J Head Trauma Rehabil

Vol. 34, No. 1, pp. 11–20

Copyright 
c 2018 Wolters Kluwer Health, Inc. All rights reserved.

Predictors of Employment Status

in Male and Female Post-9/11 Veterans
Evaluated for Traumatic Brain Injury
Jomana H. Amara, PhD; Kelly L. Stolzmann, MS; Katherine M. Iverson, PhD;
Terri K. Pogoda, PhD

Objectives: The goal of this study was to investigate predictors of employment status in male and female post-
9/11 Veterans evaluated for traumatic brain injury (TBI) in the Veterans Health Administration. Prior research
suggests there are gender differences in psychosocial characteristics among this cohort. Methods: This was a cross-
sectional analysis of post-9/11 Veterans who completed a TBI evaluation between July 2009 and September 2013.
Results: Women had lower prevalence of deployment-related TBI (65.5%) compared with men (75.3%), but the
percentages of those unemployed across the TBI diagnostic categories were similar for men (38%) and women (39%).
Adjusted log-binomial regression found that unemployment was significantly associated with age, education, marital
status, moderate/severe TBI, suspected posttraumatic stress disorder, depression, and drug abuse/dependence, and
neurobehavioral symptom severity for men, whereas for women only more severe affective and cognitive symptoms
were associated with unemployment. Conclusions: Although the unemployment rate was similar across gender,
there was a clearer pattern of demographic and health factors, including TBI severity, that was significantly associated
with employment status in men. There may be other factors contributing to the female Veteran unemployment
rate, underscoring the need to investigate unique contributors to unemployment, as well as how treatment and
employment services can be expanded and tailored for post-9/11 Veterans. Key words: gender, depression, employment,
neurobehavioral manifestations, posttraumatic stress disorder, substance use disorder, traumatic brain injury, unemployment,
post-9/11 Veterans

Author Affiliations: Defense Resources Management Institute, Naval

Postgraduate School, Monterey, California (Dr Amara); VA Health
Services Research & Development Service Center for Healthcare
Organization and Implementation Research (Ms Stolzmann and
Dr Pogoda) and Women’s Health Sciences Division of the National Center
for PTSD (Dr Iverson), VA Boston Healthcare System, Massachusetts;
Department of Psychiatry, Boston University School of Medicine,
Massachusetts (Dr Iverson); and Department of Health Law, Policy &
Management, Boston University School of Public Health, Massachusetts
(Dr Pogoda).
This material is based upon work supported in part by the Department of
Veterans Affairs (VA),Veterans Health Administration, Office of Research
and Development Health Services Research and Development (HSR&D)
service’s Investigator Initiated Research Awards #11-078 and #11-358
(Dr Pogoda). Dr Iverson’s contribution was supported by her HSR&D Ca-
reer Development Award (10-029) and a Presidential Early Career Award
for Scientists and Engineers (USA 14-275). Dr Iverson is an investigator
with the Implementation Research Institute (IRI) at the George Warren Brown
School of Social Work, Washington University in St Louis, through an award
from the National Institute of Mental Health (5R25MH08091607) and VA
HSR&D Service, Quality Enhancement Research Initiative. The views ex-
pressed in this article are those of the authors and do not necessarily reflect the
position or policy of the Department of Veterans Affairs, the Department of
Defense, or the US government.
The authors declare no conflicts of interest.
Corresponding Author: Jomana H. Amara, PhD, Defense Resources Man-
agement Institute, Graduate School of Business and Public Policy, Naval
Postgraduate School, 699 Dyer Rd, 205A Halligan Hall, Monterey, CA
93943 (jhamara@nps.edu).
M ORE THAN 2.8 million US service members
who have served in support of Operations En-
during Freedom, Operation Iraqi Freedom, and Opera-
tion New Dawn (OEF/OIF/OND) have separated from
the military and transitioned to civilian life.1 During
these engagements, service members experienced mul-
tiple deployments and deployment-related injuries. Al-
though the majority of post-9/11 Veterans demonstrate
relatively high postdeployment functioning,2 some ex-
perience difficulty with their return to civilian life, in-
cluding poor postdeployment health and functioning.3
One aspect of successful readjustment to civilian life
is gainful employment. However, post-9/11 Veterans
are less likely to be employed than their civilian coun-
terparts and less likely to be employed than Veterans
who served in Gulf War I, other service periods (pri-
marily Korea and Vietnam), and World War II.1,4 There
are multiple benefits of employment, including finan-
cial independence, having a sense of purpose, and gen-
eral well-being.5,6 Therefore, it is important to under-
stand the factors that may contribute to unemployment,
DOI: 10.1097/HTR.0000000000000404

