Who can do this Annotated Bibliography on Job Satisfaction?

Factors Associated With Civilian Employment, Work Satisfaction, and Performance Among National Guard Members C. Beau Nelson, Ph.D., Kara Zivin, Ph.D., Heather Walters, M.S., Dara Ganoczy, M.P.H., Shelley MacDermid Wadsworth, Ph.D., Marcia Valenstein, M.D.

Objective: Employment is a vital part of the postdeployment return to civilian life. This study investigated factors associ- ated with employment-related outcomes (employment status, self-reported work performance, and self-reported work satisfaction) among National Guard members return- ing from Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn deployments.

Methods: The sample consisted of 1,151 National Guard service members who had returned from overseas deploy- ments approximately six months earlier. Bivariate and mul- tivariable analyses were performed to examine associations between predictors and employment-related outcome variables.

Results: Higher-risk alcohol use was associated with re- duced odds of being employed as well as with lower ratings

of work satisfaction, whereas psychiatric symptom load was associated with lower self-reported work performance and work satisfaction ratings. Perceived social resources were associated with higher self-reported work performance and work satisfaction, whereas better physical functioning was associated with better self-reported work performance.

Conclusions: Policy makers and clinicians may need to consider and assess alcohol use among unemployed Na- tional Guard members. They may also need to consider psychiatric symptom load and physical functioning among employed service members who perceive poor work per- formance and have low work satisfaction. Further research is needed on causal links between these predictors and em- ployment outcomes.

Psychiatric Services 2015; 66:1318–1325; doi: 10.1176/appi.ps.201400334

In 2013, the U.S. Bureau of Labor Statistics (BLS) reported that there were over 21 million veterans in the U.S. pop- ulation, with an overall jobless rate of 7.0%, versus 7.9% for nonveterans (1). However, veterans ages 18–24 and 25–34 had higher unemployment rates than did similarly aged ci- vilian counterparts (20.4% versus 9.9% and 15% versus 8.2%, respectively) (1). This discrepancy is concerning, consider- ing younger veterans’ longer-term work trajectories and el- evated risk of developing a mental or substance use disorder as a result of their deployments, which might negatively affect current work status and longer-term employment outcomes (2–4). Military deployments have been found to be an independent risk factor contributing to the development of mental health and substance use conditions that impair social functioning and community reintegration of service members (4–10).

Psychiatric symptom severity and substance use are commonly associated with poor work outcomes (11–13). Users of U.S. Department of Veterans Affairs (VA) services who were diagnosed as having major depressive disorder,

posttraumatic stress disorder (PTSD), and generalized anx- iety or panic disorder reported diminished work role func- tioning (14). Similarly, lower rates of employment have been found among VA service users with diagnosed major de- pressive disorder (15), PTSD (15,16), or substance use dis- orders. Furthermore, unemployed VA service users were twice as likely as employed veterans to have a substance use disorder (15). There have been fewer studies regarding these associations in nonclinical samples of National Guard (NG) service members reentering the civilian workforce, although Erbes and colleagues (2) found in a general sample of NG members that those meeting criteria for PTSD, depression, or an alcohol use disorder had diminished work role func- tion. In their combined sample, only the Beck Depression Inventory–Second Edition was predictive of work role functioning, whereas groups with and without psychiatric disorders differed on employment status.

Several sociodemographic factors have been linked to veteran employment, such as age (17,18), rank, education, and socioeconomic status (17). One study found lower

1318 ps.psychiatryonline.org Psychiatric Services 66:12, December 2015

ARTICLES

employment among veterans discharged before the end of their service contract, followed by those who completed their service contacts; military retirees were found to have the highest rates of employment (18).

Most, although not all (2), employment research in- volving veterans and military service members has primarily focused on employment status rather than on work func- tioning; however, current employment status provides only a cursory understanding of the employment experiences within these groups. Diminished work performance, low job satisfaction, and elevated psychiatric symptoms are likely to negatively influence job retention, promotion, or future job seeking. Considerable literature supports the relationship between work outcomes (including absenteeism, pre- senteeism, productivity, and mental and interpersonal demands) and mental health problems (2,11–13). This is the only study that has assessed self-rated work performance and satisfaction in a general NG sample returning from an overseas military deployment.

