbers of visits per month and treatment duration. We aimed to investigate the effects of substance abuse and mood disorders on treatment adherence and duration in a special program for victimized children in São Paulo, Brazil. METHODS: A total of 351 participants were evaluated for psychiatric disorders and classified into one of five groups: mood disorders alone; substance abuse disorders alone; mood and substance abuse disorders; other psychiatric disorders; no psychiatric disorders. The associations between diagnostic classification and adherence to treatment and the duration of program participation were tested with logistic regression and survival analysis, respectively. RESULTS: Children with mood disorders alone had the highest rate of adherence (79.5%); those with substance abuse disorders alone had the lowest (40%); and those with both disorders had an intermediate rate of adherence (50%). Those with other psychiatric disorders and no psychiatric disorders also had high rates of adherence (75.6% and 72.9%, respectively). Living with family significantly increased adherence for children with substance abuse disorders but decreased adherence for those with no psychiatric disorders. The diagnostic correlates of duration of participation were similar to those for adherence. CONCLUSIONS: Mood and substance abuse disorders were strong predictive factors for treatment adherence and duration, albeit in opposite directions. Living with family seems to have a positive effect on treatment adherence for patients with substance abuse disorders. More effective treatment is needed for victimized substance-abusing yout

Results of phase 3 of the CATIE schizophrenia trial

Objective—The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study examined the comparative effectiveness of antipsychotic treatments for individuals with chronic schizophrenia. Patients who had discontinued antipsychotic treatment in phases 1 and 2 were eligible for phase 3, in which they selected one of nine antipsychotic regimens with the help of their study doctor. We describe the characteristics of the patients who selected each treatment option and their outcomes. Method—Two hundred and seventy patients entered phase 3. The open-label treatment options were monotherapy with oral aripiprazole, clozapine, olanzapine, perphenazine, quetiapine, risperidone, ziprasidone, long-acting injectable fluphenazine decanoate, or a combination of any two of these treatments. Results—Few patients selected fluphenazine decanoate (n=9) or perphenazine (n=4). Similar numbers selected each of the other options (range 33–41). Of the seven common choices, those who selected clozapine and combination antipsychotic treatment were the most symptomatic, and those who selected aripiprazole and ziprasidone had the highest body mass index. Symptoms improved for all groups, although the improvements were modest for the groups starting with relatively mild levels of symptoms. Side effect profiles of the medications varied considerably but medication discontinuations due to intolerability were rare (7% overall). Conclusions—Patients and their doctors made treatment selections based on clinical factors, including severity of symptoms, response to prior treatments, and physical health status. Fluphenazine decanoate was rarely used among those with evidence of treatment non-adherence and clozapine was underutilized for those with poor previous response. Combination antipsychotic treatment warrants further study