More Of The Same

In yet another GAO report released on February 16, the investigative agency questions whether the Veterans Affairs Department can adequately help troops returning from Iraq and Afghanistan with PTSD. This latest GAO report was requested by Rep. Lane Evans (D-Ill.), the House Veterans’ Affairs Committee ranking Democrat.
Data for the 2004 budget year show that fewer than half of those using VA health care are screened for PTSD. The report also said that “if veterans returning from combat do not have access to these services, many mental health experts believe that the chance may be missed to lessen the severity of symptoms and improve the overall quality of life for those with the disorder.”

The VA contends that the report did not adequately describe the type of services for PTSD that the agency has provided over the past 20 years or its ability to provide such services in the future. In a reference to the GAO report, Dr. Jonathan Perlin, the VA’s Acting Undersecretary for Health, said: “We take exception to this report,” and noted that “the VA is a world leader in PTSD treatment.”

GAO investigators said the VA has put in place only 14 of 24 recommendations from an advisory committee that Congress created, while the VA says it has completed seven. The bottom line, according to the report, is that the delay “raises questions about VA’s capacity to identify and treat veterans returning from combat who may be at risk” for developing PTSD and maintaining treatment for veterans already receiving help.

PERCEPTION WARS

In early February, Col. Thomas Burke, Director of Mental Health Policy for the Department of Defense, said that the stigma for troops seeking mental health care “is a real problem,” and that “there is a perception among the troops that seeking mental health care means you’re weak or a coward and, frankly, we in the military foster that attitude.” Burke also noted that “the biggest barrier to reducing stigma in the military is confidentiality.”

In other words, troopers who self-identify themselves as suffering from PTSD or other forms of psychological trauma and then try to pursue medical help are running into difficulties. Perhaps that’s the reason for an Army Times report of February 28 that “some troops in Iraq are taking antidepressants such as Prozac, Zoloft and Paxil.” On the other hand, this does little to explain The Guardian’s report on February 17 that some scientists in South Carolina want to offer the street drug “Ecstasy” as a treatment for PTSD and are advertising for combat veteran volunteers. The scientists note that the drug-assisted therapy sessions last up to eight hours during which music is played.

COMMITTEE NOTES

The PTSD Awareness poster is hot off the presses. The committee decided to provide a copy to each of the 206 Vet Centers, as well as to each member who attends the San Mateo meeting of VVA’s Conference of State Council Presidents. In addition, the committee has begun planning a one-day conference on the immediate mental health needs of veterans, especially those participating in the War on Terror. Lastly, with the assistance of the Government Relations staff, the committee chair submitted written testimony for the record to the VA’s Veterans Readjustment group in mid-February.

It's About The Money

Judging by the number of e-mails I’ve received in recent weeks, many of you have heard the news that the VA will be reviewing some 72,000 PTSD claims that have been granted. “Why?” is the No. 1 question that’s being asked of me in those e-mails. The answer: Because earlier this year, the Inspector General’s Office (the IG) looked at about 2,100 claims and found that in some 600 cases, “the presence of a stressor was not clearly defined.” So, according to the VA, they “will be looking to ascertain the presence of a stressor” (a specific traumatic event or experience occurring during the period of military service. For a more comprehensive look at the review issue, see the Government Relations report)

Keep in mind that this is all about money. Rep. Steve Buyer (R-Ind.), chair of the House Committee on Veterans’ Affairs, recently stated: “Many veterans stop going to therapy/treatment once they have received their 100 percent PTSD disability claim.” The fact of the matter is that PTSD and other related mental health issues represent long-term VA health care costs, not short-term costs such as those associated with a broken arm. We also know that the longer PTSD goes untreated, the worse it can become over time, and subsequent treatment costs will rise. Add to this mix the fact that many—if not most—VA facilities have neither the appropriate number of professional mental health staff or resources (programs, beds, or funds) to provide adequate mental health services, despite VA claims to the contrary.

For example, at VISN 15 at the Kansas City VA Hospital, in 1996 there were 41/2 F.T.E.s (full-time equivalencies of staff time) dedicated to 55 clients diagnosed with PTSD. In 2005, there are 21/2 F.T.E.s assigned to more than 1,000 clients. Weekly group therapy sessions consist of hundreds of clients packed into standing-room-only rooms. If you’re lucky, you can schedule a one-on-one, 30-minute therapy session once every three months. Given these facts, why do you think veterans would stop seeking long-term VA mental health services?