Unlike active-duty service members, NG service mem- bers are commonly faced with employment issues immedi- ately after deployments, a scenario that has been shown to increase stress and risk of readjustment issues (16,19). Our study examined work outcomes in a large sample of Midwestern NG members approximately six months after their overseas deployments. We examined predictors of employment status and self-rated work performance and work satisfaction. On the basis of results from prior studies, we hypothesized that age, rank, and education would predict current employment and that combat experience, mental health symptoms, and hazardous alcohol use would predict lower self-rated work performance and satisfaction.

METHODS

The VA Ann Arbor Institutional Review Board approved this study with survey data collected under a waiver of written informed consent.

Data Data were collected from service members of a Midwestern NG organization between August 2010 and July 2013, ap- proximately six months after their return from overseas deployments (Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn). Service members were recruited in person during monthly drill, by mail, or by both methods. For in-person recruitment, a study team member visited the unit during a scheduled drill weekend and briefed service members on the details of the study, emphasizing the voluntary and confidential nature of the survey. Team members distributed the survey packets and remained on site to collect completed surveys, allowing them to be completed during nonscheduled events. Surveys were mailed to soldiers who did not complete surveys during drill weekends. We used the modified Dillman (20) method for survey research, which entailed sending presurvey

notification letters, followed by the survey packets. Follow- up surveys were sent two additional times to non- respondents, followed by thank you/reminder letters, another round of survey packets mailed three weeks after, and one more round mailed seven weeks after the initial survey mailings. A total of 1,475 surveys were returned (55% response rate), 1,020 in person and 455 by mail.

Measures The outcomes of interest were employment status, work performance, and work satisfaction; the latter two items were self-reported. Employment status was determined from survey items that queried about participants’ current work situation with the following response options: home- maker, student, maternity or paternity leave, sick leave, disability, working full-time, working part-time, unemployed— looking for work, unemployed—not looking for work, re- tired, or other. Categories of employed versus unemployed were based on BLS definitions for identifying employed versus unemployed persons. The BLS considers people who report having jobs as being employed, people who report being jobless, seeking jobs, and available for work to be unemployed, and people who report being neither employed nor unemployed as not in the labor force (1). Because of the heterogeneity (for example, homemakers, retirees, and people with disabilities) and low percentage of participants in the sample who identified as not in the labor force (14%), we decided to remove this category from analyses. Of note, 216 (61%) of the 355 NG participants who identified as stu- dents also checked another option for employment, with 136 (38%) reporting full- or part-time work and 80 (23%) indicating that they were seeking work, whereas 139 (39%) did not mark additional work categories and were considered out of the workforce.

Work performance was assessed with a question from the Health and Performance Questionnaire that asked respondents to rate their job or school performance over the past four weeks (21). Work satisfaction was assessed with the following item developed for the study: “How would you rate your job/school satisfaction in the past 4 weeks?” Both questions were rated on an 11-point scale, with lower ratings reflecting diminished performance and satisfaction.

Independent variables included age, gender, education, income, rank, marital status, and whether individuals had a child at home. Additional measures include barriers to care, combat exposure, psychiatric symptoms, alcohol use, general medical health, and perceived social resources.

The Hoge adaptation of the Perceived Stigma and Bar- riers to Care for Psychological Problems was used to assess barriers to care, because not receiving care when needed may negatively affect employment outcomes (22–24). The scale consists of 16 items measured on a 5-point Likert scale (1, strongly disagree; 5, strongly agree) that address concerns about seeking mental health care, with Cronbach’s alpha ranging between .75 and .95 (25).

Psychiatric Services 66:12, December 2015 ps.psychiatryonline.org 1319

NELSON ET AL.

Respondents’ perception of social resources was measured with the 12-Item Interpersonal Support Evaluation List (ISEL-12) (26), which assesses perceptions about the availability of social resources. It contains three subscales measuring perceived availability of material aid, emotional support, and socially shared activities, as well as a total score

that provides an estimate of overall support. Items are rated on a 4-point scale ranging from “definitely true” (3) to “definitely false” (0). The ISEL-12 has excellent internal con- sistency (a=.88–.90), as well as convergent and predictive validity (26).

Items taken from the Postdeployment Health Assessment (PDHA) were used to assess combat exposure (27). The PDHA is a two-part comprehensive health screen re- quired for soldiers deployed in support of any contingency operation outside the continen- tal United States for longer than 30 days. This screen was designed to proactively identify health concerns and provide referrals for follow-up treatment for deployment-related health issues. Combat exposure items inquire about injuries sustained during deployment, engagement in direct combat, discharge of weapons, and subjective feelings of danger. Endorsement of any of these items for “any or most recent” deployments were used to de- termine combat exposure for this study.

