Work-Related Quality of Life and Posttraumatic Stress Disorder Symptoms Among Female Veterans

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1 Women's Health Issues 21-4S (2011) S169 S175 Original article Work-Related Quality of Life and Posttraumatic Stress Disorder Symptoms Among Female Veterans Paula P. Schnurr, PhD a,b, *, Carole A. Lunney, MA a a National Center for PTSD, White River Junction, Vermont b Dartmouth Medical School, Hanover, New Hampshire Article history: Received 30 November 2010; Received in revised form 18 April 2011; Accepted 19 April 2011 abstract Background: Posttraumatic stress disorder (PTSD) can have pervasive, negative effects on multiple aspects of quality of life. We investigated the relationship between PTSD symptom clusters and work-related quality of life among female veterans. Although prior studies have shown that PTSD symptom clusters are differentially related to work-related quality of life, no study has assessed these relationships in women specifically. Methods: Participants were 253 female veterans with current PTSD. We assessed three components of work-related quality of life (employment status, clinician-rated occupational impairment, and self-rated occupational satisfaction) and performed analyses with and without adjusting for self-reported depression symptoms. Results: None of the PTSD symptom clusters were associated with employment status. All PTSD symptom clusters had significant independent associations with occupational impairment. All PTSD symptom clusters except avoidance were significantly associated with lower occupational satisfaction, but none had independent associations with occupational satisfaction. No single PTSD symptom cluster emerged as most strongly associated with occupational outcomes. Symptoms of depression had substantial associations across all occupational outcomes, independent of PTSD symptoms. Conclusion: Knowledge about how PTSD relates to occupational outcomes in women veterans is important for addressing the needs of this growing segment of the VA patient population, in which PTSD is a prevalent condition. Because PTSD had differential relationships with the three components of work-related quality of life, measuring only one component, or using an aggregate measure, may obscure important distinctions. Resolving depression symptoms also may be integral to achieving meaningful recovery. Published by Elsevier Inc. Background The concept of recovery guides models of mental health care delivery in the United States and around the world (e.g., U.S. Department of Veterans Affairs [VA], 2008). The National Consensus Statement on Mental Health Recovery defines recovery from mental illness as a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of the person s choice while striving to achieve... full potential (Substance Abuse and Conducted with grant CSP #494 from the VA Cooperative Studies Program and support from the Department of Defense for CSP #494. * Correspondence to: Paula P. Schnurr, PhD, National Center for PTSD (116D), VA Medical Center (116D), White River Junction, VT Phone: ; fax: address: paula.schnurr@dartmouth.edu (P.P. Schnurr). Mental Health Services Administration, 2005). Work is an essential component of the recovery model. It is easy to understand why. Besides income and productivity, work also provides social support and social identity, self-esteem, and a sense of purpose (Boardman, Grove, Perkins, & Shepherd, 2003; Jahoda, 1981). Work and mental health mutually influence one another. Poor mental health leads to difficulties at work (e.g., Druss et al., 2009; Kessler & Frank, 1997; Sanderson & Andrews, 2006). In turn, work exerts positive and negative influences on mental health, depending on personal and situational factors (e.g., Llena-Nozal, Lindeboom, & Portrait, 2004; Schnurr, Lunney, Sengupta, & Spiro, 2005; World Health Organization, 2002). In short, work is a mental health issue. Our focus in this paper is on posttraumatic stress disorder (PTSD) and work-related quality of life in female veterans. PTSD is a serious and prevalent mental health condition in veterans (Magruder & Yaeger, 2009). More than one in seven veterans /$ - see front matter Published by Elsevier Inc. doi: /j.whi

