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

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?

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.

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).

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

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.

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.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of Defense or the Department of Veterans Affairs.