The PTSD Checklist–Military version (PCL-M) (28) was used to assess symptoms of PTSD. The PCL-M is a self-report measure that screens 17 DSM-IV symptoms of PTSD and asks respondents to rate, using a 5-point scale (1, not at all; 5, extremely), the degree to which they were “bothered” by specified military experiences. Scores above 50 repre- sent a positive screen for PTSD in military samples. The PCL-M has shown excellent internal consistency in use with Vietnam and Persian Gulf veterans (r=.94–.97) (29).

The seven-item Generalized Anxiety Dis- order scale (GAD-7) was used to measure symptoms of anxiety (30), with scores rang- ing from 0 to 21 and “cut scores” for mild, moderate, and severe anxiety. Scores above 10 were used as a positive screen on the GAD-7. The scale has demonstrated good psycho- metric properties, good operating character- istics for detection and severity ratings of panic and social anxiety disorders (31).

The nine-item Patient Health Question- naire (PHQ-9) (32) was used to assess symptoms of depression. Total scores range from 0 to 27, with higher scores suggestive of increased psychopathology and lower func-

tioning. Scores above 10 were used as a positive screen on the PHQ-9. A meta-analysis found pooled sensitivity of 80% and specificity of 92% (33), and the PHQ-9 has demon- strated good internal consistency and convergent validity with the Center for Epidemiologic Studies Depression Scale (34).

TABLE 1. Sample characteristics of 1,151 returning National Guard service members

Characteristic

Employed (N=839)

Unemployed (N=312)

N % N %

Gender Male 787 94 281 90 Female 52 6 31 10

Age 18–30 354 42 198 63 31–40 233 28 68 22 $41 252 30 46 15

Marital status Yes 570 68 167 54 No 269 32 145 46

Children in home Yes 436 52 123 39 No 403 48 189 61

Service rank Enlisted (E1–E4) 271 32 189 61 Noncommissioned officer 421 50 106 34 Officer (commissioned and warrant) 147 18 17 5

Combat exposure Yes 625 74 223 71 No 214 26 89 29

Any barrier to care Yes 386 46 150 48 No 453 54 162 52

Education Diploma or GED 204 24 107 34 Some college 635 76 205 66

Income ,$25,000 112 13 165 53 $25,001–$50,000 306 36 101 32 .$50,000 412 49 46 15

Hazardous alcohol use Yes 378 45 179 57 No 461 55 133 43

Meets criterion for PTSD Yes 118 14 47 15 No 721 86 265 85

Meets criterion for depression Yes 142 17 74 24 No 697 83 238 76

Meets criterion for anxiety ($10) Yes 110 13 65 21 No 729 87 247 79

12-item Short-Form PCS (M6SD)a 51.168.6 50.668.8 ISEL-12 overall score (M6SD)b 27.167.1 26.267.2

a PCS, physical component score, standardized to a mean of 50, with scores .50 indicating better health

b 12-Item Interpersonal Support Evaluation List. Possible scores range from 0 to 36, with higher scores indicating greater perceived social support.

1320 ps.psychiatryonline.org Psychiatric Services 66:12, December 2015

CIVILIAN EMPLOYMENT, WORK SATISFACTION, AND PERFORMANCE OF NATIONAL GUARD MEMBERS

The Alcohol Use Dis- orders Identification Test (AUDIT) (35) indexes aver- age alcohol consumption and binge drinking over the past three months, with higher scores reflecting in- creased problematic alco- hol use. The Alcohol Use Disorders Identification Test– Consumption Questionnaire (AUDIT-C) uses the first three items from the AUDIT and was used in this study to assess risk of problematic drinking. Hazardous alcohol use was determined with score cutoffs of 3 for women and 4 for men. A recent re- view supports the psycho- metric properties of the AUDIT-C for identifying haz- ardous alcohol use at these cutoffs (36).

The physical health com- ponent subscale (PCS) of the 12-Item Short Form (SF-12) (37) was used to measure physical functioning. This six-item component of the SF-12 provides a summary of physical functioning over the past four weeks (37). Items assess participants’ opinion of their general medical health and the extent to which it limits their day-to-day activities. PCS scores are standardized with a mean6SD of 50610, with higher scores indicative of better health. The reliability and validity of the SF-12 in general and clinical populations have been well docu- mented (37).

