A Political
Debate On Stress Disorder -- As Claims Rise, VA Takes Stock
Since 12-27-05
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Subject: A Political Debate On Stress Disorder -- As Claims Rise, VA Takes Stock
A Political Debate On Stress Disorder
As Claims Rise, VA Takes Stock
By Shankar Vedantam
Washington Post Staff Writer
Tuesday, December 27, 2005
The spiraling cost of post-traumatic stress disorder among war veterans has
triggered a politically charged debate and ignited fears that the government is
trying to limit expensive benefits for emotionally scarred troops returning from
Iraq and Afghanistan.
In the past five years, the number of veterans receiving compensation for the
disorder commonly called PTSD has grown nearly seven times as fast as the number
receiving benefits for disabilities in general, according to a report this year
by the inspector general of the Department of Veterans Affairs. A total of
215,871 veterans received PTSD benefit payments last year at a cost of $4.3
billion, up from $1.7 billion in 1999 -- a jump of more than 150 percent.
Army Reserve Sgt. Jared Myers is shown with his mother, Judy Smith, who admitted
him to the Dwight D. Eisenhower Veterans Affairs Medical Center in Leavenworth,
Kan., where he spent three weeks being diagnosed and treated for post-traumatic
stress disorder.
Experts say the sharp increase does not begin to factor in the potential impact
of the wars in Iraq and Afghanistan, because the increase is largely the result
of Vietnam War vets seeking treatment decades after their combat experiences.
Facing a budget crunch, experts within and outside the Veterans Affairs
Department are raising concerns about fraudulent claims, wondering whether the
structure of government benefits discourages healing, and even questioning the
utility and objectivity of the diagnosis itself.
"On the one hand, it is good that people are reaching out for help," said Jeff
Schrade, communications director for the Senate Veterans Affairs Committee. "At
the same time, as more people reach out for help, it squeezes the budget
further."
Among the issues being discussed, he said, was whether veterans who show signs
of recovery should continue to receive disability compensation: "Whether anyone
has the political courage to cut them off -- I don't know that Congress has that
will, but we'll see."
Much of the debate is taking place out of public sight, including an internal VA
meeting in Philadelphia this month. The department has also been in negotiations
with the Institute of Medicine over a review of the "utility and objectiveness"
of PTSD diagnostic criteria and the validity of screening techniques, a process
that could have profound implications for returning soldiers.
The growing national debate over the Iraq war has changed the nature of the
discussion over PTSD, some participants said. "It has become a
pro-war-versus-antiwar issue," said one VA official who spoke on the condition
of anonymity because politics is not supposed to enter the debate. "If we show
that PTSD is prevalent and severe, that becomes one more little reason we should
stop waging war. If, on the other hand, PTSD rates are low . . . that is
convenient for the Bush administration."
As to whether budget issues and politics are playing a role in the agency's
review of PTSD diagnosis and treatment, VA spokesman Scott Hogenson said: "The
debate is over how to provide the best medical services possible for veterans."
People with PTSD have paralyzing memories of traumatic episodes they experienced
or witnessed, a range of emotional problems, and significant impairments in
day-to-day functioning. Underlying the political and budget issues, many experts
acknowledged, is a broader scientific debate over how best to diagnose
trauma-related pathology, what the goal of treatment should be -- even what
constitutes trauma.
Harvard psychologist Richard J. McNally argues that the diagnosis equates sexual
abuse, car accidents and concentration camps, when they are entirely different
experiences: A PTSD diagnosis has become "a way of moral claims-making," he
said. "To underscore the reprehensibility of the perpetrator, we say someone has
been through a traumatic event."
Chris Frueh, director of the VA clinic in Charleston, S.C., said the
department's disability system encourages some veterans to exaggerate symptoms
and prolong problems in order to maintain eligibility for benefits.
