Quantifying the Contribution of VA Service-Connected Disability Pensions to the “Check Effect”

In a study of 105 veterans with schizophrenia and cocaine abuse at a Department of Veterans Affairs (VA) medical center, Shaner and colleagues (1) demonstrated a cycle of cocaine use and psychiatric hospitalization that coincided with receipt of disability benefits checks at the beginning of each month. They observed monthly peaks and troughs, with almost two-thirds of admissions occurring in the first half of the month. These findings were interpreted as establishing a causal relationship between receipt of public support payments, substance abuse, and utilization of psychiatric services that has been referred to as the “check effect” and may have influenced the federal government's decision to eliminate disability benefits for substance use disorders in 1997.

However, subsequent research suggests that these payments affect recipients' timing of use but not necessarily their overall use of substances or psychiatric services. The Social Security Administration's elimination of disability benefits for individuals with substance use disorders did not affect the number of visits to psychiatric emergency departments by persons in this group (2). Moreover, studies of homeless veterans with serious mental illness and co-occurring substance-related disorders have shown no difference in levels of substance use among those who receive public support payments and those who do not (3) and no increase in substance use after initiation of benefits (4). On the other hand, several studies have confirmed a pattern of increased substance abuse and psychiatric service utilization during the earlier part of the month (5,6).

If this temporal pattern of substance abuse and use of psychiatric services is partly attributable to receipt of disability checks, then such patterns might be mitigated by altering the timing of check disbursement. The VA currently disburses all service-connected disability pension checks at the beginning of each month. However, disbursement of checks to half the recipients at the beginning of the month and to the other half on the 15th might smooth out the peaks and troughs in service use, thereby reducing the need for fixed resources, such as professional staff or psychiatric beds. Previous VA studies that showed a large check effect (1,7) did not attempt to quantify the extent to which the effect was attributable to receipt of a VA pension check or to other financial events that coincide with the beginning of the month, such as receipt of Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), employment checks and rent, utility, and child support payments. These other events might also affect substance abuse and use of psychiatric services (5) but would be unaffected by a change in VA policy. Further, previous studies were limited to small catchment areas and did not assess whether the check effect was concentrated among veterans with serious mental illnesses or those with multiple recent hospitalizations. The study reported here used national VA health system data to examine these issues.