Statistical Analysis Descriptive statistics were used to summarize sample char- acteristics. Unadjusted predictors were assessed in bivariate analyses on the primary outcomes, with t tests used for continuous variables and chi square used for dichotomous variables. We included demographic characteristics and significant bivariate predictors into the adjusted multivariate models. Multivariable logistic regression was used to assess the effects of these variables on employment status by cal- culating odds ratios with 95% confidence intervals. For employed NG participants, predictors of self-rated work performance and satisfaction were determined with multi- ple linear regressions. Significant bivariate predictors were included in each adjusted model. Age, gender, service rank, and level of education were included as predictors in all adjusted analyses. Psychiatric symptom load was created to

examine the impact of one, two, or three positive psychiatric symptom screens (on the PHQ-9, GAD-7, and PCL-M) on outcome variables. Psychiatric symptoms were used as categorical variables (positive or negative screen) for all analyses. All analyses were conducted with SAS statistical software.

RESULTS

The study sample consisted of 1,151 NG members, of whom 839 (73%) reported being employed and 312 (27%) reported being unemployed. The sample composition was 84% (N=967) Caucasian, 6% (N=64) African American, 4% (N=45) Hispanic, 3% (N=31) multiethnic, and 2% (N=27) “other.” Most of our sample (74%, N=848) reported combat experi- ence (Table 1).

Multivariable logistic regression was used to predict employment status among NG respondents. In bivariate analyses, factors associated with increased odds of being employed were higher age, education, rank, and income. Being male, being in a committed relationship, having a child at home, and reporting greater perceived social resources contributed to greater odds of being employed, whereas hazardous alcohol use and positive screens for depression and anxiety reduced odds of being employed (Table 2). The

TABLE 2. Multivariable logistic regression analyses of potential predictors of employment status for 1,151 returning National Guard service members

Predictor Unadjusted Adjusted

OR 95% CI OR 95% CI

Age (reference: 18–30) 31–40 1.92** 1.39–2.64 .91 .60–1.38 $41 3.06** 2.14–4.39 .91 .56–1.46

Gender (reference: female) 1.67* 1.05–2.66 1.56 .92–2.66 Some college education (reference: high school or GED)

1.63** 1.23–2.15 .95 .68–1.31

Rank (reference: junior enlisted) Noncommissioned officer 2.77** 2.08–3.68 1.51* 1.04–2.18 Commissioned or warrant officer 6.03** 3.53–10.30 1.91* 1.01–3.61

Income (reference: ,$25,000) $25,000–$50,000 4.13** 2.99–5.72 3.75** 2.68–5.26 .$50,000 12.21** 8.32–17.94 9.18** 5.77–14.58

In committed relationship (reference: no) 1.84** 1.41–2.40 1.01 .72–1.41 Child in home (reference: no) 1.66** 1.28–2.17 1.02 .73–1.44 ISEL-12 overalla 1.02* 1.00–1.04 1.02 .99–1.04 Hazardous alcohol use (reference: no) .61** .47–.79 .73* .54–.98 PHQ-9 score $10 (reference: ,10)b .66** .48–.90 — — GAD-7 score $10 (reference: ,10)c .57** .57–1.07 — — PCL-M score $50 (reference: ,50)d .92 .64–1.33 — — Psychiatric symptom counte

1 — — 1.16 .69–1.92 2 — — .78 .44–1.38 3 — — .88 .52–1.50

a 12-Item Interpersonal Support Evaluation List b 9-item Patient Health Questionnaire for assessing depression c 7-item Generalized Anxiety Disorder scale d PTSD Checklist–Military version e Count of positive screens among the following three symptom measures: PHQ-9 (score $10), GAD-7 (score $10), or PCL-M (score $50)

* p,.05, **p,.01

Psychiatric Services 66:12, December 2015 ps.psychiatryonline.org 1321

NELSON ET AL.

adjusted model revealed that higher rank and income increased odds of employment, whereas hazardous al- cohol use reduced odds of being employed (Table 2), classifying 77% cases correctly. Likelihood of employ- ment increased for noncommissioned officers (ad- justed odds ratio [AOR]=1.51) and commissioned officers (AOR=1.91), relative to enlisted respondents, but de- creased for respondents reporting hazardous alcohol use (AOR=.73).