11

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
12 JOURNAL OF HEAD TRAUMA REHABILITATION/JANUARY–FEBRUARY 2019
such as deployment-related physical and psychiatric
conditions.
Traumatic brain injury (TBI), often referred to as a
hallmark injury of post-9/11 service members, is associ-
ated with unemployment in that Veteran population.7
TBI can result in emotional, physical, and cognitive is-
sues, affecting different domains of readjustment.8–13
Since 2000, more than 360 000 US military service mem-
bers were diagnosed with TBI.14 Approximately 82%
of the documented cases are categorized as mild TBI
(mTBI), 12% as moderate/severe TBI, and the remain-
ing diagnoses are penetrating TBI or unclassifiable.15
During the most recent conflicts, women were de-
ployed in unprecedented numbers, and research sug-
gests there are several gender differences in the asso-
ciations between deployment-related TBI and health
conditions.16 For example, compared with men, after
adjusting for injury etiology, women were 2 times more
likely to have a diagnosis of depression, and also re-
ported significantly more severe affective, somatosen-
sory, cognitive, and vestibular symptoms compared with
men.17 Similarly, female service members consistently
reported more health symptoms following mTBI as
compared with male service members.18 These gender
differences in health symptoms following TBI,19 along
with data demonstrating that female post-9/11 women
Veterans are more likely than men to be unemployed,2
highlight the potential utility of examining the associ-
ations between TBI and employment status separately
among male and female Veterans.
There is an influx of US post-9/11 service members
transitioning from the military to civilian society, in-
cluding more than a half million (502 338 in 2015)
women.20 TBI and other conditions are related to phys-
ical and psychological symptoms that can increase risk
for health conditions that negatively impact their post-
deployment psychosocial functioning.3,19,21,22 Given
prior work suggesting gender differences in psychoso-
cial outcomes following TBI among post-9/11 Veter-
ans, this study presents analyses separately for men and
women to identify differences in the associations be-
tween suspected psychiatric conditions and neurobehav-
ioral symptoms with employment status.16,23 As women
have demonstrated greater psychiatric and neurobehav-
ioral burden following deployment-related TBI,17 the
primary goal of this study is to investigate the effect
of deployment-related TBI on employment outcomes
for male and female Veterans and whether unemploy-
ment is associated with greater TBI severity, more po-
tential mental health conditions, and more negative
neurobehavioral health symptoms.7 Physical and psy-
chiatric conditions may result in problems with ob-
taining and maintaining employment, and the con-
tributions of these factors may differ for men and
women.2,3,22
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
METHODS
Design
This was a cross-sectional analysis of post-9/11 Vet-
erans who completed a Veterans Health Administration
(VHA) comprehensive TBI evaluation (CTBIE) between
July 1, 2009, and September 30, 2013. Procedures were
approved by the local Veterans Affairs (VA) human sub-
jects institutional review board.
Data sources
Demographic, military, and health-related data were
provided by the VHA Office of Patient Care Services,
VHA National OEF/OIF/OND Roster, and the Corpo-
rate Data Warehouse. As described in detail elsewhere,
VHA provides standard TBI screening for post-9/11
Veterans.7,24 Those who screen positive are referred to
a CTBIE, which includes a physical examination and
a semistructured clinical interview that documents pa-
tient reports of injury and postinjury sequelae that allow
clinicians to indicate whether the Veteran’s history and
clinical course is consistent with TBI. The Neurobe-
havioral Symptom Inventory (NSI) is used for patient
self-report of current neurobehavioral health symptoms,
and clinicians indicate suspected psychiatric conditions
from a checklist.25
Participants
Among the 86 451 electronic CTBIE entries, dupli-
cate records (n = 311) were eliminated. Additional cases
were removed if TBI severity could not be determined
because of incomplete information on VA/Department
of Defense (DoD) TBI criteria (n = 20 083),24,26 or if
data were missing for gender (n = 72) or employment
status (n = 1647). Because of their low representation,
those who identified their primary employment status
as homemakers (0.64%, n = 410) or volunteers (0.21%,
n = 133) were also excluded. The final sample in-
cluded 63 795 Veterans. We used an algorithm based
on VA/DoD criteria to further categorize deployment-
related TBI history as none, mild, or moderate/severe.26
All TBI history determinations reported here were based
on VHA clinical interviews derived from the CTBIE.
Neurobehavioral Symptom Inventory
As part of the CTBIE, Veterans complete the 22-item
NSI25 in which they report the extent to which they
have been impacted by various symptoms within the
last 30 days on a 0 (none) to 4 (very severe) Likert-type
scale. A factor analysis on the NSI25,27,28 yielded a 4-
factor solution for classifying symptom domains: affec-
tive, cognitive, somatosensory, and vestibular. The CT-
BIE included an additional question about pain, which
 Predictors of Employment for Post-9/11 Veterans
loaded on the somatosensory factor and was included
in that scale.27
Psychiatric and behavioral conditions
Suspected psychiatric conditions listed in the CT-
BIE that clinicians could identify for further assessment
included posttraumatic stress disorder (PTSD), anxi-
ety, depression, alcohol abuse/dependence, and drug
abuse/dependence.
Employment
Self-reported CTBIE employment categories that
were included in the analysis, after excluding home-
maker and volunteer, were employed full-time, em-
ployed part-time, student, unemployed/looking for
work, and unemployed/not looking for work.
Statistical analysis
All analyses were stratified by gender. The primary
analysis used log-binomial regression models to estimate
adjusted prevalence ratios (aPRs) and their associated
95% confidence intervals (CIs) to examine potential
predictors of unemployment: demographics, military
service characteristics, deployment-related TBI history,
suspected psychiatric conditions, and NSI symptom
severity. The latter 2 sets of variables were selected as co-
variates because they are assessed at the time of CTBIE,
and because they are commonly observed conditions
among post-9/11 Veterans29,30 and/or individuals with
TBI.25 All models included a 2-way interaction of TBI
with each of the 5 categories of suspected psychiatric
conditions (not shown), and described any significant
interactions. For each model, the referents were as
follows: “employed full-time” for employment status,
“25-29” for age, “bachelor’s degree or higher” for highest
education level achieved, “mTBI” for deployment-
related TBI history, and each suspected psychiatric
condition that clinicians could identify for further
assessment. Each model had successful convergence.
Demographic, military service, and health factor differ-
ences between employment groups were examined using
χ 2 and analysis of variance for categorical and quanti-
tative data, respectively. Between-group differences for
NSI symptoms were analyzed with multivariate analysis
of variance and post hoc Tukey tests. A threshold of
P < .05 was considered statistically significant. Analyses
were performed with SAS software, version 9.4 (SAS
Institute Inc, Cary, North Carolina, 2013).
RESULTS
Individual and deployment-related characteristics
Of the 63 795 participants in the final sample, 94%
were male. Among them, 42.1% were employed, 19.2%
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
13
were students, 22.8% were unemployed/looking for
work, and 15.9% were unemployed/not looking for
work, resulting in a total of 38.7% unemployment rate
(see Table 1). They had an average age of 34.1 ± 8.3
years.
Among the women in the final sample (6%), 35.2%
were employed, 25.6% were students, 20.3% were un-
employed/looking for work, and 18.9% were unem-
ployed/not looking for work, resulting in a 39.2% un-
employment rate (see Table 2). They had an average age
of 35.2 ± 8.7 years.
As the sample was composed of those who completed
a CTBIE, there was a high rate of deployment-related
TBI history, as well as suspected psychiatric conditions.
The rate of being employed or a student was about
two-thirds among male Veterans with deployment-
related mTBI (61.6%) or no TBI history (63.7%), whereas
it was significantly lower for those with deployment-
related moderate/severe TBI history (51.7%), χ 2 (2) =
92.02, P < .0001. Nearly a quarter (23.2%) of male
Veterans with moderate/severe TBI history were un-
employed/not looking for work, a rate significantly
higher than those with mTBI (15.4%) or no TBI his-
tory (14.7%), χ 2 (2) = 192.48, P < .0001.
Similar to their male counterparts, for females ap-
proximately two-thirds with deployment-related mTBI
(60.4%) or no TBI (64.4%) history were employed or
students, but the rate was significantly lower for those
with moderate/severe TBI history (49.7%), χ 2 (2) = 9.88,
P = .0072.
Univariate associations with employment status
For both male and female Veterans, in bivariate analy-
ses (Tables 1 and 2), employment status was significantly
associated with demographic, deployment, and health
factors. Of note, those with deployment-related moder-
ate/severe TBI history were approximately twice as likely
to be unemployed/not looking for work (males = 12.5%,
females = 12.6%) than employed full-time (males =
6.7%, females = 6.5%). Among males, those who were
unemployed/not looking for work had the highest pro-
portion of suspected PTSD, depression, anxiety, alcohol
abuse/dependence, drug abuse/dependence, and num-
ber of suspected psychiatric conditions relative to the
other employment status groups. Female Veterans ex-
hibited similar associations as their male counterparts,
except for alcohol abuse/dependence. For both males
and females, those who were unemployed/not looking
for work reported higher symptom severity across all 4
NSI domains relative to the other employment status
groups.
Factors associated with employment status
The log-binomial models regressing employment
status on the possible predictors of interest, including
www.headtraumarehab.com
14 JOURNAL OF HEAD TRAUMA REHABILITATION/JANUARY–FEBRUARY 2019

