The Official Voice of Vietnam Veterans of America, Inc. ®
An organization chartered by the U.S. Congress
MAY/JUNE 2006
FEATUREPTSD
AGAIN IN THE EYE OF THE STORM
BY BARBARA DREYFUSS Even while the military’s own studies are showing that one-third of Iraqi War veterans are seeking mental health services during their first year home, the legitimacy of veterans’ claims that they suffer from Post-traumatic Stress Disorder is under the gun. Questions are being raised in Congress, at the Department of Veterans Affairs, and by a small number of vocal academics, whose views are not shared by most PTSD experts, about whether there even is such a thing as PTSD and if there is, whether those claiming to suffer from it actually do.
“There are some folks out there who say we see a lot of guys claiming to be ill and they are doing it just to get benefits,” says Jeff Schrade, a spokesman for the Senate Veterans’ Affairs Committee. Congress is hearing this from “within the VA,” he said, and this is prompting interest from committee chair Sen. Larry E. Craig (R-Idaho) about how PTSD is diagnosed and treated. “There’s a vocal group of folks who are quite adamant about this issue and think it’s a waste of money,” Schrade adds.
Why, more than a quarter century after PTSD was officially recognized and defined by the psychiatric community, is it being called into question? One key reason is that Washington policymakers face a budget crisis and the cost of treating and paying disability compensation to veterans with PTSD is high and is likely to get higher, given the increasing numbers of newer veterans seeking mental health services.
VA officials and Congress are “concerned about money,” says Dr. Sally Satel, one of the most vocal PTSD skeptics. But, said Satel, they “can’t say it too loudly.” Instead, officials rely on people like Satel, a former VA psychiatrist who is now a resident scholar at the conservative American Enterprise Institute, to wage a campaign to discredit PTSD as a diagnosis and portray veterans who suffer from it as looking for easy disability benefits that provide an incentive for staying sick rather than getting well. The implication is sick veterans are welfare cheats.
Since the invasion of Iraq, Satel has written several newspaper articles questioning PTSD and those who are diagnosed with it; has been skeptical about the generally well-regarded Vietnam Veterans Readjustment Study; has testified before the House Veterans’ Affairs Committee about PTSD; and has organized a recent seminar, “Soldiers, Psyche, and the Department of Veterans Affairs: What Are the Lessons of Vietnam?”, at the American Enterprise Institute with speakers partial to her views. The announcement for the event spoke of how care provided by the VA “played a role in many veterans becoming chronic psychiatric patients,” regressive treatment “involving the incessant retelling of war stories with insufficient emphasis on practical problem-solving,” and how “generous Veterans Affairs entitlements for chronic PTSD may have created financial incentives for veterans to claim psychological disorders and reduced the motivation to recover.”
Faced with enormous budget deficits, Republican chairs of the House and Senate Veterans’ Affairs Committees are raising concerns about hikes in disability spending. Sen. Craig called the jump in disability payments “stunning increases that are going to require a reality check from Congress.” PTSD sufferers make up one-fifth of all veterans receiving compensation. While no one denies that a veteran missing legs or arms has a disability, PTSD is less visible and easier to question.
There is also concern that the number of veterans with PTSD who receive disability compensation is growing faster than other disability cases. In 1999, about 122,000 veterans received disability compensation for PTSD and over 90,000 were veterans of the Vietnam period. By late 2004, over 161,000 veterans of the Vietnam period were getting disability compensation for PTSD, and the total number of veterans being compensated for PTSD was nearly 218,000. From 1999 to 2004, there was an 80 percent jump in the number of veterans being paid benefits for PTSD, while overall veterans receiving disability grew 12 percent. Vietnam veterans constituted most of the 80 percent jump. At the same time, according to a report last year by the VA Inspector General, PTSD disability payments rose from $1.7 billion to $4.3 billion. Veterans receiving disability compensation for PTSD are becoming increasingly expensive and most of them are veterans of the Vietnam era. Efforts to control the cost of PTSD would affect not only Vietnam veterans, but also the newer veterans of Iraq and Afghanistan who are starting to apply for VA benefits. Some of them are the sons and daughters of Vietnam veterans.
Budget issues are not the only thing driving this debate, claim former VA officials. There is concern that military recruitment efforts could be significantly hindered if people see the psychological toll of combat. Some are worried “about the publicity the psychological effects of the war is getting,” says Dr. Susan Mather, a former top VA official who retired in January as its chief public health officer. “They already have a recruitment problem . . . the parents of these youth, if they think their children will come back from the military experience changed forever—which they undoubtedly will be; not only changed but disabled by the experience, mentally as well as physically—they are going to be a lot less anxious to have these kids join up. And there’s a feeling that if this gets too much publicity and appears to be too widespread, it will hurt recruitment.”
Given the dozens of news articles that have appeared about combat veterans from Iraq or Afghanistan who have reported mental health problems or symptoms of PTSD since their return, the concern about publicity is understandable. One recent example is the news that the young, grim, battle-weary, helmeted Marine photographed in Fallujah in 2004, with a cigarette dangling from his lips, who instantly became known as “Marlboro Man” when the famous photo flashed around the world, now has PTSD and is no longer a Marine.