For employed NG respondents (N=787), bivariate analyses revealed that self-rated work performance was inversely related to age, rank, combat experience, psy- chiatric symptom severity, hazardous alcohol use, and barriers to care and positively associated with physical functioning and perceived social resources. Adjusted analysis revealed an inverse relationship between self- rated work performance and psychiatric symptom load (two or more positive psychiatric symptom screens), and greater physical functioning and greater perceived social resources were associated with better work performance (R2=.19, F=16.19, df=11 and 775, p,.001) (Table 3).

Multiple linear regressions were used to investigate predictors of self-rated work sat- isfaction among employed NG respondents (N=786). Bivariate analyses found that ratings of work satisfaction were inversely related to age, rank, combat experience, psychiatric symptom severity, alcohol use, and barriers to care and were positively associated with physical functioning and perceived social resources. Adjusted analyses revealed inverse associations between self-rated work satis- faction and rank, hazardous alcohol use, barriers to care, and psychiatric symptom load. In addition, the variable for perceived social resources was associated with greater self-rated work satisfaction (R2=.16, F=11.34, df=13 and 772, p,.001) (Table 4).

DISCUSSION

To our knowledge, this is the largest study to investigate predictors of employment-based outcomes in a general sample of NG mem- bers six months after returning from a de- ployment. Consistent with previous studies (17,18) and national reports (1), we found el- evated rates of unemployment among junior- ranking enlisted service members, who made up approximately two-thirds (61%) of the unemployed respondents. General rates of employment in military and veteran samples are influenced by multiple factors (such as populations sampled, economic factors, and time frame), and we found lower rates than found in some studies (2,17,18) but not

others (14,38). Consistent with previous studies, we did not find an effect

of psychiatric symptoms on employment status (2,18), al- though Horton and colleagues (18) found that veterans screening positive for depression or anxiety, who were routinely retired from the military, were more likely to be unemployed. These studies used nonclinical samples from active-duty, NG, and Reserve forces (2). NG members have been shown to experience significant increases in mental health symptoms between three and 12 months after a combat deployment (9). As such, NG and Reserve service members may not initially experience difficulty returning to civilian employment but may struggle to stay employed as a result of absenteeism and presenteeism as symptoms in- crease. This was not supported in a study by Erbes and colleagues (2) that examined employment status one year postdeployment.

Greater psychiatric symptom load was associated with lower self-ratings of work performance and satisfaction in this study, which is consistent with other research showing reduced work functioning among individuals with more

TABLE 3. Multiple linear regression analyses of potential predictors of work performance among 787 employed National Guard members postdeploymenta

Predictor

Unadjusted Adjusted

B SE B SE

Age 31–40 –.31* .13 –.17 .14 $41 –.30* .13 –.12 .15

Male –.01 .23 .15 .21 Some college education –.14 .13 — — Rank Noncommissioned officer –.37** .12 –.21 .14 Commissioned or warrant officer –.28 .16 –.26 .17

Income $25,000–$50,000 –.01 .17 — — .$50,000 –.10 .17 — —

In committed relationship –.15 .12 — — Child in home –.06 .11 — — Any perceived barrier to care –.58** .11 –.16 .11 Combat exposure –.29* .13 .09 .12 ISEL-12 overallb .07** .01 .04** .01 Hazardous alcohol use –.31** .11 –.07 .10 12-item Short-Form physical component .03** .01 .03* .01 PHQ-9 score $10c –1.46** .14 — — GAD-7 score $10d –1.39** .15 — — PCL-M score $50e –1.28** .14 — — Psychiatric symptom countf

1 — — –.23 .18 2 — — –1.05** .23 3 — — –1.29** .21

a Complete data were available for 787 of 839 employed. b 12-Item Interpersonal Support Evaluation List c 9-item Patient Health Questionnaire for assessing depression d 7-item Generalized Anxiety Disorder scale e PTSD Checklist–Military version f Count of positive screens among the following three symptom measures: PHQ-9 (score $10), GAD-7 (score $10), or PCL-M (score $50)

* p,.05, **p,.01

1322 ps.psychiatryonline.org Psychiatric Services 66:12, December 2015

CIVILIAN EMPLOYMENT, WORK SATISFACTION, AND PERFORMANCE OF NATIONAL GUARD MEMBERS

severe psychiatric symptoms (2,13,14). Di- minished perceived work performance and satisfaction coupled with elevated psy- chiatric symptoms likely exert a negative influence on job retention, promotion, or future employment seeking. This is con- cerning for NG members who do not re- ceive VA services and for those who are eligible for but are not aware of, or are not able to access, VA vocational services. Vet- eran recognition of vocational need repre- sents the largest delay in service entry, with many participating in mental health or substance abuse treatment programs to address their vocational needs (39). This finding highlights the need to screen for vocational needs and to increase access to vocational services for veterans prior to developing mental and substance-related issues.

