With all the recent scrutiny from the press and (belatedly) Congress into the state of affairs of veterans' health care, there is an important issue which may not be getting the attention it deserves. Mark Boal has an extensive report in this month's Playboy magazine about the under-diagnosis of Post-Traumatic Stress Disorder (PTSD) in soldiers returning from combat. While the article does not conclusively prove that the Department of Defense (DOD) and the Veterans Administration (VA) are intentionally doing so in order to save money, it does raise many disturbing questions. Questions that should be addressed by congressional committees, and by the new blue-ribbon commission (headed by Bob Dole and Donna Shalala) charged with investigating the state of veterans' health care.
Boal's article is rather long, but definitely worth reading. Interestingly, the article was published before the recent revelations about the Walter Reed situation.
The article first introduces a horrific case of a PTSD diagnosis being ignored by the military, with tragic results (the soldier, days after returning to civilian life, killed his friend for no apparent reason); but then it goes on to examine the wider picture of how many soldiers statistically should be diagnosed with PTSD versus the actual numbers reported by the military (which are a fraction of what would be expected). Several reasons are explored for this discrepancy in numbers:
...DOD and VA doctors are being pressured to limit diagnoses of PTSD in order to save the military money and manpower. The DOD's official medical policy toward PTSD was recently amended to include new criteria making it a virtual certainty that many soldiers who exhibit symptoms of the disease will not be diagnosed. And the VA itself has been quietly working to arrive at new, stricter formulations of PTSD -- contradicting those of the American Psychiatric Association -- that would allow the agency to diagnose far fewer cases.
. . .
[T]his past May, a General Accounting Office inquiry found that only one out of every five soldiers identified as being at risk for PTSD by military questionnaires given when troops come home are referred to doctors for follow-up and monitoring. The DOD, the report states, "cannot provide reasonable assurance that all service members who need referrals for further mental health or combat-stress evaluations receive them."
The wide gap between what medical experts say is the prevalence of PTSD and the actual diagnosis of the condition has outside observers of the Pentagon deeply worried. Dr. Robert Roswell, a former undersecretary at the VA, tells me bluntly, "PTSD is being underdiagnosed on a fairly wholesale level."
. . .
The Department of Veterans Affairs also continues to issue rosy estimates of its PTSD resources, even though every significant oversight agency has denounced the VA, claiming it's as unprepared as FEMA was to handle the aftermath of Hurricane Katrina. Here's the VA's own national advisory board on PTSD in a report released in February 2006: "The VA cannot meet the ongoing needs of veterans of past deployments while also reaching out to new combat veterans of [Iraq and Afghanistan] and their families within current resources and current models of treatment."
Pentagon and VA officials vigorously deny there is a policy to underdiagnose PTSD. "That would be immoral and unethical," says Dr. Michael Kilpatrick, the assistant secretary of defense for troop readiness. They attribute the low rates of diagnosis to a reluctance on the part of military doctors to "stigmatize the person or bring harm to their careers" by labeling them with PTSD, according to Lieutenant Colonel Dr. Charles Engel, the director of the deployment health clinical center at Walter Reed Medical Center. "It's out of respect for the patient that they don't make the diagnosis."
The article goes on to examine the history and origins of PTSD, concentrating on when the term "PTSD" first appeared post-Vietnam. Shockingly, this leads to the current politicization of the subject by conservatives. One would think medical diagnoses would be beyond the realm of interference by conservative ideologues bent on making political statements, but sadly, this is not the case:
Medical opinions began to change in the 1960s with what was then called post-Vietnam syndrome, a condition marked by rage at being "duped and manipulated by society." The doctors who worked on defining the diagnosis were often outspoken critics of Vietnam, and they encouraged their patients to take up antiwar activism as part of working through their trauma and transforming it into productive feelings. Rather than blame the character of the soldier, doctors blamed the war itself.
For all but a small group of conservative thinkers, PTSD has outgrown its early links to the antiwar movement to become an objective psychiatric category, as above the fray of politics as anxiety or depression. Still, an influential group of culture warriors and military commanders believes PTSD was an invention of liberals seeking to justify their politics with science. "For some in the military and for some of these conservatives, PTSD is still basically an anti-war concept," explains Dr. Ray Scurfield, a psychiatrist and pioneer in PTSD study.