2 S170 P.P. Schnurr, C.A. Lunney / Women's Health Issues 21-4S (2011) S169 S175 returning from the conflicts in Iraq and Afghanistan have PTSD (Ramchand et al., 2010). PTSD is especially prevalent among women. Among veterans who used the VA in 2009, 10.2% of women and 7.8% of men had a diagnosis of PTSD (Northeast Program Evaluation Center, 2010). Among U.S. adults, the lifetime prevalence of PTSD is 9.7% in women and 3.6% in men (National Comorbidity Survey-Replication, 2007). PTSD can have pervasive negative effects on work-related quality of life (c.f. Schnurr, Lunney, Bovin, & Marx, 2009). Viewed from the perspective of a multicomponent model of quality of life (Gladis, Gosch, Dishuk, & Crits-Christoph, 1999), the problems occur in social-material conditions such as employment status and earnings, functional impairment, and subjective wellbeing and satisfaction. PTSD is associated with an increased likelihood of unemployment (e.g., Kimerling et al., 2009; Resnick & Rosenheck, 2008; Smith, Schnurr, & Rosenheck, 2005; Zatzick et al., 1997) or failure to return to work after a traumatic event (e.g., MacDonald, Colotla, Flamer, & Karlinsky, 2003; Matthews, 2005). Among workers, PTSD is associated with lower hourly wages (Savoca & Rosenheck, 2000), increased absenteeism (e.g., Breslau, Lucia, & Davis, 2004; ESEMeD/MHEDEA, 2004; Hoge, Terhakopian, Castro, Messer, & Engel, 2007), difficulty with work-related demands (e.g., Kessler & Frank, 1997; Stein, McQuaid, Pedrelli, Lenox, & McCahill, 2000; Wald, 2009; Zatzick et al., 2008), and lower work satisfaction (e.g., North et al., 2002). In one study, PTSD explained a greater percentage of variance in work impairment than impairment in social or family functioning (Taylor, Wald, & Asmundson, 2006). The few studies of female veterans have also found that PTSD is related to poor work-related quality of life. The National Vietnam Veterans Readjustment Study showed that female Vietnam veterans with PTSD were 10 times more likely than those without PTSD to be unemployed (Zatzick et al., 1997). Female veterans of the wars in Iraq and Afghanistan who sought PTSD treatment were more likely than their male counterparts to be unemployed at admission (Fontana, Rosenheck, & Desai, 2010). Female veterans who screened positive for PTSD had significantly lower role functioning and were more likely to be in the lowest quartile of role functioning than other female VA patients without PTSD (Dobie et al., 2004). PTSD is reflected in symptom clustersdreexperiencing, avoidance/numbing, and hyperarousaldthat may differ in their effects on occupational outcomes. For example, avoidance may have lesser effects than hyperarousal symptoms, such as anger and concentration difficulties, unless a job context or its specific duties elicit traumatic reminders that an individual feels a need to avoid. Numbing also might have powerful effects by impairing workplace relationships. Knowing how symptoms relate to specific problems with work can help to identify individual targets for treatment, which also facilitates another principal of the recovery model, person-centered care. Prior studies have shown that PTSD symptom clusters are differentially related to work-related quality of life. However, the results of these studies, which focused on occupational functioning, fail to show a consistent pattern. Kuhn, Blanchard, and Hickling (2003) assessed major role functioning (which included occupational functioning) in two samples of motor vehicle accident survivors. The investigators examined the effect of each cluster, adjusted for the effects of all other clusters. In treatment-seeking patients, only hyperarousal was uniquely associated with functioning; in contrast, in a sample of survivors with less severe symptoms, all clusters except hyperarousal had unique associations. Shea, Vujanovic, Mansfield, Sevin, and Liu (2010) found that avoidance/numbing and hyperarousal symptoms were uniquely associated with occupational functioning. Using a slightly different clustering of PTSD symptoms, Pietrzak, Goldstein, Malley, Rivers, and Southwick (2010) found that only dysphoria symptoms (numbing symptoms plus the hyperarousal symptoms of irritability, sleep disturbance, and difficulty concentrating) were uniquely associated with work difficulties. Taylor et al. (2006) found that reexperiencing and hyperarousal symptoms were related to occupational impairment. Taylor et al. (2006) also found that depression symptoms were related to occupational impairment. PTSD and depression often co-occur (e.g., Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Orsillo, Weathers, Litz, Steinberg, & Keane, 1996), and some symptoms overlap between the disorders (Franklin & Zimmerman, 2001; Keane, Taylor, & Penk, 1997). Individuals with comorbid PTSD and depression have greater functional impairment than those with PTSD alone (e.g., Frayne et al., 2005; Ikin, Creamer, Sim, & McKenzie, 