While budget costs and recruitment are key concerns driving the new debate, recent changes in the VA’s culture have made the agency more receptive to skepticism about PTSD. In the past, VA headquarters was staffed in large part by civilians who had spent years in the field working with veterans and seeing first-hand the psychological toll of war. They were sympathetic to veterans suffering from PTSD. But the high cost of living in Washington and the heated political atmosphere now pervading the agency have made it difficult to bring in people from regional VA centers, say VA insiders. Instead, VA ranks are increasingly filled by retired military.
Some of these ex-military personnel are uncomfortable with mental illness and question whether it is as real as physical disability. Their view, say other VA officials, is that troubled veterans need to “suck it up” and deal with their psychological problems. As in a war zone, they just need to get back on the line. Steeped in this mentality, they are easily swayed by arguments that many receiving PTSD benefits are faking it or not admitting they are getting better for fear of losing their payments. Indeed, some VA officials believe some veterans “are lying” about PTSD, Matt Friedman, executive director of the National Center on PTSD, told a public meeting in February.
With many officials skeptical about the diagnosis and concerned about budget and recruitment issues, VA last year used a government report questioning how PTSD is diagnosed as an excuse to announce it would review all PTSD cases granted 100 percent disability since 1999. The VA was responding to an Inspector General’s report that had found 25 percent of PTSD claims reviewed did not have adequate proof the veteran was actually exposed to significant stress, a precondition for PTSD diagnosis. After veterans’ groups, including VVA, protested that this was just an excuse to cut benefits, as well as action by members of Congress, the VA backed off. In November came the announcement that the VA wouldn’t audit claims. VA said that rather than showing evidence veterans committed fraud, the lack of data underscored problems in how staff review claims.
These events could have led the VA to focus on improving the consistency of claims processing by hiring more staff or initiating better training programs. Instead, a few days after ending the audit, the VA began a total reassessment of PTSD, including how it is defined, diagnosed, and compensated.
Former VA officials and staffers on Capitol Hill believe this review was initiated to support changing the definition of PTSD, with the aim of decreasing the number of people diagnosed with it. They also see it as part of an effort to change the benefits structure in order to reduce compensation.
To give the imprimatur of objectivity to this, the VA asked the Institute of Medicine (IOM), an independent group of prominent medical experts, to do the work and provided a $1.3 million contract for the study. IOM was asked to assess the criteria for diagnosing PTSD, determine the validity of screening procedures, and judge the efficacy of current treatment. The report is expected in June. A second study, due in December, will recommend proposals for structuring compensation.
The emphasis is not better treatment, says former VA official Mather, but disability payments. “I don’t think the IOM is going to come up with better treatment programs,” she said. Rather, the creators of the review hope they will redefine PTSD to narrow its scope, which would be a more politically acceptable way to cut spending. “I think those folks who are interested in how much it’s costing would like to find a way to define it differently because they don’t want to appear hard-hearted,” said Mather.
“This is happening in a context where the Secretary and the Veterans Disability Benefits Commission are looking at compensation for all health conditions, including for PTSD,” admits Dr. Toni Zeiss, VA’s deputy chief of mental health services.
Ron Aument, deputy undersecretary for benefits at the VA, denies that the VA wants to reduce benefits but admits “there is concern that the number of veterans with PTSD has grown so quickly.” He says that congressmen responsible for veterans’ affairs have raised questions about the consistency and accuracy of VA’s determination of benefits.
The VA could have asked its internal PTSD experts to do this assessment. Its National Center for PTSD is one of the premier authorities on PTSD. The VA also has a Special Committee on PTSD composed of VA physicians who are PTSD experts.
But both are replete with people who have spent years working with PTSD veterans and firmly believe it is a real disorder that should be compensated. “PTSD has proven to be a very useful and valid diagnosis after 25 years,” Mathew Friedman, the National Center for PTSD’s executive director, told the IOM committee at its first public meeting.
When asked why the National Center couldn’t have performed the IOM analysis, AEI’s Sally Satel said derisively, “They have a vested interest” in it. “They are the experts,” agreed Mather, referring to the National Center, but “I think there is sometimes a feeling that the Center is also an advocate for PTSD.” As advocates, they would not be likely to go along with those who want to reduce the number of people getting compensated for PTSD by changing the criteria for its diagnosis.
A recent study illustrated how the psychological toll of the war in Iraq can change depending on how PTSD is defined. The study, in The New England Journal of Medicine, reported as few as 12 percent or as many as 20 percent of returning Iraqi war veterans had PTSD, depending on how the screen for PTSD is used.
For 26 years, mental health practitioners and researchers and many state and federal programs, including the VA, have relied on the American Psychiatric Association to define and diagnose PTSD. The APA publishes its Diagnostic and Statistical Manual, which has explicit criteria defining PTSD, is used throughout the medical profession, and is incorporated into 650 state and federal regulations. APA is now revising its 1994 edition. Although it won’t be ready until 2011, the APA has already convened an international research conference to assess existing scientific knowledge and to suggest further research. But VA’s Zeiss says the department cannot wait for APA to complete its work.