TABLE 1 Post-9/11 male Veteran demographic and health characteristics

Unemployed/ Unemployed/
Working Working looking not looking
Total full-time part-time Student for work for work
(n = 59 988) (n = 21 414) (n = 3809) (n = 11 530) (n = 13 688) (n = 9547)
Age, ya
18-24 4.7 3.1 6.3 6.5 5.9 3.4
25-29 30.6 23.0 35.3 43.8 34.0 25.1
30-39 40.9 42.5 38.4 40.2 40.0 40.6
≥40 23.8 31.4 20.1 9.4 20.1 30.8
Educationa
High school or less 63.3 60.2 63.3 63.3 66.3 66.0
Some post-high school 31.5 32.1 32.3 34.3 29.3 29.5
Bachelor’s degree or 5.2 7.8 4.4 2.4 4.4 4.5
higher
Marital statusa
Single, never married 26.9 20.0 34.9 37.6 29.6 22.5
Married/partnered 50.7 60.9 41.3 41.2 44.5 51.7
Divorced/separated/ 22.4 19.1 23.9 21.2 25.9 25.8
widowed
Duration between military 2.4 ± 2.4 2.9 ± 2.4 2.6 ± 2.3 2.0 ± 2.0 1.9 ± 2.2 2.5 ± 2.5
separation and CTBIE,
mean ± SD, ya,b
Military brancha
Army 71.6 72.1 70.2 64.3 73.2 78.0
Marines 19.1 17.9 21.3 26.5 17.4 14.4
Air force, navy, or coast 9.3 10.0 8.5 9.3 9.4 7.6
guard
Military componenta
Active duty 71.1 59.0 72.3 83.8 76.2 74.8
Reserves/national guard 28.9 41.0 27.7 16.2 23.8 25.2
Deployment-related TBI historya
None 24.7 27.0 25.5 23.2 23.4 22.8
Mild TBI 66.7 66.2 66.3 69.0 67.2 64.7
Moderate/severe TBI 8.6 6.7 8.2 7.8 9.4 12.5
Suspected psychiatric condition
PTSDa 62.2 58.0 61.2 61.0 62.9 72.5
Anxietya 26.1 25.1 25.2 24.8 27.5 28.1
Depressiona 35.9 31.6 35.5 31.0 39.9 46.1
Alcohol abuse/ 7.6 6.2 7.5 6.2 9.6 9.8
dependencea
Drug abuse/dependencea 2.9 1.3 2.3 1.7 4.3 5.9
Number of suspected psychiatric conditionsa
None of the above 19.6 23.4 20.1 21.3 17.4 11.9
One of the above only 41.5 42.6 41.9 44.0 40.3 37.7
Multiple 38.9 34.0 38.0 34.7 42.3 50.4
NSI symptoms, mean ± SD
Affectivea 2.3 ± 1.0 2.1 ± 1.0 2.2 ± 1.0 2.1 ± 1.0 2.4 ± 1.0 2.7 ± 0.9
Cognitivea 2.0 ± 1.1 1.8 ± 1.0 1.9 ± 1.0 1.9 ± 1.1 2.0 ± 1.1 2.4 ± 1.0
Somatosensorya 1.4 ± 0.8 1.3 ± 0.7 1.4 ± 0.7 1.3 ± 0.7 1.5 ± 0.8 1.7 ± 0.8
Vestibulara 1.1 ± 0.9 1.0 ± 0.8 1.1 ± 0.8 1.0 ± 0.8 1.2 ± 0.9 1.5 ± 0.9

Abbreviations: CTBIE, comprehensive TBI evaluation; NSI, Neurobehavioral Symptom Inventory; PTSD, posttraumatic stress disorder;
SD, standard deviation; TBI, traumatic brain injury.
a P ≤ .0001.
b Military separation and CTBIE dates were available for 62% (n = 37 169) of males.

