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Unemployment Biggest Predictor of PTSD Symptom Severity

Pauline Anderson


NEW YORK ― Severity of posttraumatic stress disorder (PTSD) symptoms appears to be linked to the likelihood of not having a job, according to a new study, which showed that almost two thirds of PTSD patients were unemployed.

"What this analysis showed was that it was specifically the severity of PTSD symptoms, meaning recurrent memories or reexperiences of the trauma, or going to great lengths to avoid reminders of the trauma ― those types of core PTSD symptoms ― that were related to unemployment, more than, for example, depression," study investigator James W. Murrough, MD, assistant professor, Departments of Psychiatry and Neuroscience, and associate director, Mood and Anxiety Disorders Program, Icahn School of Medicine at Mount Sinai in New York City, told Medscape Medical News.

In some ways, added Dr. Murrough, this finding makes sense, "but we showed this empirically in a sample."
Presented here at the American Psychiatric Association 2014 Annual Meeting, the findings highlight the negative impact of PTSD on functional ability, he added.

Sexual Trauma

Symptoms of PTSD impair one's ability to function in the workplace and in society and to hold meaningful relationships because of the effect of trauma on the brain and the way one responds to stress and emotional information, said Dr. Murrough.

"We basically compared people with PTSD who were unemployed to those who were employed and asked what was different," Dr. Murrough told Medscape Medical News. "We asked what the biggest predictor of severity of PTSD was, and found that it was unemployment."

Data on the 104 patients in the study were collected as part of the screening process for PTSD treatment trials. The sample was mostly female (73%), and the mean age was 37.5 years. Most (71%) reported more than 1 traumatic event, and 38.5% indicated that sexual assault was their most severe trauma.

In addition to unemployment, more severe types of trauma, for example, combat or military history or a sexual trauma before age 18 years, were other large predictors of the severity of PTSD (both P = .006).

Because most of the cohort was female, it is hard to "parse out" the gender effect of sexual trauma, although this association applied to males as well as females, said Dr. Murrough.

In this study sample, the average PTSD severity level was high, with a mean Clinician-Administered PTSD Scale score of 77.14. Most study patients also had a diagnosis of depression (80%) or an anxiety disorder, such as social phobia or panic disorder. More than a third (36.5%) had a history of substance abuse or dependence.

Overall, the study showed that higher PTSD severity levels were associated with increased unemployment (P ˂ .05).

It is difficult to "tease out causality" in the PTSD and employment equation, but it is pretty clear that "the more ill you are, the less likely you are to work," he said.

Workplace Stigma

PTSD may carry with it a workplace stigma. Sarah Horn, clinical research coordinator, psychiatry, Icahn School of Medicine at Mount Sinai, reported that when the Center for New American Security in Washington, DC, asked personnel at 69 leading companies how they felt about hiring veterans, 61% said that they were uncertain about the safety of bringing onboard someone who has PTSD.

According to the Bureau of Labor Statistics, the unemployment rate for veterans of Iraq and Afghanistan aged 24 years and younger was 29.1%, compared with a national average unemployment rate of 8.2%, and for older veterans of this war, the unemployment rate was 10.3%, compared with 7.5% for other veterans, said Horn.

In this current sample, it is difficult to determine whether the impact of PTSD on employment is any greater than that of other mental illnesses, for example, major depression, because so many of the patients also suffered other psychiatric disorders, said Dr. Murrough.

However, psychiatric illnesses other than PTSD do have an impact on employment. According to Horn, the employment rate is 40% to 60% for people reporting major depression and 20% to 35% for those reporting an anxiety disorder. Unemployment rates for people with serious and persistent psychiatric disabilities such as schizophrenia are the highest, typically 80% to 90%, she said.
Dr. Murrough commented that although the situation has improved, there is still some disparity about insurance coverage for nonmedical illnesses.

"The question is, how is a psychiatric illness like PTSD weighed by society vs a medical condition," he said. "Part of the problem is that a psychiatric disorder is hard to measure; you can't do a blood test to see if you have PTSD or not."

PTSD is an increasingly prevalent public health issue, said the authors. Research shows that 6.8% of American adults suffer from this condition at some point in their lives, and that race, sex, socioeconomic status, age, comorbid diagnoses, and history of childhood trauma are risk factors.

Unique Study

Approached for a comment, Terrance Lim, MBBS, FRANZCP, a consultant psychiatrist and clinical lecturer, University of Sydney, Australia, who has an interest in PTSD, said that the study is unique in that it emphasizes the vocational impact of PTSD, but that the relationship between vocation and this psychiatric condition is complex and may involve more than 1 type of employment.

"For example, apart from the military, there may be many other vocations that might contribute to the development of PTSD, such as emergency or law enforcement professions."

An "emerging trend" is the development of psychological distress as a result of workplace bullying that might not qualify clinically for a diagnosis of PTSD but that may have as much impact as full-blown PTSD, said Dr. Lim.

"Toxic work environments can lead to employee distress which, whilst not necessarily meeting the diagnostic threshold for PTSD, may lead to as much, if not more, economic impact due to days lost at work than clinically confirmed PTSD."

Workplace-related bullying has significant implications for healthcare economics, said Dr. Lim, adding that insurance companies may have a vested interest in whether such a condition is eligible for coverage.

The study was funded by the US Department of Defense and the National Institutes of Health.
American Psychiatric Association's 2014 Annual Meeting. Abstract NR6-155. Presented Monday, May 5, 2014.

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