"We have young men and women coming back from Iraq who are having PTSD and
getting the message that this is a disorder they can't be treated for, and they
will have to be on disability for the rest of their lives," said Frueh, a
professor of public psychiatry at the Medical University of South Carolina. "My
concern about the policies is that they create perverse incentives to stay ill.
It is very tough to get better when you are trying to demonstrate how ill you
are.
Most veterans whom Frueh treats for PTSD are seeking disability compensation, he
said. Veterans Affairs uses a sliding scale; veterans who are granted 100
percent disability status receive payments starting at around $2,300 a month.
The VA inspector general's report found that benefit payments varied widely in
states and said that was because VA centers in some states are more likely to
grant veterans 100 percent disability.
Psychiatrist Sally Satel, who is affiliated with the conservative American
Enterprise Institute, said an underground network advises veterans where to go
for the best chance of being declared disabled. The institute organized a recent
meeting to discuss PTSD among veterans.
Once veterans are declared disabled, they retain that status indefinitely, Frueh
and Satel said. The system creates an adversarial relationship between doctors
and patients, in which veterans sometimes take legal action if doctors decline
to diagnose PTSD, Frueh said. The clinician added that some patients who really
need help never get it because they are unwilling to undergo the lengthy process
of qualifying for disability benefits, which often requires them to repeatedly
revisit the painful episodes they experienced.
The concern by Frueh and Satel about overdiagnosis and fraud -- what researchers
call "false positives" -- has drawn the ire of veterans groups and many other
mental health experts.
A far bigger problem is the many veterans who seek help but do not get it or who
never seek help, a number of experts said. Studies have shown that large numbers
of veterans with PTSD never seek treatment, possibly because of the stigma
surrounding mental illness.
"There are periodic false positives, but there are also a lot of false negatives
out there," said Terence M. Keane, one of the nation's best-known PTSD
researchers, who cited a 1988 study on the numbers of veterans who do not get
treatment. "Less than one-fourth of people with combat-related PTSD have used
VA-related services."
Larry Scott, who runs the clearinghouse
http://www.vawatchdog.org/ , said conservative groups are trying to cut VA
disability programs by unfairly comparing them to welfare.
Compensating people for disabilities is a cost of war, he said: "Veterans
benefits are like workmen's comp. You went to war. You were injured. Either your
body or your mind was injured, and that prevents you from doing certain duties
and you are compensated for that."
Scott said Veterans Affairs' objectives were made clear in the department's
request to the Institute of Medicine for a $1.3 million study to review how PTSD
is diagnosed and treated. Among other things, the department asked the institute
-- a branch of the National Academies chartered by Congress to advise the
government on science policy -- to review the American Psychiatric Association's
criteria for diagnosing PTSD. Effectively, Scott said, Veterans Affairs was
trying to get one scientific organization to second-guess another.
PTSD experts summoned to Philadelphia for the two-day internal "expert panel"
meeting were asked to discuss "evidence regarding validity, reliability, and
feasibility" of the department's PTSD assessment and treatment practices,
according to an e-mail invitation obtained by The Washington Post. The goal, the
e-mail added, is "to improve clinical exams used to help determine benefit
payments for veterans with Post Traumatic Stress Disorder."
"What they are trying to do is figure out a way not to diagnose vets with PTSD,"
said Steve Robinson, executive director of the National Gulf War Resource
Center, a veterans advocacy group. "It's like telling a patient with cancer, 'if
we tell you, you don't have cancer, then you won't suffer from cancer.' "
Hogenson, the VA spokesman, said the department is not seeking to overturn the
established psychiatric criteria for diagnosing PTSD.
"We are reviewing the utility and the objectivity of the criteria . . . and are
commenting on the screening instruments used by VA," he said. "We want to make
sure what we do for screening comports with the latest information out there."
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Contributed,
YNCS Don Harribine, USN(ret)
Any man or woman who may be asked in this century what they did to make life
worthwhile in their lifetime....can respond with a great deal of pride and
satisfaction, "I served a career in the United States Navy