In other news: In July 2004, a report in The New England Journal of Medicine estimated that 17 percent of service personnel returning from Operation Iraqi Freedom had PTSD-related symptoms. But Dr. Al Batres, who heads the VA’s Readjustment Counseling Service (Vet Centers), believes the rate is now higher—and growing. So far this year some 14,000 veterans have sought counseling at the 207 community Vet Centers he oversees. About 27 percent of them, he explains, report such symptoms. “The numbers coming in are escalating,” says Batres, who stresses that his data are anecdotal.

PTSD continues to be an acronym the military doesn’t like. Rather, it prefers “temporary adjustment disorder,” with an emphasis on “temporary.” If Batres’s numbers prove correct, the overall rates of PTSD could equal those of the Vietnam War.

The Downhill Spiral Continues

With the number of American soldiers killed in Iraq having topped 2,000, those fortunate enough to return face the task of putting the war behind them and resuming their lives. Some are getting reacquainted with wives and children they left behind a year or more ago. Many face the task of catching up on bills or fixing homes that have gone in need of repair. Some lost jobs or had their businesses falter while they were gone. More than a few have found they have returned home with their war anxieties.

“They are witnessing far more traumatic experiences than they did in the first Gulf war,” said Terri Tanielian, a senior military health policy analyst for the Rand Corporation. Longer deployments, fiercer engagements, and more casualties have left Iraq war veterans more vulnerable to psychological trauma than Gulf War veterans, Tanielian said. She said many veterans may be shunning counseling services offered by the military out of a misplaced sense of honor. “Their training is to go on with the mission and put on the brave face,” Tanielian said.

A recent article in USA Today noted that more than one in four American troops have come home from Iraq with health problems that require medical or mental health treatment. According to the Pentagon’s first detailed screening of service members leaving the war zone, almost 1,700 returning this year said they harbored thoughts of hurting themselves or that they would be better off dead. More than 250 said they had such thoughts “a lot.” Nearly 20,000 reported nightmares or unwanted war recollections; more than 3,700 said they had concerns that they might “hurt or lose control” with someone else.

The survey results, which have not been publicly released, were provided to USA Today by the Army Center for Health Promotion and Preventive Medicine. They offer a window on the war and how the ongoing insurgency has added to the strain on troops.

Overall, since the war began, some 28 percent of Iraq veterans—about 50,000 service members this year alone—returned with problems ranging from lingering battle wounds to toothaches, and from suicidal thoughts to strained marriages. The figure dwarfs the Pentagon’s official Iraq casualty count: more than 2,000 U.S. troops dead and more than 15,220 wounded as of early November. A greater percentage of soldiers and Marines surveyed in 2004-05 said they felt in “great danger” of being killed than those surveyed in 2003 after a more conventional phase of fighting. Twice as many surveyed in 2004-05 had fired a weapon in combat.

At the same time, months after VA officials told Congress that they expected the processing time for veterans’ disability claims to drop, agency internal reports indicate little or no progress. Records show that the department is struggling in its attempt to reduce veterans’ waiting time, in part because the productivity of VA employees nationwide is only three-quarters of what it expected. In some regional offices, it is far lower. The delays mean tens of thousands of veterans who were injured serving the country are waiting far longer to have their cases decided than lawmakers—or the VA—would like.

In March, the department came under fire from lawmakers for poor service. VA Secretary James Nicholson told Congress he expected processing times to drop to 145 days for the fiscal year, a target that had been changed from prior goals that aimed to bring the average to 100 or fewer days. For the first 11 months of the 2005 fiscal year, which ended Sept. 30, the department’s average time to process disability claims was 167 days, one day slower than last year, according to a VA report obtained by Knight-Ridder. The average for August claims was 169 days.

Michael Walcoff, a top official in the VA’s benefits division, said that Nicholson fully expected the department to meet its goals but that staff productivity had suffered throughout the year. “The secretary had very high expectations for us,” Walcoff said. “I am concerned about productivity. I believe we have the capacity to be more productive than we have been this year.”

Many claims for disability compensation, which pays veterans for injuries sustained while serving in the military, take far longer than the average. The VA report said 4,300 cases from August had taken longer than a year to decide. And while some categories of claims have shown improvement in the last two years, others showed a “marked deterioration in performance,” and on balance things have not improved at all, the report said. As a result, the backlog of pending claims is rising—just the opposite of what the department had anticipated. Only last year, VA officials said the backlog should drop to 250,000 claims nationwide. Instead, it is now greater than 350,000.

