Changes in post-traumatic stress disorder service connection among veterans under age 55: An 18-year ecological cohort study

Introduction: Mandatory, age-based re-evaluations for post-traumatic stress disorder (PTSD) serviceconnection contribute substantially to the Veterans Benefits Administration's work load, accounting for almost 43% ofthe 168,013 assessments for PTSD disability done in Fiscal Year 2017 alone. The impact of these re-evaluations onVeterans' disability benefits has not been described. Materials and Methods: The study is an 18-year, ecological,ambispective cohort of 620 men and 970 women receiving Department of Veterans Affairs PTSD disability benefits.Veterans were representatively sampled within gender; all were eligible for PTSD disability re-evaluations at least oncebecause of age. Outcomes included the percentage whose PTSD service connection was discontinued, reduced, reinstated, or restored. We also examined total disability ratings among those with discontinued or reduced PTSD serviceconnection. Subgroup analyses examined potential predictors of discontinued PTSD service connection, including service era, race/ethnicity, trauma exposure type, and chart diagnoses of PTSD or serious mental illness. Our institution'sInternal Review Board reviewed and approved the study. Results: Over the 18 years, 32 (5.2%) men and 180 (18.6%)women had their PTSD service connection discontinued; among them, the reinstatement rate was 50% for men and34.3% for women. Six men (1%) and 23 (2.4%) women had their PTSD disability ratings reduced; ratings wererestored for 50.0% of men and 57.1% of women. Overall, Veterans who lost their PTSD service connection tended tomaintain or increase their total disability rating. Predictors of discontinued PTSD service connection for men were service after the Vietnam Conflict and not having a Veterans Health Administration chart diagnosis of PTSD; for women,predictors were African American or black race, Hispanic ethnicity, no combat or military sexual assault history, nochart diagnosis of PTSD, and persistent serious mental illness. However, compared to other women who lost theirPTSD service connection, African American and Hispanic women, women with no combat or military sexual assaulthistory, and women with persistent serious illness had higher mean total disability ratings. For both men and womenwho lost their PTSD service connection, those without a PTSD chart diagnosis had lower mean total disability ratingsthan did their counterparts. Conclusions: Particularly for men, discontinuing or reducing PTSD service connection inthis cohort was rare and often reversed. Regardless of gender, most Veterans with discontinued PTSD service connection did not experience reductions in their overall, total disability rating. Cost-benefit analyses could help determine ifmandated, age-based re-evaluations of PTSD service connection are cost-effective.