EMPLOYMENT

Closely related to the disabling effects of PTSD on a person’s ability to function is its effect on the ability to find and maintain employment. The committee reviewed five studies regarding the effect of deployment to a war zone on employment and earnings. The two that were designated as primary studies used data from the NVVRS, a nationally representative sample of male Vietnam veterans. Of the three secondary studies, two were based on data from the National Comorbidity Survey (NCS) and these were considered secondary because the subjects were selected nonrandomly and because there was no control or comparison group. The third secondary study had a nonrepresentative sample consisting only of veterans in treatment for PTSD. Primary studies are summarized in Table 7-4.

Zatzick et al. (1997a,b) studied the relationship between PTSD and functioning and quality of life. One sample included male Vietnam veterans, and the other, female Vietnam veterans. The authors used archival data from the NVVRS NSVG, a study that was completed in 1988 and included a cohort of 1200 male and 432 female Vietnam-theater veterans, and 412 male and 304 female era veterans. Most male veterans were middle-aged and married at the time of the interview; over 50% had some college education. About 17% of veterans were of black or Hispanic backgrounds. PTSD symptom level at the time of the interview was assessed with the Mississippi Scale for Combat-Related PTSD; a study cutoff score of 94 and 89 was used to define current PTSD in the men and women, respectively. Psychiatric comorbidity was diagnosed with the DIS. A single question assessed the subjects’ ability to function in a particular role on the job, at home, or at school. Male veterans who were gainfully employed (n = 1033), active with schoolwork (n = 2), or engaged in housework (n = 2) were categorized as working. Logistic models were used to determine the association between PTSD and outcome; adjustment was made for demographic characteristics and comorbid psychiatric and other medical conditions. The results showed that veterans with PTSD (n = 242) were more likely not to be working at the time of the survey than veterans without PTSD (n = 948), for an OR of 3.3 (95% CI 1.5-7.6) adjusted for age, ethnicity, marital status, educational attainment, region of country, and comorbidity; 10 veterans did not complete the scale and were not included in the analyses.

The study of 432 female Vietnam veterans also used archival data from the NVVRS (Zatzick et al. 1997b). Aside from the use of a cutoff of 89 for a PTSD diagnosis, the methods for this study were the same as for the study of male veterans. About 8.9% (37) women were estimated to have PTSD. Once again, logistic models were used to determine the association between PTSD and various outcomes, including employment. Adjusted for age, ethnicity, marital status, educational attainment, region of country, and comorbidity, PTSD was associated with approximately 10 times greater odds of not working (OR 10.4, 95% CI 1.8-61.9). This was the strongest association found between PTSD and the various outcomes, which also included subjective well-being and self-reported physical health status. A limitation of both Zatzick et al. studies is that they were cross-sectional, making it impossible to determine the extent to which PTSD may have caused this functional impairment.

Savoca and Rosenheck (2000) also used data from the NVVRS NSVG to explore the influence of psychiatric disorders on the civilian labor-market experiences of 1417 Vietnam-era veterans. The authors used the NSVG lifetime diagnoses of major depression, anxiety disorders, substance abuse or dependence, constructed with the DIS and combat-related PTSD based on the



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