2010). The degree of work impairment is similar in PTSD and depression (e.g., Druss et al., 2009; ESEMeD/MHEDEA, 2004; Kessler & Frank, 1997). We investigated the relationship between PTSD symptoms clusters and work-related quality of life by using data from a randomized clinical trial of PTSD treatment for female veterans and active duty personnel (Schnurr, Friedman et al., 2005, 2007). We aimed to extend the existing literature by using multiple occupational outcomes representing the three domains in Gladis et al. s (1999) multicomponent model: employment status (social-material conditions), clinician-rated occupational impairment (functioning), and self-rated occupational satisfaction (subjective well-being). It was difficult to make predictions given the variation in the existing literature, which could be due to a number of factorsdnot just the samples or the type(s) of trauma they experienced, but also the analytic procedures. Kuhn et al. (2003), Pietrzak et al. (2010), and Shea et al. (2010) used multiple regression to estimate the independent association of each PTSD cluster with functioning, but Shea et al. (2010) also adjusted for Axis I disorders and other covariates. Taylor et al. (2006) used multiple regression, but did not report the independent associations of each symptom cluster. We addressed this variation by performing both simple and multiple regression, with and without adjustment for depression to extend the findings of Taylor et al. (2006). Methods An institutional review board at each site approved the research protocol. All participants provided written informed consent. Participants Participants were 253 female veterans and active duty personnel drawn from a randomized clinical trial of PTSD treatment (Schnurr, Friedman et al., 2005, 2007). Participants were recruited between 2002 and 2005 from nine VA Medical Centers, two VA Readjustment Counseling Centers, and one military hospital. Inclusion criteria were current PTSD according to the 1/2 rule (at least monthly frequency and moderate intensity required to count a symptom as present) and minimum severity of 45 or higher on the Clinician-Administered PTSD Scale (CAPS; Weathers, Keane, & Davidson, 2001); 3 or more months since experiencing trauma; a clear memory of the trauma that caused PTSD; agreement to not receive other psychotherapy for PTSD

3 P.P. Schnurr, C.A. Lunney / Women's Health Issues 21-4S (2011) S169 S175 S171 during study treatment; and, for those on psychoactive medication, a stable regimen for the prior 2 months. Exclusion criteria were current psychotic symptoms, mania, or bipolar disorder; current substance dependence; prominent current suicidal or homicidal ideation; cognitive impairment; current involvement in a violent relationship; and self-mutilation within the past 6 months. Of 353 women who met with staff to learn about the study, 284 were enrolled; 33 did not complete prescreening, 30 did not complete assessment, 5 failed inclusion/exclusion criteria, and 1 could not be randomized because a therapist was not available. Because work-related quality of life was the main outcome of interest, we excluded 31 retired participants from the original study sample of 284. Retired participants were an average of 11.5 years older than working or unemployed participants, t(282) ¼ 6.91, p <.001, but the groups did not differ in PTSD symptoms, depression symptoms, occupational impairment, or occupational satisfaction. Participants ranged between 22 and 66 years old (M ¼ 43.5). Most had some post-secondary education (88.5%; n ¼ 224), 32.8% were married or cohabitating (n ¼ 83), and 45.5% (n ¼ 115) were non-white. Seven women (2.8%) were on active duty. Participants had experienced between 1 and 15 different types of traumatic events. Sexual trauma was the most frequent (92.9%; n ¼ 235), followed by physical assault (83.4%; n ¼ 211), and transportation accident (73.9%; n ¼ 187). Sixty-five participants (25.7%) had experienced warzone exposure; 70.4% (n ¼ 178) reported at least one sexual experience during military service that was unwanted and involved force or threat of force. According to the Structured Clinical Interview for DSM-IV (SCID; Spitzer, Williams, Gibbon & First, 1995), 78.3% (n ¼ 198) had a current comorbid Axis I disorder, most frequently a mood disorder (62.5%; n ¼ 158). Major depressive disorder was the most common mood disorder (49.4%; n ¼ 125), followed by other depressive disorders (18.2%, n ¼ 46), and bipolar disorders (2.4%; n ¼ 6). Almost half had a current anxiety disorder other than PTSD (47.0%; n ¼ 