With the election of George W. Bush, these fairly radical views were suddenly given a much more receptive hearing. B.G. Burkett, a retired Texas stockbroker, has spent the past 20 years waging a one-man crusade against deceitful American soldiers. He calls them "phony veterans" and believes PTSD has become a tool of antiwar liberals. Ask him about Lifton, the psychiatrist who helped define PTSD, and Burkett's voice rises with anger. "Lifton was an antiwar activist, for Christ's sake! If it were up to him, we'd have no war at all!" Then, more calmly, "Look, death encounters are a part of life. I watched my mother die. Do I have PTSD? It wasn't easy, but I'm still here. Whatever happened to resilience as a virtue?"
Burkett is one of the administration's talking heads on mental health as it deals with the fallout of the Iraq war. Burkett cheerfully and forcibly presents the notion that PTSD has become a scam used by antiwar liberals and that thousands of Vietnam veterans are faking illnesses in order to cash in on federal disability payments. Burkett co-authored the book Stolen Valor (for which he received a thank-you note from Bush), which documents several cases of brazen fraud perpetrated by Vietnam veterans.
. . .
The American Psychiatric Association insists that PTSD is marked by clear biological changes as well as emotional symptoms. "PTSD is an illness that is related to structural and chemical changes in the brain," according to the APA, the most respected association of its kind. Scurfield is slightly less diplomatic about this administration's offhand approach to soldiers' mental illness. "It's just bullshit," he says. "If spontaneous remission were a reality, why have 30 percent of Vietnam vets had a lifetime of PTSD?"
. . .
The government's attitude seems to be having the desired effect of keeping PTSD patients out of the DOD health care system and transferring the caseload burden to Veterans Affairs when the soldiers return home. Since the wars in Iraq and Afghanistan started, 631,000 people have been discharged from the military, including National Guard and Reserve soldiers who are now deactivated. Of those, 73,000 have sought mental health treatment at the VA.
Critics say the VA, like the DOD, is falling short. A rumor going around the veterans community claims that, even in cases of existing injuries, military doctors are underdiagnosing PTSD at military hospitals, preferring instead to use labels that do not entitle the soldier to combat-related compensation. "We've been hearing it all the time from our guys in the field who are working with these Iraq vets," says Joe Violante of Disabled American Veterans. Military doctors "are being told not to diagnose PTSD."
In 2004 leadership changed at the VA. The head of the agency, Anthony Principi, a longtime favorite of veterans groups, resigned. The timing of his resignation was suspect, as it came shortly after he told Congress the agency lacked funds to take care of veterans, and the move was widely interpreted as a firing. Bush replaced Principi with a high-level party operative named James Nicholson. A Republican power broker and a party heavyweight, he chaired the Republican National Committee during the 2000 presidential campaign, when he called Dick Cheney "one of the most qualified, beloved people in America."
Soon after Nicholson moved into his new offices, the VA, like the DOD, began to aggressively roll back its support for PTSD. First, in a move that echoed Burkett's charges, Nicholson ordered an investigation into the files of 72,000 veterans who had received PTSD compensation. Senate Democrats managed to undercut the review. In response, Nicholson commissioned a study at the Institute of Medicine to craft a new definition of PTSD, one more restrictive than that used by the American Psychiatric Association. That too fizzled. Finally, a second study was commissioned to "assess how PTSD compensation might influence beneficiaries' attitudes and behaviors in ways that might serve as barriers to recovery."
. . .
But veterans advocates fear the attack has already succeeded. They describe the unfolding situation as a train wreck, a catastrophe and a scandal. "You have large numbers of needy people coming back from the war, looking for help, and you have a government attempting to reduce expenditures, as well as conservatives who want to raise the bar and make it harder for vets to get the diagnoses," says Dr. Charles Figley, editor of Traumatology, who has written numerous books on PTSD and has been studying combat-related PTSD in veteran populations for 20 years. He is not an antimilitary person, and he recently spent a year on a Fulbright scholarship at Kuwait University. Figley adds, "What's going to happen? It's a perfect storm."
So while congressional committees on both sides of the Hill are grilling the medical brass this week, they should be aware that cutting corners on veterans' medical treatment may not be limited to ignoring moldy walls. And they should use some of their questions to ask why the military seems so hostile to accurately diagnosing and treating PTSD. Otherwise thousands of returning veterans are going to be just as haunted as the Vietnam vets were. And that would be a tragedy. An avoidable tragedy, and one that must be addressed now.
[Sorry I missed posting last week, I was still on the sick list. Thanks to all who sent "get well soon" emails!]
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