How VA Psychiatry Residents Can Help Veterans Establish Service Connection for Schizophrenia When the First Episode Was After Military Service

Hypothetical Cases

You are a psychiatry resident at a Department of Veterans Affairs (VA) hospital. You treat veterans with schizophrenia who lack service connection for this illness.

A 30-year-old Navy veteran had his first break within 6 months of discharge, which followed a 2-year period of depression and behavioral changes while in service.

A veteran in his 20s with a history of combat-related traumatic brain injury while in the Army developed hallucinations (hearing voices and seeing lights) and delusional thinking (messages from space), within a few years after discharge.

A former Navy submariner in his 30s spent time at sea in the Navy with no mental health history and was hospitalized with symptoms of schizophrenia (disorganization and catatonia) 3 years after discharge.

You wish to pursue service connection for these veterans—that is, you believe they are disabled due to injury or illness that was incurred in, aggravated by, or related to exposures or experiences during military service. However, personnel in the social work department inform you that these veterans do not qualify for service connection because their illness manifested after leaving the service. How can you, as a VA resident psychiatrist, help these veterans obtain service-connected disability benefits?

[Introduction]

It is generally understood that service-connected disabilities correctly entitle veterans to cost-free care for their condition, as well as compensation in the form of tax-free monthly payments up to $3,146.42 (USD) (100% service connection) in 2021 (1). For some veterans with mental illness, this compensation is their only income.

To determine service connection, the VA reviews the patient's federal medical records. Federal facilities include VA hospitals and clinics and military medical records (2). Thus, records from VA providers, including house staff, play a role in determining whether a veteran will receive VA disability benefits.

What Determines Service Connection?

Federal law provides service connection for chronic conditions (including mental illness) when a veteran can prove "inception or aggravation during service" (3). Thus, a veteran who manifests signs of new mental illness or exacerbation of preservice medical conditions will generally qualify for service connection.

The initial manifestation of disease need not be severe to merit service connection. For example, the Board of Veterans' Appeals found service connection in the case of a veteran with type 2 diabetes diagnosed 3–4 years after discharge, due to elevated prediabetic glucose readings ("100–126 mg/dl range") while in the service. The board reasoned that the veteran's mildly elevated in-service glucose levels were "part and parcel of an ongoing disease process that had its genesis in service" (4).

Additionally, the law provides other pathways to service connection. For example, certain chronic illnesses first manifesting within 1 year after discharge can also qualify for service connection (5). The list of chronic conditions for which a veteran can seek service connection includes, among others, diabetes, cardiovascular-renal disease, and "psychoses" (6).

How Residents Can Document Service Connection For Schizophrenia

Applying principles from the prior section to the hypothetical cases above, several avenues to VA service connection appear possible.

Psychosis Developing Within 1 Year After Leaving Military Service

First, a veteran could pursue service connection if his or her schizophrenia developed within 1 year of discharge, as in the first case listed above. Because "psychoses" are explicitly listed, a veteran whose schizophrenia first presented in the 1-year window could qualify for service connection. Residents can ensure that this history is appropriately gathered and documented.

Prodromal Schizophrenia During Military Service

Second, there is a possibility that behavioral changes during service were prodromal to schizophrenia. Based on one current estimate, 75% of persons with schizophrenia go through a prodromal stage, which can include a range of symptoms, such as cognitive deficits, mood changes, and "subtle changes such as social withdrawal" (7). These prodromal symptoms can precede psychosis by months or even years.

The prodrome is to schizophrenia as prediabetes is to diabetes, "part and parcel" of the same psychopathological process. A diligent psychiatry resident could archive this history in VA records (preferably with collateral materials), which are reviewed during the service connection process.

The Genesis of Schizophrenia Using the Stress-Vulnerability Model

The third avenue for establishing service connection, without time limits on symptom onset, involves the stress-vulnerability model. This theory states that schizophrenia manifests when "precipitating factors in the form of stressors act upon a person's inherent predisposition to psychosis in such a way that the person experiences schizophrenia symptoms," as described by Fleming and Martin (8). That is, environmental stressors, such as trauma, act on genetic predisposition, increasing the likelihood of schizophrenia.

Well-known stressors experienced by service members include combat, traumatic injuries, deployments, and military sexual trauma. Less obvious stressors include the transition from childhood to emerging adulthood (for young enlistees), difficult living situations (e.g., tight berthing on a ship or submarine), and the psychological rigor of military service.

In one case, the Board of Veterans' Appeals reviewed the claim of a veteran with schizophrenia who served a few months in the Marine Corps and appeared to have developed schizophrenia after discharge. A psychologist's report noted that schizophrenia "possessed a genetic component coupled with an activating form of severe stress" and opined that it was "very possible, if not probable" that the veteran's short stint of active duty played a role in the development schizophrenia.

As part of its decision, the board directed the VA's reviewers to answer the question: "Is it at least as likely as not … that the veteran's schizophrenia is etiologically related to an incident of his service?" (9). This question shows openness to the stress-vulnerability model as a way to establish service connection for schizophrenia.

In these cases, a treating resident could investigate in-service stressors (including gathering collateral documentation) and highlight them as contributing to development of schizophrenia according to the stress-vulnerability model.

Notably, the burden of proof in service connection cases is "as likely as not," meaning that a documenting provider need not be 100% certain that a stressor contributed to the development of schizophrenia. Other terms, such as "likely," "probably," or "in all likelihood," would also satisfy this standard.

Case Outcomes

The veteran in the first hypothetical case could argue for service connection based on the onset of symptoms within 1 year of discharge and prodromal symptoms in service. The other two veterans could argue under the stress-vulnerability model alone, unless they find evidence of the onset of symptoms during service or in the year immediately after discharge.

Conclusions

Veterans living with schizophrenia that manifests after discharge may have difficulty establishing service connection and obtaining much-needed benefits. VA resident psychiatrists can help veterans by documenting thorough histories and by memorializing the timeline of symptoms (including prodromal ones) and any major stressors (e.g., combat experience, stressful deployments) that may have contributed to the development of schizophrenia under the stress-vulnerability model. Once the psychiatry team has created this record, the veteran and his or her supports (e.g., family, social workers) can be counseled to apply to the VA for benefits. Establishing a service connection can help provide steady income to this vulnerable population, ameliorating a social stressor that further exacerbates illness.

Key Points/Clinical Pearls