119), most commonly social phobia (20.6%; n ¼ 52) or generalized anxiety disorder (19.0%; n ¼ 48). Thirty-two participants (12.6%) had an eating disorder and 4 (1.6%) had a substance abuse disorder. Measures PTSD symptoms were measured using the CAPS (Weathers et al., 2001), a structured interview in which the frequency and intensity of each of the 17 DSM-IV PTSD symptoms (American Psychiatric Association, 1994) are rated on a 5-point scale. The CAPS has excellent psychometric properties (Weathers et al., 2001). Schnurr et al. (2007) reported that the intraclass correlation for interrater reliability on CAPS severity scores in the clinical trial was.92. Reexperiencing (B) and hyperarousal (D) symptom clusters were defined according to the DSM-IV. Separate avoidance and numbing subscales were created based on evidence that avoidance and numbing form separate clusters (e.g., King, Leskin, King, Weathers, 1998). Severity is calculated by adding symptom frequency and intensity. Cluster severity scores are calculated as the sum of symptom severity within each cluster. The range is 0 to 40 for reexperiencing, numbing and hyperarousal, and 0 to 16 for avoidance. Depression symptoms were assessed using the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), a 21-item self-report scale. Each item has four response options, ordered in increasing intensity ranging from 0 (least intense) to 3 (most intense). The overall score is computed by summing the items, resulting in a scale with a range of 0 to 63. Employment status at study entry was coded as 1 if the participant was currently employed full or part time, and 0 if the participant responded unemployed or other. Occupational impairment was assessed using the CAPS item, which asks, In the past month, have these (PTSD SYMPTOMS) affected your work or your ability to work? How so? The interviewer is instructed to consider work history, including number and duration of jobs as well as the quality of work relationships. Impairment is rated on a 5-point scale from 0 ¼ none to 4 ¼ extreme. Occupational satisfaction was assessed using the work item from the Quality of Life Inventory (Frisch, 1994), which asks, How satisfied are you with your work? The Quality of Life Inventory is a questionnaire on which 16 domains are rated in terms of satisfaction ( 3 ¼ very dissatisfied to þ3 ¼ very satisfied) and importance (0 ¼ not important to 2 ¼ extremely important). We used only the work satisfaction rating to ensure that our measure was a pure indicator of satisfaction. Procedure Referring clinicians provided information about inclusion and exclusion criteria to study staff, who then met with potential participants to explain the study. Women who met eligibility criteria were randomized to receive 10 weekly sessions of either Prolonged Exposure (Foa & Rothbaum, 1998) or Present-Centered Therapy (Schnurr, Friedman et al., 2005). A masters- or doctorallevel clinician who was blind to participants treatment assignment performed assessments. Data reported below were collected at baseline. Data Analysis We calculated Pearson correlations to assess associations among PTSD symptoms, depression symptoms, and occupational outcomes. Logistic regression (for current employment status) and linear regression (for occupational impairment and satisfaction) were used to examine the association between the four PTSD symptom clusters and occupational outcomes. We performed separate analyses, regressing each outcome on each individual PTSD symptom cluster score, and simultaneous analyses, regressing each outcome on all four PTSD symptom clusters at once. Findings from these simultaneous analyses show the independent associations between each outcome and each PTSD symptom cluster. Separate and simultaneous analyses were also performed using depression symptoms as a covariate. In addition to unstandardized regression coefficients and standard errors (SEs), we report odds ratios (ORs) per standard deviation (SD) increase (for employment status) and standardized regression weights (for occupational impairment and satisfaction). The standardized regression coefficient can be interpreted as the predicted SD increase in the outcome given a 1.0-SD increase in the independent variable, controlling for other variables (if any) in the model. We explored the need to adjust for demographic characteristics and trauma exposure by examining whether these variables were associated with occupational outcomes. None of the variables were related to any of the outcomes, so we did not include demographic or trauma variables in the analyses.