Hazardous alcohol use was high in our sample (48%) and had a negative effect on employment status. Despite a clear link be- tween substance use disorders and poor em- ployment outcomes, alcohol use had not previously been associated with employ- ment status (2,18) but has been shown to negatively affect work satisfaction. Di- minished work satisfaction, coupled with reintegration stressors, may reduce job re- tention among employed NG members over time. This finding is consistent with studies reporting poor postdeployment readjust- ment after rapid return to work (16,19).

Our results also underscore the value of perceived social resources and physical functioning on work outcomes among employed respondents. These findings are consistent with research showing that di- minished physical functioning is associated with work functioning (12,14,40,41). Burnett-Zeigler and colleagues (17) found that although physical functioning was not a predictor of employment status, it was predictive of whether someone was employed full-time. The link be- tween physical functioning and work performance is in- tuitive, considering that soldiers returning home injured will likely experience difficulties performing their civilian jobs.

There were several limitations to this study. The response rate was only 55%, and we were unable to assess differences between study respondents and nonrespondents. How- ever, this response rate is typical of surveys of NG per- sonnel (9,17), and our sample was fairly consistent with the NG demographic characteristics overall (42). Another limitation involved our two self-rated outcome variables (work performance and work satisfaction). Subjective in- dices are influenced by a variety of transient factors, such as

mood, personality, and response set. Stability of these indices and their effects has yet to be determined and requires replication to support our findings. In addition, the psychi- atric symptom measures that made up our composite vari- able of psychiatric symptom load are likely influenced by worry and rumination, which may be elevated among service members reintegrating with civilian roles. Future studies are needed to elucidate the effects of psychiatric symptom load on work outcomes in this population.

CONCLUSIONS

Our findings underscore the importance of assessing alcohol use among unemployed NG members and of aligning treat- ment options that can facilitate awareness of vocational needs while addressing hazardous alcohol use. For employed service members reporting work-related difficul- ties or low satisfaction with their current employment, VA service providers should also consider the assessment of and interventions targeting physical functioning and psychiatric symptom load. Within the VA, many of the symptom screens

TABLE 4. Multiple linear regression analyses of potential predictors of work satisfaction among 786 employed National Guard members postdeploymenta

Predictor

Unadjusted Adjusted

B SE B SE

Age 31–40 –.42* .20 –.32 .21 $41 –.42* .19 –.32 .22

Male –.04 .34 –.21 .30 Some college education –.36† .19 — — Rank Noncommissioned officer –.35† .19 –.09 .21 Commissioned or warrant officer –.70** .24 –.56* .26

Income $25,000–$50,000 –.03 .25 — — .$50,000 –.16 .25 — —

In committed relationship –.13 .17 — — Child in home –.11 .16 — — Any perceived barrier to care –.96** .16 –.40* .16 Combat exposure –.38* .18 .09 .18 ISEL-12 overallb .09** .01 .06** .01 Hazardous alcohol use –.73** .16 –.56** .16 12-item Short-Form physical component .02* .01 .00 .01 PHQ-9 score $10c –1.83** .21 — — GAD-7 score $10d –1.47** .23 — — PCL-M score $50e –1.60** .23 — — Psychiatric symptom countf

1 — — –.39 .27 2 — — –.76* .34 3 — — –1.60** .31

a Complete data were available for 786 of 839 employed. b 12-Item Interpersonal Support Evaluation List c 9-item Patient Health Questionnaire for assessing depression d 7-item Generalized Anxiety Disorder scale e PTSD Checklist–Military version f Count of positive screens among the following three symptom measures: PHQ-9 (score $10), GAD-7 (score $10), or PCL-M (score $50)

* p,.05, **p,.01 † p,.10, marginal effect

Psychiatric Services 66:12, December 2015 ps.psychiatryonline.org 1323

NELSON ET AL.

used in this study to determine psychiatric symptom load are already in use and could be used to prompt a screen to assess for vocational need. Furthermore, early engagement in mental health care may play an important role in increasing work performance and satisfaction, and subsequently in improving long-term employment outcomes. Future studies are needed to clarify the causal links between these pre- dictors and employment outcomes.