demographics, military service characteristics, time, male Veterans in the other employment status
deployment-related TBI history, and health fac- groups were more likely to be single, never mar-
tors, are shown in Table 3 (males) and Table 4 (females). ried or divorced/separated/widowed, and also more
Relative to male Veterans who were employed full- likely to have completed up to high school or some

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Predictors of Employment for Post-9/11 Veterans 15

TABLE 2 Post-9/11 female Veteran demographic and health characteristics

Unemployed/
Working Working Unemployed/ not looking
Total full-time part-time Student looking for for work
(n = 3807) (n = 1055) (n = 286) (n = 974) work (n = 771) (n = 721)
Age, ya
18-24 3.9 3.6 5.6 5.1 3.9 2.2
25-29 26.4 19.1 33.2 35.9 26.1 21.6
30-39 41.0 40.3 36.4 45.1 41.8 37.6
≥40 28.7 37.1 24.8 13.9 28.3 38.6
Educationa
High school or less 47.8 45.3 48.6 49.6 48.4 48
Some post-high school 41.0 38 42.3 45 39.3 41.2
Bachelor’s degree or higher 11.2 16.7 9.1 5.4 12.3 10.8
Marital status
Single, never married 31.5 31 31.1 32.1 33.5 29.4
Married/partnered 34.8 35.7 35.3 33.8 31.7 37.9
Divorced/separated/ 33.7 33.3 33.6 34.1 34.8 32.7
widowed
Military branchb
Army 76.8 79.4 77.1 74 76.1 77.2
Marines 5.3 3.9 7 8.2 4.9 3.2
Air force, navy, or coast 17.9 16.7 15.9 17.8 19 19.6
guard
Duration between military 2.5 ± 2.4 3.0 ± 2.5 2.7 ± 2.3 2.1 ± 2.1 2.1 ± 2.3 2.8 ± 2.6
separation and CTBIE,
mean ± SD, ya,c
Military componenta
Active duty 64.4 47.7 58.1 76.2 71.5 67.7
Reserves/national guard 35.6 52.3 41.9 23.8 28.5 32.3
Deployment-related TBI historyb
None 34.5 37.4 36.7 35.6 30.1 32.7
Mild TBI 56.4 56 53.8 56.6 59.1 54.6
Moderate/severe TBI 9.1 6.5 9.4 7.8 10.8 12.6
Suspected psychiatric condition
PTSDa 55.0 51.6 48.3 52.4 54.7 66.6
Anxietyd 31.8 29.1 30.4 30.6 33.7 35.9
Depressiona 46.2 40.3 44.8 43.6 46.4 58.4
Alcohol abuse/dependence 4.2 3.3 5.6 3.6 4.9 4.7
Drug abuse/dependencea 1.4 0.5 1.4 0.7 1.7 3.3
Number of suspected psychiatric conditionsa
None of the above 19.2 22.7 25.2 21 17.8 10.7
One of the above only 38.2 41.2 33.9 39.1 39.4 33
Multiple 42.6 36.1 40.9 39.8 42.8 56.3
NSI symptoms, mean ± SD
Affectivea 2.4 ± 1.0 2.3 ± 1.1 2.3 ± 1.1 2.4 ± 1.0 2.5 ± 1.0 2.7 ± 0.9
Cognitivea 2.1 ± 1.1 1.8 ± 1.1 2.0 ± 1.2 2.0 ± 1.1 2.1 ± 1.1 2.5 ± 1.1
Somatosensorya 1.7 ± 0.8 1.5 ± 0.8 1.6 ± 0.8 1.6 ± 0.7 1.7 ± 0.8 1.9 ± 0.8
Vestibulara 1.4 ± 0.9 1.2 ± 0.9 1.3 ± 1.0 1.3 ± 0.9 1.4 ± 0.9 1.6 ± 1.0

Abbreviation: CTBIE, comprehensive TBI evaluation; NSI, Neurobehavioral Symptom Inventory; PTSD, posttraumatic stress disorder;
SD, standard deviation; TBI, traumatic brain injury.
a P ≤ .0001.
b P ≤ .001.
c Military separation and CTBIE completion dates were available for 53% (n = 2005) of females.
d P ≤ .05.

post-high school education. For female Veterans, Employed part-time

employment status was not associated with marital
Male Veterans who were employed part-time were
status.
more likely to be between 18 and 24 years old, but less

www.headtraumarehab.com

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
16 JOURNAL OF HEAD TRAUMA REHABILITATION/JANUARY–FEBRUARY 2019

likely to be 30 years or older. Regarding health condi-
tions, they were more likely to have no TBI history, and
to have a higher likelihood of suspected PTSD, depres-
sion, and for reporting more severe cognitive difficulties.
Female Veterans were less likely to be employed
part-time if they were older than 30 years. There were
no other characteristics that differentiated women who
worked part-time or full-time.
Student
Male Veterans who were students were less likely to
be 30 years or older. They were more likely to have
deployment-related moderate/severe TBI history, sus-
pected PTSD, and to report more severe cognitive dif-
ficulties. However, they had a lower likelihood for sus-
pected alcohol abuse/dependence, and for reporting af-
fective, somatosensory, and vestibular difficulties.
Female Veterans who were students were less likely
to be older than 30 years, and were more likely to have
completed up to high school or some post-high school
education. There were no other characteristics that
differentiated women who were students or employed
full-time.
Unemployed/looking for work
Male Veterans who were unemployed/looking for
work were more likely to be 18 to 24 years old, and
less likely to be older than 30 years. They had a higher
likelihood for deployment-related moderate/severe TBI
history, suspected depression, and for reporting higher
affective and cognitive symptoms. A significant TBI
× suspected drug abuse/dependence interaction found
that, compared with those who were employed full-time,
Veterans who were unemployed/looking for work were