4 S172 P.P. Schnurr, C.A. Lunney / Women's Health Issues 21-4S (2011) S169 S175 Results Table 1 presents descriptive information about participants PTSD and depression symptoms and the three occupational outcomes. Average PTSD symptom severity reflected severe PTSD. Average depression severity was in the moderate to severe range. Fewer than half of participants were employed at study enrollment (43.9%; n ¼ 111); one participant in the unemployed/ other group reported that she was a stay-at-home parent. On average, occupational impairment fell between moderate and severe (M ¼ 2.38; SD ¼ 0.97). Occupational satisfaction was negative (M ¼ 0.24; SD ¼ 2.19), indicating mild dissatisfaction with work on average. About half of participants expressed some degree of dissatisfaction with work (51.8%; n ¼ 131). Table 1 also presents information about the correlation among PTSD symptoms and among occupational outcomes. All four PTSD symptom clusters were correlated with one another and with depression symptoms. The magnitude of these correlations was small to medium. There also were modest correlations among the occupational outcomes. Employment was correlated with lower impairment and higher occupational satisfaction, and higher impairment was correlated with lower satisfaction. Table 2 contains the results of regressions of work-related quality of life on PTSD symptom clusters, with and without adjusting for depression symptoms. None of the PTSD symptom clusters were related to current employment status in either the separate or simultaneous regression analyses. Only depression was significantly associated with current employment status. In the separate analysis, each SD increase in depression symptoms was associated with a 35% reduction in the odds of working. The effect was unchanged in the simultaneous analysis when the symptoms of PTSD were taken into account. In the separate and simultaneous analyses, all PTSD symptom clusters were associated with a higher level of occupational impairment. The pattern of findings for PTSD was the same after controlling for symptoms of depression, except that the association between hyperarousal and occupational impairment no longer met a conventional level of significance (p ¼.054). Symptoms of depression also were associated with greater impairment in both the separate analysis and in the simultaneous analysis that included PTSD. In the separate analyses, occupational satisfaction was negativelyassociated with reexperiencing, numbing, and hyperarousal symptoms. However, in the simultaneous analysis, none of the PTSD symptom clusters had independent associations with satisfaction. After controlling for depression, no individual cluster was associated with occupational satisfaction in the separate analyses. Only depression was associated with occupational satisfaction in the simultaneous analysis. Discussion Women represent a growing proportion of the active duty and veteran populations (VA Office of Policy and Planning, 2007). We examined how types of PTSD symptoms are associated with work-related quality of life in a sample of these women, who have been included in few prior studies on PTSD and occupational outcomes (e.g., Fontana et al., 2010; Zatzick et al., 1997). There were three main findings. First, greater PTSD severity was related to poor occupational outcomes, although the associations differed across the three components of work-related quality of life. Second, no single symptom cluster was most strongly associated with occupational outcomes. Third, depression symptoms were related to all components, independent of PTSD symptoms. We discuss these findings in light of previous studies, and then suggest directions for research and implications for treatment. We were surprised that none of the PTSD symptom clusters were associated with employment status. However, most prior studies showing that PTSD was related to unemployment had compared PTSD versus no PTSD groups (e.g., Zatzick et al., 1997), whereas all participants in our study had PTSD. No other study examined the association between PTSD symptom clusters and the probability of working, although Smith et al. (2005), in their study of male Vietnam veterans, reported higher scores for all PTSD clusters for veterans who were unemployed versus those who were working. It is possible that our findings differ from Smith et al. s because the relationship between mental disorder and work-related quality of life differs between men and women (Llena-Nozal et al., 2004; Scott & Collings, 2010). All PTSD clusters were related to clinician-rated occupational impairment. Each cluster had independent associations as well. Controlling for symptoms of depression had little effect on the findings, except that the independent relationship for hyperarousal was no longer significant. We cannot draw firm conclusions about whether certain PTSD symptoms have particularly strong relationships with occupational functioning. Shea et al. (2010), who used the same measure of occupational functioning as we did but also controlled for additional covariates, Table 1 Correlations and Descriptive Statistics for PTSD Symptoms, Depression Symptoms, and Work-Related Quality of Life Outcomes Among Female Veterans and Active Duty Personnel (1) (2) (3) (4) (5) (6) (7) (8) (1) Reexperiencing 1.00 (2) Avoidance 0.32 * 1.00 (3) Numbing 0.23 * 0.16 y 1.00 (4) Hyperarousal 0.44 * 0.30 * 0.33 * 1.00 (5) Depression 0.32 * 0.18 z 0.44 * 0.34 * (6) Employment status * 1.00 (7) Occupational impairment 0.38 * 0.32 * 0.32 * 0.36 * 0.37 * 0.27 * 1.00 (8) Occupational satisfaction 0.18 z z 0.21 * 0.30 * 0.35 * 0.23 * 1.00 M SD Abbreviations: M, mean; PTSD, posttraumatic stress disorder; SD, standard deviation. Note. n ¼ 253. Entries in the top section of the table are Pearson correlations. * p <.001. y p <.05. z p <.01.

