A Political Debate On Stress Disorder

A Political Debate On Stress Disorder
As Claims Rise, VA Takes Stock

By Shankar Vedantam
Washington Post Staff Writer
Tuesday, December 27, 2005; A01

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.

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.”

An article in the Washington Post, “A Political Debate On Stress Disorder,” by Shankar Vedantam, reports that in 2004 the US Veterans Affairs Department spent $4.3 billion on PTSD benefit payments to a total of 215,871 veterans. If the results of the second half of our MDMA/PTSD study are as promising as the results of the first half, we will have data suggesting that it would be financially wise for the VA to fund the entire $5 million cost of MAPS’ Phase III studies to evaluate whether MDMA-assisted psychotherapy for PTSD should become approved by the FDA as a legally-available treatment for PTSD.