TABLE 3 Log-binomial regression examining likelihood of current employment status

of post-9/11 male Veteransa
Unemployed/ Unemployed/
Employed looking for not looking
part-time aPR Student aPR work aPR for work aPR
Reference: Employed full-time (95% CI) (95% CI) (95% CI) (95% CI)
(n = 18 709) (n = 3351) (n = 10 337) (n = 12 187) (n = 8140)
Age, y (reference: 25-29)
18-24 1.19 (1.06-1.34)b 1.01 (0.96-1.06) 1.09 (1.02-1.15)b 1.00 (0.87-1.16)
30-39 0.72 (0.67-0.78)c 0.76 (0.73-0.78)c 0.82 (0.79-0.85)c 0.94 (0.88-1.00)
≥40 0.65 (0.59-0.72)c 0.41 (0.39-0.44)c 0.73 (0.69-0.77)c 1.03 (0.95-1.11)
Education (reference: bachelor’s degree or higher)
High school or less 1.24 (1.06-1.47)b 1.59 (1.41-1.78)c 1.26 (1.15-1.38)c 1.36 (1.18-1.56)c
Some post-high school 1.36 (1.15-1.60)d 1.81 (1.61-2.03)c 1.22 (1.11-1.34)c 1.31 (1.13-1.51)d
Marital status (reference: married/partnered)
Single, never married 1.91 (1.77-2.06)c 1.40 (1.35-1.44)c 1.35 (1.30-1.40)c 1.25 (1.17-1.34)c
Divorced/separated/widowed 1.57 (1.45-1.7)c 1.22 (1.18-1.27)c 1.32 (1.27-1.37)c 1.21 (1.14-1.29)c
Deployment-related TBI history status (reference: mild TBI)
None 1.17 (1.02-1.33)e 1.01 (0.95-1.07) 1.04 (0.97-1.13) 1.07 (0.92-1.25)
Moderate/severe TBI 1.21 (0.97-1.50) 1.12 (1.02-1.23)e 1.16 (1.04-1.29)b 1.58 (1.31-1.91)c
Suspected psychiatric condition
PTSD 1.10 (1.01-1.19)e 1.06 (1.02-1.10)b 1.02 (0.98-1.06) 1.33 (1.23-1.45)c
Anxiety 0.96 (0.88-1.04) 0.98 (0.94-1.02) 1 .00 (0.96-1.05) 1.02 (0.95-1.09)
Depression 1.10 (1.02-1.19)e 1.01 (0.97-1.04) 1.13 (1.09-1.18)c 1.22 (1.14-1.30)c
Alcohol abuse/dependence 1.03 (0.9-1.18) 0.91 (0.85-0.98)b 1.04 (0.98-1.11) 0.98 (0.9-1.06)
Drug abuse/dependence 1.10 (0.87-1.4) 0.98 (0.86-1.10) 1.28 (1.19-1.37)c 1.44 (1.32-1.57)c
NSI health symptoms
Affective 0.96 (0.91-1.00) 0.96 (0.94-0.98)c 1.06 (1.03-1.08)c 1.10 (1.04-1.15)d
Cognitive 1.12 (1.07-1.17)c 1.09 (1.07-1.11)c 1.06 (1.04-1.09)c 1.21 (1.16-1.26)c
Somatosensory 1.00 (0.94-1.06) 0.97 (0.94-1.00)e 1.01 (0.98-1.05) 1.09 (1.04-1.15)d
Vestibular 1.03 (0.97-1.08) 0.96 (0.94-0.99)b 1.00 (0.98-1.03) 1.08 (1.03-1.12)d

Abbreviations: aPR, adjusted prevalence ratio; CI, confidence interval; NSI, Neurobehavioral Symptom Inventory; PTSD, posttraumatic
stress disorder; TBI, traumatic brain injury.
a Other variables adjusted for in the model were military branch, military component, and injury etiology. Each model included TBI ×

suspected psychiatric condition interactions (not shown).

b P ≤ .01.
c P ≤ .0001.
d P ≤ .001.
e P ≤ .05.

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Predictors of Employment for Post-9/11 Veterans 17

TABLE 4 Log-binomial regression examining likelihood of current employment status

of post-9/11 female Veteransa
Unemployed/ Unemployed/
Employed looking for not looking
part-time aPR Student aPR work aPR for work aPR
Reference: Employed full-time (95% CI) (95% CI) (95% CI) (95% CI)
(n = 875) (n = 224) (n = 824) (n = 630) (n = 580)
Age, y (reference: 25-29)
18-24 0.82 (0.39-1.74) 0.92 (0.63-1.35) 0.98 (0.87-1.09) 0.74 (0.33-1.62)
30-39 0.58 (0.40-0.84)b 0.80 (0.67-0.97)c 1.00 (0.95-1.04) 0.86 (0.64-1.16)
≥40 0.41 (0.26-0.67)d 0.48 (0.36-0.65)e 0.97 (0.92-1.02) 1.04 (0.74-1.44)
Education (reference: bachelor’s degree or higher)
High school or less 1.52 (0.79-2.91) 1.64 (1.09-2.45)c 1.02 (0.96-1.09) 1.22 (0.82-1.81)
Some post-high school 1.53 (0.80-2.93) 1.83 (1.22-2.73)b 1.03 (0.96-1.10) 1.22 (0.83-1.80)
Marital status (reference: married/partnered)
Single, never married 0.85 (0.57-1.28) 1.00 (0.82-1.22) 1.03 (0.99-1.08) 0.95 (0.72-1.26)
Divorced/separated/widowed 1.03 (0.69-1.52) 1.00 (0.82-1.23) 1.03 (0.99-1.08) 0.92 (0.70-1.21)
Deployment-related TBI history status (reference: mild TBI)
None 0.74 (0.40-1.40) 0.96 (0.70-1.32) 0.77 (0.69-0.86)e 0.97 (0.56-1.68)
Moderate/severe TBI 0.87 (0.30-2.56) 1.13 (0.63-2.04) 1.04 (0.93-1.18) 1.53 (0.65-3.60)
Suspected psychiatric condition
PTSD 0.73 (0.47-1.13) 0.90 (0.73-1.11) 0.99 (0.95-1.03) 1.30 (0.93-1.80)
Anxiety 0.66 (0.41-1.07) 0.96 (0.77-1.20) 1.01 (0.97-1.05) 0.96 (0.70-1.31)
Depression 1.02 (0.66-1.56) 1.02 (0.82-1.26) 1 (0.96-1.04) 1.32 (0.98-1.78)
Alcohol abuse/dependence 1.48 (0.68-3.20) 0.89 (0.52-1.51) 0.96 (0.86-1.07) 1.08 (0.56-2.09)
Drug abuse/dependence 3.24 (0.45-23.56) 1.56 (0.36-6.82) 1.05 (0.56-1.97) 2.31 (0.77-6.93)
NSI health symptoms
Affective 0.98 (0.75-1.27) 1.02 (0.89-1.16) 1.04 (1.01-1.07)b 0.99 (0.81-1.21)
Cognitive 1.12 (0.89-1.41) 1.12 (1.00-1.27) 1.02 (0.99-1.04) 1.23 (1.03-1.45)c
Somatosensory 1.13 (0.83-1.54) 0.91 (0.77-1.07) 0.98 (0.95-1.02) 1.05 (0.84-1.31)
Vestibular 0.90 (0.69-1.17) 0.96 (0.84-1.10) 0.99 (0.97-1.02) 1.01 (0.84-1.21)