5 P.P. Schnurr, C.A. Lunney / Women's Health Issues 21-4S (2011) S169 S175 S173 Table 2 Regressions of work-related quality of life on PTSD symptom clusters, with and without adjusting for depression symptoms Employment Status Unadjusted Adjusted for Depression Separate Regressions Simultaneous Regression Separate Regressions Simultaneous Regression B SE B OR (95% CI) B SE B OR (95% CI) B SE B OR (95% CI) B SE B OR (95% CI) Reexperiencing ( ) ( ) ( ) ( ) Avoidance ( ) ( ) ( ) ( ) Numbing ( ) ( ) ( ) ( ) Hyperarousal ( ) ( ) ( ) ( ) Depression * ( ) * ( ) Occupational Impairment Unadjusted Adjusted for depression Separate Regressions Simultaneous Regression Separate Regressions Simultaneous Regression B SE B b B SE B b B SE B b B SE B b Reexperiencing y y y * Avoidance y * y * Numbing y * * z Hyperarousal y z y Depression y * Occupational Satisfaction Unadjusted Adjusted for depression Separate Regressions Simultaneous Regression Separate Regressions Simultaneous Regression B SE B b B SE B b B SE B b B SE B b Reexperiencing * Avoidance Numbing * Hyperarousal y Depression y y Abbreviations: PTSD, posttraumatic stress disorder; B, unstandardized regression coefficient; SE; standard error; OR; odds ratio per SD; CI; confidence interval; b, standardized regression coefficient. Note. In separate analyses, each outcome was regressed on each PTSD symptom cluster individually. In simultaneous analyses, each outcome was regressed on all clusters at once. * p <.01. y p <.001. z p <.05. did not find that reexperiencing was independently associated with functioning. Other investigators have found different patterns of relationships (Kuhn et al., 2003; Pietrzak et al., 2010; Taylor et al., 2006). The variation may be due to some combination of sample characteristics, measures, and analytic methods. The only common finding across studies is that greater PTSD severity is related to poorer functioning. All PTSD symptom clusters except avoidance were associated with occupational satisfaction, but none of the clusters had an independent association. Nonsignificance in the simultaneous analyses does not mean that PTSD symptoms are unrelated to satisfaction; rather, it means that no cluster contributed unique variance. This is not merely an artifact of the correlation among symptoms. The symptom clusters were independently associated with occupational impairment. Furthermore, prior studies have found independent associations between PTSD symptom clusters domains of quality of life (e.g., Kuhn et al., 2003; Lunney & Schnurr, 2007; Taylor et al., 2006). We were unable to identify prior studies that used a measure of occupational satisfaction to investigate the relationship between PTSD symptom clusters and work-related quality of life. Because there is general consensus that satisfaction is an important component of quality of life (e.g., Mendlowicz & Stein, 2000; Mogotsi, Kaminer, & Stein, 2000), we recommend that researchers measure work-related satisfaction to more fully investigate the relationship between PTSD and occupational outcomes. In contrast with PTSD symptoms, depression symptoms had independent associations with all occupational outcomes, which is consistent with findings reported by Taylor et al. (2006). Depression is a common mental health condition that negatively affects multiple domains of quality of life (McKnight & Kashdan, 2009), comparable to the effects of PTSD (e.g., Druss et al., 2009; ESEMeD/MHEDEA, 2004; Kessler & Frank, 1997). Although PTSD and depression often co-occur (e.g., Kessler et al., 1995; Ramchand et al., 2010), the fact that depression had effects statistically independent of PTSD indicates that comorbidity does not account for the findings. Understanding the shared and unique effects of these two disorders on quality of life is necessary. Other Axis I disorders that often co-occur with PTSD, such as anxiety and substance use disorders (e.g., Kessler et al., 1995), also deserve attention. Men and women differ substantially in labor force participation. According to the Bureau of Labor Statistics (2009) women are less likely than men to work, and more likely to work part time. Women earn about 80% as much as men and are slightly more likely to live in poverty. Given such differences, it is possible that there could be gender differences in how PTSD affects workrelated quality of life. However, most investigations of occupational outcomes in veterans with PTSD have included only men or