AUTHOR AND ARTICLE INFORMATION

Dr. Nelson is with the Division of Mental Health Services, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan. He is also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: [email protected]), where Dr. Zivin and Dr. Valenstein are affiliated. Dr. Zivin and Dr. Valenstein are also with the Center for Clinical Management Research, U.S. Department of Veterans Affairs, Ann Arbor, where Ms. Walters and Ms. Ganoczy are affiliated. Dr. MacDermid Wadsworth is with the Center for Families and the Military Family Research Institute, Purdue University, West Lafayette, Indiana.

This study was funded by grants RRP 09-420 and SDP 10-047 from the Department of Veterans Affairs Health Services Research and Devel- opment Service.

The authors report no financial relationships with commercial interests.

Received July 28, 2014; revisions received January 31 and March 27, 2015; accepted April 13, 2015; published online August 17, 2015.

REFERENCES 1. Employment Situation of Veterans—2012. Washington, DC, Bureau

of Labor Statistics, US Department of Labor, 2013 2. Erbes CR, Kaler ME, Schult T, et al: Mental health diagnosis and

occupational functioning in National Guard/Reserve veterans returning from Iraq. Journal of Rehabilitation Research and De- velopment 48:1159–1170, 2011

3. Gorman LA, Blow AJ, Ames BD, et al: National Guard families after combat: mental health, use of mental health services, and perceived treatment barriers. Psychiatric Services 62:28–34, 2011

4. Blow AJ, Gorman L, Ganoczy D, et al: Hazardous drinking and family functioning in National Guard veterans and spouses post- deployment. Journal of Family Psychology 27:303–313, 2013

5. Burnett-Zeigler I, Ilgen M, Valenstein M, et al: Prevalence and correlates of alcohol misuse among returning Afghanistan and Iraq veterans. Addictive Behaviors 36:801–806, 2011

6. Eisen SV, Schultz MR, Vogt D, et al: Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan. American Journal of Public Health 102 (suppl 1):S66–S73, 2012

7. Sayer NA, Noorbaloochi S, Frazier P, et al: Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatric Services 61:589–597, 2010

8. Shen YC, Arkes J, Williams TV: Effects of Iraq/Afghanistan deployments on major depression and substance use disorder: analysis of active duty personnel in the US military. American Journal of Public Health 102(suppl 1):S80–S87, 2012

9. Thomas JL, Wilk JE, Riviere LA, et al: Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry 67:614–623, 2010

10. Vasterling JJ, Proctor SP, Friedman MJ, et al: PTSD symptom increases in Iraq-deployed soldiers: comparison with nondeployed soldiers and associations with baseline symptoms, deployment experiences, and postdeployment stress. Journal of Traumatic Stress 23:41–51, 2010

11. Cohen SI, Suri P, Amick MM, et al: Clinical and demographic factors associated with employment status in US military veterans returning from Iraq and Afghanistan. Work 44:213–219, 2013

12. Lagerveld SE, Bültmann U, Franche RL, et al: Factors associated with work participation and work functioning in depressed workers: a systematic review. Journal of Occupational Rehabilitation 20: 275–292, 2010

13. Lerner D, Henke RM: What does research tell us about depression, job performance, and work productivity? Journal of Occupational and Environmental Medicine 50:401–410, 2008

14. Adler DA, Possemato K, Mavandadi S, et al: Psychiatric status and work performance of veterans of Operations Enduring Freedom and Iraqi Freedom. Psychiatric Services 62:39–46, 2011

15. Zivin K, Bohnert ASB, Mezuk B, et al: Employment status of patients in the VA health system: implications for mental health services. Psychiatric Services 62:35–38, 2011

16. Interian A, Kline A, Callahan L, et al: Readjustment stressors and early mental health treatment seeking by returning National Guard soldiers with PTSD. Psychiatric Services 63:855–861, 2012

17. Burnett-Zeigler I, Valenstein M, Ilgen M, et al: Civilian employ- ment among recently returning Afghanistan and Iraq National Guard veterans. Military Medicine 176:639–646, 2011

18. Horton JL, Jacobson IG, Wong CA, et al: The impact of prior de- ployment experience on civilian employment after military service. Occupational and Environmental Medicine 70:408–417, 2013