Abbreviations: aPR, adjusted prevalence ratio; CI, confidence interval; NSI, Neurobehavioral Symptom Inventory; PTSD, posttraumatic
stress disorder; TBI, traumatic brain injury.
a Other variables adjusted for in the model were military branch, military component, and injury etiology. Each model included TBI ×

suspected psychiatric condition interactions (not shown).

b P ≤ .01; c P ≤ .05; d P ≤ .001; e P ≤ .0001.

less likely to have moderate/severe TBI history and sus-
pected drug abuse/dependence (aPR = 0.75; 95% CI =
0.62-0.91).
Female Veterans who were unemployed/looking for
work were less likely to have no TBI history compared
with having deployment-related mTBI history. They
were also more likely to report higher affective symp-
toms. A TBI × suspected depression interaction showed
that, compared with those who were employed full-time,
female Veterans had a higher likelihood of being un-
employed/looking for work if they had suspected de-
pression without TBI history (aPR = 1.15; 95% CI =
1.02-1.30). There were no other characteristics that dif-
ferentiated women who were unemployed/looking for
work or were employed full-time.
Unemployed/not looking for work
Male Veterans who were unemployed/not looking
were more likely to have moderate/severe TBI history,
suspected PTSD and drug abuse/dependence, and to
report higher affective, cognitive, somatosensory, and
vestibular symptoms. Two significant interactions were
detected: TBI × suspected alcohol abuse/dependence
and TBI × suspected drug abuse/dependence. Com-
pared with those who were employed full-time, those
who were unemployed/not looking for work were more
likely to have suspected alcohol (aPR = 1.29; 95% CI =
1.05-1.59) and drug (aPR = 1.28; 95% CI = 1.03-1.60)
abuse/dependence without TBI history.
Female Veterans who were unemployed/not looking
for work were more likely to report increased cognitive
symptom severity.
DISCUSSION
This study examined demographic, military, and
health factors associated with employment status in
male and female post-9/11 Veterans who received a
VHA CTBIE. The Bureau of Labor Statistics defines
www.headtraumarehab.com

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
18 JOURNAL OF HEAD TRAUMA REHABILITATION/JANUARY–FEBRUARY 2019

the unemployment rate as the percentage of people in Veterans who were unemployed/not looking for work.
the labor force who are jobless, looking for a job, and Increased psychological distress likely interferes with
available for work.31 In our sample, 20% to 23% of Veterans’ motivation, confidence, overall functioning,
male and female Veterans were unemployed and actively and ability for sustained employment. Effective mental
looking for work. The Bureau of Labor Statistics reports health treatments may lead to improvements in finding
an unemployment rate of 8.8% among post-9/11 Vet- and maintaining meaningful work.
erans, an 8.6% unemployment rate for Veterans with More than 60% of separated post-9/11 Veterans have
disabilities, an unemployment rate of 7.8% for male used VA healthcare since October 2001.34 Many VA
non-Veterans, and an unemployment rate of 9.6% for medical centers have vocational rehabilitation teams
female non-Veterans, which is significantly lower than that provide a range of employment services.35 As em-
the percentages for the cohort examined in this study.1 ployment status is documented at the time of CTBIE,
Thus, these data provide strong evidence that male and future efforts may consider indications of unemploy-
female post-9/11 Veterans who have undergone evalua- ment as triggers for referral to VA or community-based
tion for TBI in VHA experience particularly high rates of employment services.36,37
unemployment.
The current findings also shed light on common and Limitations
distinct factors that are associated with employment
This study is based on data obtained from Veterans
status among male and female post-9/11 Veterans.
who completed a VHA CTBIE, and results may not
For both men and women, in unadjusted analyses,
represent the experiences of other Post-9/11 Veterans,
deployment-related moderate/severe TBI history was
especially those who are receiving non-VHA healthcare.
significantly associated with unemployment. Nearly
Because data for the time between military separation
half of those with moderate/severe TBI history were
and CTBIE completion were missing for approximately
unemployed, in comparison to about one-third of those
one-third and one-half of the male and female sam-
with mTBI or no TBI history, which is consistent with
ples, respectively, we do not know the extent to which
other literature.7,31,32 Those with deployment-related
this variable affected employment status, while taking
mTBI history generally did not differ from those
into account other factors. For both males and females,
with no TBI history in being unemployed, which is
those who were employed full-time had the longest du-
consistent with other post-9/11 Veteran cohort32 and
ration between these 2 time points; however, this in-
civilian33 findings that did not find a reliable rela-
terval did not differ systematically. For example, for
tionship between mTBI history and unemployment.
males, there was no difference between those who were
However, when taking demographic and health factors
unemployed/not looking for work or employed part-
into account, TBI—specifically deployment-related
time, and for females, it did not differ between those
moderate/severe TBI history—remained significantly
who were employed full-time or unemployed/not look-
associated with unemployment in men only, in addition
ing for work. It is also unknown whether suspected
to age, education, marital status, suspected PTSD, de-
psychiatric conditions were verified through other med-
pression, and drug abuse/dependence, and more severe
ical records or documentation. There are vastly unequal
neurobehavioral symptoms. Being married/partnered
differences in the number of males and females in the
was significantly associated with being employed
study. Consequently, this may result in prevalence ra-
full-time in males only, whereas for females any such
tios of the same or similar magnitude that are statistically
relationship was uniformly absent. For women, only
significant among males but not among females. Future
affective and cognitive symptoms were associated with
studies that include a larger sample size of female Vet-
unemployment after examining other demographic
erans may yield stronger effects, allowing us to draw
and health factors. This suggests that there may be
more confident conclusions about predictors of unem-
unaccounted variables that are affecting employment
ployment in male and female Veterans. Future studies
status in women. This is an important area for future
should examine these factors to understand employ-
research and clinical inquiry, given the relatively high
ment status and other aspects of reintegration among
rates of unemployment observed among this cohort.
male and female Veterans. Finally, this study focused
Approximately 80% of the sample, both male and
on employment status only and future work is needed
female, had at least one suspected psychiatric con-
to more comprehensively examine employment-related
dition. Those who were unemployed/not looking for
outcomes such as occupational functioning, as well as
work had the highest prevalence of multiple psychiatric
work-related quality and satisfaction, as these factors
conditions at 50.4% for males and 56.3% for females.
may be impacted by TBI, psychiatric conditions, and
The most common suspected psychiatric condition was
gender.
PTSD, followed by depression for both male and female