6 S174 P.P. Schnurr, C.A. Lunney / Women's Health Issues 21-4S (2011) S169 S175 have not reported gender comparisons (e.g., Hoge et al., 2007; Resnick & Rosenheck, 2008; Shea et al., 2010; Smith et al., 2005). Gender differences in type of trauma exposure, perceived social support from colleagues, prevalence of PTSD, and other health issues have implications for our ability to generalize from findings with male veterans (Street, Vogt, & Dutra, 2009). We noted examples of how generalizations about work and mental disorder based on men would not apply to women (Llena-Nozal et al., 2004; Scott & Collings, 2010). It is important to know whether these findings would generalize to female veterans. The only study of gender differences in occupational outcomes in veterans found that female veterans seeking treatment from VA PTSD programs were more likely than their male counterparts to be unemployed (Fontana et al., 2010). It also is important for research to include samples of women that are large enough to permit meaningful comparisons with men. We suggest that this research proceed along several lines. The first are descriptive, observational studies like this one that investigate how demographic, clinical, and experiential factors (e.g., type of trauma) moderate the relationship between PTSD and occupational outcomes in men and women. Second, longitudinal studies would be especially valuable to further understanding of the dynamic interplay between PTSD and workrelated quality of life. Last are intervention studies that attempt to improve work-related quality of live and promote recovery. In all of this work we recommend clarity about constructs. Terms such as functioning, well-being, and quality of life are often used interchangeably (Schnurr et al., 2009). Our findings show that results may vary across outcomes, so careful definition is required. We have found the three-component model described by Gladis et al. (1999) to be most useful because it captures objective and subjective information and includes socio-material conditions as well as behavior and feelings. Studies should be designed to optimally measure all of the components. Our study was not designed to specifically investigate quality of life. Consequently, we had limited measures of work outcomes, such as a single item for work satisfaction. Another limitation is that the participants were seeking PTSD treatment from the VA. Women who use the VA and who consent to research do not represent all women veterans. Similarly, women who engage in treatment, regardless of whether the treatment is delivered in a research project, do not represent all women veterans or VA users. Our findings should be generalized cautiously to individuals with less severe symptoms or who are not seeking PTSD care. Because our sample includes only female veterans and active duty personnel, the findings may not generalize to non-veteran women with PTSD either. Although we used a cross-sectional design that does not permit definitive inferences about cause and effect, our findings suggest useful clinical implications. The most obvious is that treating PTSD could improve work-related quality of life. Reducing PTSD symptoms may not be sufficient, however. Addressing occupational outcomes may be required. Johnson, Fontana, Lubin, Corn, & Rosenheck (2004) found that selfrated occupational functioning did not improve in a treatmentseeking sample of Vietnam veterans, despite perceived improvements in symptoms and other areas of functioning. The effectiveness of targeted occupational interventions such as supported employment or compensated work therapy may depend on PTSD status, such as the likelihood of employment at the end of a VA Compensated Work Therapy program was lower for veterans with PTSD than those without PTSD (Resnick & Rosenheck, 2008). Another clinical implication is that because PTSD had differential relationships with domains of work-related quality of life, these domains may vary in terms of how they respond to treatment. Measuring only one domain or using an aggregate measure such as the Global Assessment of Functioning scale in the SCID (Spitzer et al., 1995) may obscure important distinctions. Also, resolving depression in patients undergoing PTSD treatment may be necessary to help an individual function optimally and return to work if not working. All of these issues are integral to achieving meaningful recovery in women and men. 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Posttraumatic stress disorder and functioning and quality of life outcomes in female Vietnam veterans. Military Medicine, 162, Zatzick, D., Jurkovich, G. J., Rivara, F. P., Wang, J., Fan, M. Y., Joesch, J., et al. (2008). A national study of posttraumatic stress disorder, depression, and work and functional outcomes after injury hospitalization. Annals of Surgery, 248, Author Descriptions Paula P. Schnurr, PhD, is a psychologist who serves as Deputy Executive Director of the VA National Center for PTSD and Research Professor of Psychiatry at Dartmouth Medical School. Her research focuses on PTSD treatment and longitudinal studies of traumatic exposure. Carole A. Lunney, MA, is a social science analyst with the VA National Center for PTSD. Her research interests include the relationship between PTSD and quality of life, as well as research design and data analysis.