19. Yan GW, McAndrew L, D’Andrea EA, et al: Self-reported stressors of National Guard women veterans before and after deployment: the relevance of interpersonal relationships. Journal of General Internal Medicine 28(suppl):2549–2555, 2013

20. Dillman DA: Mail and Telephone Surveys: The Total Design Method. New York, Wiley, 1978

21. Kessler RC, Barber C, Beck A, et al: The World Health Organization Health and Work Performance Questionnaire (HPQ). Journal of Occupational and Environmental Medicine 45:156–174, 2003

22. Hoge CW, Castro CA, Messer SC, et al: Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351:13–22, 2004

23. Kehle SM, Polusny MA, Murdoch M, et al: Early mental health treatment-seeking among US National Guard soldiers deployed to Iraq. Journal of Traumatic Stress 23:33–40, 2010

24. Wright KM, Cabrera OA, Bliese PD, et al: Stigma and barriers to care in soldiers postcombat. Psychological Services 6:108, 2009

25. Valenstein M, Gorman L, Blow AJ, et al: Reported barriers to mental health care in three samples of US Army National Guard soldiers at three time points. Journal of Traumatic Stress 27: 406–414, 2014

26. Cohen S, Mermelstein R, Kamarck T, et al: Measuring the func- tional components of social support. Social Support: Theory, Re- search and Applications 24:73–94, 1985

27. Enhanced Post-deployment Health Assessment Process (DD Form 2796). Washington, DC, Department of Defense

28. Weathers FW, Litz BT, Herman DS, et al: The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. Presented at the annual meeting of the International Society for Traumatic Stress Studies, San Antonio, Tex, Oct 1993

29. Blanchard EB, Jones-Alexander J, Buckley TC, et al: Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy 34:669–673, 1996

30. Spitzer RL, Kroenke K, Williams JB, et al: A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine 166:1092–1097, 2006

31. Löwe B, Decker O, Müller S, et al: Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical Care 46:266–274, 2008

32. Kroenke K, Spitzer RL, Williams JB: The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 16:606–613, 2001

1324 ps.psychiatryonline.org Psychiatric Services 66:12, December 2015

CIVILIAN EMPLOYMENT, WORK SATISFACTION, AND PERFORMANCE OF NATIONAL GUARD MEMBERS

33. Gilbody S, Richards D, Brealey S, et al: Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. Journal of General Internal Medicine 22:1596–1602, 2007

34. Milette K, Hudson M, Baron M, et al: Comparison of the PHQ-9 and CES-D depression scales in systemic sclerosis: internal con- sistency reliability, convergent validity and clinical correlates. Rheumatology 49:789–796, 2010

35. Saunders JB, Aasland OG, Babor TF, et al: Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Col- laborative Project on Early Detection of Persons with Harmful Alcohol Consumption—II. Addiction 88:791–804, 1993

36. Meneses-Gaya CD Zuardi AW, Loureiro SR, et al: Alcohol Use Dis- orders Identification Test (AUDIT): an updated systematic review of psychometric properties. Psychology and Neuroscience 2:83–97, 2009

37. Ware J, Jr, Kosinski M, Keller SD: A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical Care 34:220–233, 1996

38. Naragon-Gainey K, Hoerster KD, Malte CA, et al: Distress symptoms and high-risk behaviors prospectively associated with treatment use among returning veterans. Psychiatric Services 63:942–944, 2012

39. Drebing CE, Mueller L, Van Ormer EA, et al: Pathways to voca- tional services: factors affecting entry by veterans enrolled in Veterans Health Administration mental health services. Psycho- logical Services 9:49–63, 2012

40. Geuskens GA, Hazes JM, Barendregt PJ, et al: Predictors of sick leave and reduced productivity at work among persons with early inflammatory joint conditions. Scandinavian Journal of Work, Environment and Health 34:420–429, 2008

41. Zonneveld LN, Sprangers MA, Kooiman CG, et al: Patients with unexplained physical symptoms have poorer quality of life and higher costs than other patient groups: a cross-sectional study on burden. BMC Health Services Research 13:520, 2013

42. Demographics 2012: Profile of the Military Community. Arlington, Va, Defense Manpower Data Center, 2012

Psychiatric Services 66:12, December 2015 ps.psychiatryonline.org 1325

NELSON ET AL.