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Predictors of Employment for Post-9/11 Veterans
Public health implications
There are different reasons for why Veterans may be
unemployed and not looking for work, including hav-
ing a disability, being retired, and receiving government
benefits that may deter employment seeking even in
individuals who have the capacity to work.7 The per-
centages of those unemployed across the TBI diagnostic
categories are similar for both male and female Veterans.
However, with female Veterans reporting similar unem-
REFERENCES
1. U.S. Department of Labor Bureau of Labor Statistic. Employment
situation of Veterans news release. https://www.bls.gov/news.
release/archives/vet 03202014.htm. Published 2014. Accessed Au-
gust 8, 2017.
2. Vogt D, Smith BN, Fox AB, Amoroso T, Taverna E, Schnurr PP.
Consequences of PTSD for the work and family quality of life
of female and male U.S. Afghanistan and Iraq War veterans. Soc
Psychiatry Psychiatr Epidemiol. 2017;52(3):341–352.
3. Sayer NA, Noorbaloochi S, Frazier P, Carlson K, Gravely A, Mur-
doch M. Reintegration problems and treatment interests among
Iraq and Afghanistan combat veterans receiving VA medical care.
Psychiatr Serv. 2010;61(6):589–597.
4. Kleykamp M. Unemployment, earnings and enrollment among
post 9/11 veterans. Soc Sci Res. 2013;42(3):836–851.
5. McKee-Ryan F, Song Z, Wanberg CR, Kinicki AJ. Psychological
and physical well-being during unemployment: a meta-analytic
study. J Appl Psychol. 2005;90(1):53–76.
6. Ross CE, Mirowsky J. Does employment affect health? J Health
Soc Behav. 1995;36(3):230–243.
7. Pogoda TK, Stolzmann KL, Iverson KM, et al. Associations be-
tween traumatic brain injury, suspected psychiatric conditions,
and unemployment in Operation Enduring Freedom/Operation
Iraqi Freedom veterans. J Head Trauma Rehabil. 2016;31(3):191–
203.
8. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro
CA. Mild traumatic brain injury in U.S. soldiers returning from
Iraq. N Engl J Med. 2008;358(5):453–463.
9. Lew HL, Otis JD, Tun C, Kerns RD, Clark ME, Cifu DX. Preva-
lence of chronic pain, posttraumatic stress disorder, and persistent
postconcussive symptoms in OIF/OEF veterans: polytrauma clin-
ical triad. J Rehabil Res Dev. 2009;46(6):697–702.
10. Tanielian T, Jaycox LH. Invisible Wounds of War: Psychological and
Cognitive Injuries, Their Consequences, and Services to Assist Recovery.
Santa Monica, CA: RAND Corporation; 2008.
11. Hendricks AM, Amara J, Baker E, et al. Screening for mild trau-
matic brain injury in OEF-OIF deployed US military: an empirical
assessment of VHA’s experience. Brain Inj. 2012;27(2):125–134.
12. Institute of Medicine. Returning Home From Iraq and Afghanistan:
Assessment of Readjustment Needs of Veterans, Service Members, and
Their Families. Washington, DC: The National Academies Press;
2013.
13. Okie S. Traumatic brain injury in the war zone. N Engl J Med.
2005;352(20):2043–2047.
14. Defense and Veterans Brain Injury Center. DoD Worldwide Num-
bers for TBI. http://dvbic.dcoe.mil/dod-worldwide-numbers-tbi.
Published 2017. Accessed August 8, 2017.
15. Defense and Veterans Brain Injury Center. DoD Numbers for
Traumatic Brain Injury Worldwide—Totals. http://dvbic.dcoe.mil
/files/tbi-numbers/DoD-TBI-Worldwide-Totals_2016_Q3_Nov-
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
19
ployment percentages as their male counterparts and
lower prevalence of deployment-related TBI, there may
be other factors contributing to the female Veteran un-
employment rate. These findings therefore underscore
the need to further investigate factors impacting employ-
ment among female Veterans, and the need to under-
stand how treatment and employment services should
be expanded and tailored for women. This would help
fill a critical gap and assist Veterans with their specific
needs for readjusting to civilian life.
10-2016_v1.0_508_2016-12-27.pdf. Published 2016. Accessed
January 6, 2017.
16. Amara J, Iverson KM, Krengel M, Pogoda TK, Hendricks A. An-
ticipating the traumatic brain injury-related health care needs of
women veterans after the Department of Defense change in com-
bat assignment policy. Womens Health Issues. 2014;24(2):e171–176.
17. Iverson KM, Hendricks AM, Kimerling R, et al. Psychiatric di-
agnoses and neurobehavioral symptom severity among OEF/OIF
VA patients with deployment-related traumatic brain injury: a gen-
