The Relationship Between Mental Health and Employment Status Among United States Veterans: A Systematic Review.

Introduction: Post-9/11 U.S. veterans experience disproportionately high rates of mental health conditions. They are also more likely than non-veterans to be unemployed. Many studies have examined potential relationships between those phenomena. We aimed to systematically review this literature.

Materials and methods: Articles published between September 2001 and September 2021 were identified using PubMed, Web of Science, and Google Scholar. These studies were cohort, cross-sectional, mixed methods, or qualitative studies that reported associations between mental health status or diagnoses and employment and were published in English. Primary mental health conditions of interest were post-traumatic stress disorder (PTSD), alcohol use disorder, bipolar disorder, depression, and other mood, psychiatric, or eating disorders. Two authors screened identified articles for inclusion, and disagreements were resolved by a third author.

Results: Twenty-eight articles met inclusion criteria. Three reported PTSD to be positively associated with unemployment, although 7 found null results. Seven of 9 studies examining depression found positive associations between depression and unemployment, with 2 studies showing null findings. One study reported impaired job performance among veterans with alcohol or substance use disorder, but 2 studies on alcohol use disorder reported no significant association with unemployment. Study methodologies varied significantly, including in their populations, employment definitions, and choice of potential confounders.

Conclusions: The review suggests a relationship between depression and employment status, but evidence for relationships between other conditions and employment status is mixed, which may be because of significant methodological differences between individual studies. Future work should address this by using a generalizable sample of post-9/11 veterans, a standardized definition of unemployment, and base the statistical model on a theoretical framework describing the relationship between mental health and employment.