This has raised concerns at APA. “My concern is that they not attempt to establish their own diagnostic criteria for PTSD,” said Darrel Regier, the APA’s director of research. Regier said that would be interpreted as “the VA is doing this to alter the prevalence rates and the liability rates they have with PTSD.” There is, he warns, “a history in psychiatry of political misuse of diagnosis.”
In addition to defining PTSD, IOM was asked to look at how compensation relates to diagnosis, how long payments should last, and what evidence should be used to prove disability. During the IOM’s first public meeting on the PTSD study, AEI’s Satel raised a number of questions about PTSD compensation. So did Harvard professor Richard McNally, a psychologist, whose recent book, Remembering Trauma, applied clinical research findings on memory to the debate about repressed memories of childhood sexual abuse, and received a glowing review from Satel, who expanded the review with a discussion of PTSD.
First, Satel and McNally raised the specter of fraud and questioned current rules allowing VA claims raters to accept a veteran’s testimony as proof that he experienced a traumatic event that caused his disability. Satel was most blunt, charging, “That’s life: People cheat.”
Second, both claim that cases of delayed onset of PTSD “are rare to nonexistent,” asMcNally has written. Satel proposed to the IOM that veterans not be permitted to apply for PTSD disability more than five years after the event triggering their illness.
Third, Satel also argued that PTSD is an acute—not a chronic—disease and only rarely should there be a “need to give long-term disability.” PTSD is “easier to treat early on,” she says. In fact, she argues that long-term disability is a disincentive to people getting well because they don’t want to lose benefits. She derides disability compensation as a “retirement plan” for people who cannot get good jobs.
McNally referenced a few small, questionable studies and Satel presented her comments as opinion without citing any data. Their charges were strongly refuted by the National Center’s Friedman, who cited many studies confirming delayed onset of PTSD and others showing the validity of veterans’ self-reports of stress incidents. A new study not yet published by a Columbia University professor also was presented at the meeting confirming the validity of self-reports. Friedman also cited studies showing that mental health utilization is actually higher for people given disability than for those who apply and are turned down. They “are not taking the money and running,” said Friedman.
Still, some at VA believe that even if veterans continue treatment, compensation payments can affect a person’s desire to get well. VA officials have been grappling for years with how compensation can be structured so that ill veterans can focus on getting better without fear of losing benefits. But unlike many who are raising this issue to set a limit on benefits, others would like to see a large infusion of money to improve treatment and training.
Dick McCormick, former chair of VA’s Committee on Serious Mental Illness, proposes enough money to insure state-of-the-art treatment nationally and a hefty initial payment to make sure veterans get therapy and vocational training. “Then I would have continuation of the money contingent on continuing to try to stay in treatment.” He says he would rather err in giving someone who doesn’t deserve compensation the money rather than not giving it to someone who does.
Despite the motives for initiating the IOM reports, it’s unclear whether they will satisfy those who asked for them. IOM committee members did not respond kindly to Satel, asking many tough and somewhat angry questions about her opinions. Several members also were upset when they found that the panel would be discussing diagnostic criteria for PTSD but no one from the American Psychiatric Association had been invited to comment. They raised their concerns with committee staff, who quickly invited APA’s research director.
Whatever the IOM reports say, the bigger question is how Congress will use them. Some Capitol Hill staffers concerned about what is happening with veterans benefits noted there is intense pressure to cut the budget and they will be watching how Congress reacts to the IOM reports “with raised skepticism.” IOM has a strong record of not acting with political bias or limiting benefits for the sake of saving money, said one staffer, but “we’re very worried about what Congress will do with these results.”
Even VA officials say the key to how the IOM report affects benefits will rest with Congress, which determines the compensation system. VA’s Aument agrees that “there certainly are a lot of broad public policy questions here,” but wants VA to stay away from making these kinds of decisions. “Some of those questions are best left to the public policymakers such as Sen. Craig.”
Craig’s Senate Veterans’ Affairs Committee will hold hearings this year and next on these issues, promises a committee spokesman. So will the House Veterans’ Affairs Committee. Its chair, Rep. Steve Buyer (R-Ind.), who last year replaced longtime veterans’ advocate Rep. Chris Smith (R-N.J.) after Smith was ousted by the House Republican leadership, says on his committee web site that the prevalence of PTSD in returning troops and the ability of the VA to care for them will be a major focus of his committee this year. But his committee will look at not just treatment but the way VA “goes to diagnose, validate, and compensate” PTSD patients.Veterans will have a major fight over the coming months to maintain adequate funding for treatment, diagnosis, and support for those suffering from serious mental trauma. While that is going on, veterans’ advocates worry that the campaign being waged to discredit PTSD will further reinforce the stigma that exists about acknowledging psychological problems. This could keep more veterans from getting the care they need and deserve. That just could be what the PTSD critics want.
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