der comparison. Women Health Issues. 2011;21(4):S210–217.
18. Brickell TA, Lippa SM, French LM, Kennedy JE, Bailie JM, Lange
RT. Female service members and symptom reporting after com-
bat and noncombat-related mild traumatic brain injury. J Neuro-
trauma. 2017;34(2):300–312.
19. Amoroso T, Iverson KM. Acknowledging the risk for traumatic
brain injury in women veterans. J Nerv Ment Dis. 2017;205(4):318–
323.
20. Department of Veterans Affairs. National Center for Veterans Ana-
lysis and Statistics. http://www.va.gov/vetdata/. Published 2015.
Accessed December 25, 2016.
21. Lew HL, Poole JH, Guillory SB, Salerno RM, Leskin G, Sig-
ford B. Persistent problems after traumatic brain injury: the need
for long-term follow-up and coordinated care. J Rehabil Res Dev.
2006;43(2):vii–x.
22. Wilk JE, Thomas JL, McGurk DM, Riviere LA, Castro CA, Hoge
CW. Mild traumatic brain injury (concussion) during combat: lack
of association of blast mechanism with persistent postconcussive
symptoms. J Head Trauma Rehabil. 2010;25(1):9–14.
23. Amara J, Krengel M, Iverson K. Policy implications for Veteran’s
Affairs health care following the Department of Defense change
in combat assignment policy for women: a focus on TBI care.
Women Health Iss. 2014;24(2):174–176.
24. Pogoda TK, Iverson KM, Meterko M, et al. Concordance of clin-
ician judgment of mild traumatic brain injury history with a diag-
nostic standard. J Rehabil Res Dev. 2014;51(3):363–375.
25. Cicerone KD, Kalmar K. Persistent postconcussion syndrome—
the structure of subjective complaints after mild traumatic brain
injury. J Head Trauma Rehab. 1995;10(3):1–17.
26. Department of Veterans Affairs and Department of Defense.
VA/DoD Clinical Practice Guideline for the Management of Concus-
sion/Mild Traumatic Brain Injury. Washington, DC: Department
of Veterans Affairs and Department of Defense; 2016.
27. Meterko M, Baker E, Stolzmann KL, Hendricks AM, Cicerone
KD, Lew HL. Psychometric assessment of the neurobehavioral
symptom inventory-22: the structure of persistent postconcussive
symptoms following deployment-related mild traumatic brain in-
jury among veterans. J Head Trauma Rehabil. 2012;27(1):55–62.
28. Vanderploeg RD, Silva MA, Soble JR, et al. The structure
of postconcussion symptoms on the neurobehavioral symptom
www.headtraumarehab.com
20 JOURNAL OF HEAD TRAUMA REHABILITATION/JANUARY–FEBRUARY 2019
inventory: a comparison of alternative models. J Head Trauma
Rehabil. 2015;30(1):1–11.
29. Carlson KF, Nelson D, Orazem RJ, Nugent S, Cifu DX, Sayer NA.
Psychiatric diagnoses among Iraq and Afghanistan war veterans
screened for deployment-related traumatic brain injury. J Trauma
Stress. 2010;23(1):17–24.
30. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing
the war back home: mental health disorders among 103,788 US
veterans returning from Iraq and Afghanistan seen at Department
of Veterans Affairs facilities. Arch Intern Med. 2007;167(5):476–
482.
31. US Bureau of Labor Statistics. How the Government Measures Un-
employment. Washington, DC: US Department of Labor; 2014:
1–14.
32. Barnes SM, Walter KH, Chard KM. Does a history of mild trau-
matic brain injury increase suicide risk in veterans with PTSD?
Rehabil Psychol. 2012;57(1):18–26.
33. Temkin NR, Corrigan JD, Dikmen SS, Machamer J. Social
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
functioning after traumatic brain injury. J Head Trauma Rehabil.
2009;24(6):460–467.
34. Epidemiology Program; Post-Deployment Health Group; Office
of Patient Care Services; Veterans Health Administration; Depart-
ment of Veterans Affairs. Analysis of VA Health Care Utilization
among Operation Enduring Freedom, Operation Iraqi Freedom, and Op-
eration New Dawn Veterans, from 1st Qtr FY 2002 through 3rd Qtr FY
2015 (October 1, 2001–June 30, 2015). Washington, DC: Washing-
ton, DC; Veterans Health Administration; January 2017.
35. Pogoda TK, Levy CE, Helmick K, Pugh MJ. Health services and
rehabilitation for active duty service members and veterans with
mild TBI. Brain Inj. 2017;31(9):1220–1234.
36. Carlson KF, Pogoda TK, Gilbert T, et al. Supported employment
for veterans with traumatic brain injury: patient perspectives. Arch
Phys Med Rehabil. 2018;99(2S):S4–S13.e1.
37. Pogoda TK, Carlson KF, Gormley KE, Resnick SG. Supported
employment for veterans with traumatic brain injury: provider
perspectives. Arch Phys Med Rehabil. 2018;99(2S):S14–S22.