The downhill spiral continues.

Connecting The Dots

It started in December 2004 when the Chicago Sun-Times ran a series of articles highlighting variations among states’ veterans disability compensation payments. The report showed that New Mexico had the highest compensation payments and Illinois the lowest. Rep. Lane Evans (D-Ill.) and other Illinois members of Congress sent a letter to VA Secretary Nicholson calling for a review. Subsequently, the Secretary asked for the Office of the Inspector General (OIG) to report on the differences.

In May 2005 the resultant OIG report noted that a review of 2,100 PTSD compensation cases found that in approximately 600 cases the compensation payment outcomes differed as a result of the stressor verification requirements varying from state to state. Members of Congress used the results of this OIG report as the basis for claiming “fraud” among PTSD claims, especially those involving Vietnam veterans.

Secretary Nicholson then issued notice that there would be a review of 72,000 PTSD claims awarded at 100 percent disability from 1999-2005. But after pressure from veterans’ groups (including VVA) and Sen. Patty Murray’s (D-Wash.) amendment to halt the review passed the Senate 98-0, the VA Secretary announced cancellation of the review last November 10.

However, just six days later, another PTSD review was announced in a press release issued by Sen. Larry Craig (R-Idaho), the chair of the Senate Committee on Veterans’ Affairs. This time neither the Secretary nor the VA announced the review. Sen. Craig’s press release stated that the VHA had contracted with the Institute of Medicine (IOM) to conduct a new review of PTSD diagnosis, treatment, and compensation for approximately $1.4 million. According to a subsequent VA “fact sheet,” the IOM will form two committees to conduct its review. One committee will “review the literature of various treatment modalities (including pharmacotherapy and psychotherapy).” This phase is expected to be completed in 12 months.

The other committee will review “the objective measures used in the diagnosis of PTSD and known risk factors for the development of PTSD,” and “the utility and objectiveness of the criteria in the DSM-IV and will comment on the validity of current screening instruments and their productive capacity for accurate diagnoses.” This phase is expected to be completed within six months.

Perhaps you’re now thinking along the lines of a December article penned by Larry Scott in OpEdNews.com, who wrote that “they are trying to rewrite the book on PTSD.” But there are more pieces to this puzzle.

In a front-page Washington Post article on December 27, reporter Shankar Vedantam noted that “PTSD experts were summoned to Philadelphia” for a secret two-day “expert panel” meeting in which they 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 Post. The goal, the e-mail said, was “to improve clinical exams used to help determine benefit payments for veterans with Post-traumatic Stress Disorder.”

The so-called experts quoted in this article included Sally Satel, the American Enterprise Institute’s conservative voice on PTSD, along with Chris Frueh from the Charleston, South Carolina, VA Clinic, whose claim to fame includes trying to show fraud among veterans seeking treatment for PTSD, and VA spokesperson Scott Hogenson, the former executive director of the Conservative Communications Center. In this article, Satel makes the outrageous claim that “an underground network advises veterans where to go for the best chance of being declared disabled.” VVA President John Rowan formally responded to the Post article on December 28, asking for the list of participants at the Philadelphia meeting. But as of this writing, VVA has not received a response to the request for the meeting’s participant list.

But here’s more: David Oaks, Director of MindFreedom International, a mental health advocacy organization, wrote in a January 6 editorial that “the U.S. government is helping to fund a series of private conferences throughout the world with the American Psychiatric Association (APA) about the Future of Psychiatric Diagnosis.” According to Oaks, “the Bush administration provided the APA with $1.1 million for the meetings.” One goal of this series of invitation-only conferences is “to promote international collaboration in order to increase the likelihood of developing a future unified DSM/ICD,” Oaks said.

“The DSM is the APA’s psychiatric label book, while ICD is the disease classification system used internationally. In other words, these meetings are about the U.S. and the APA influencing a global system of classifying psychiatric disorders.”

You don’t have to be a rocket scientist to connect the dots on this one.

Wrong Answers

A December 31 Kansas City Star article reports that, according to the VA’s own data, people who call the agency’s regional offices for help and advice are more likely to receive completely wrong answers than completely right ones. During 2004, VA benefits experts called each of its regional offices that process veterans’ disability claims to see how well its employees answer typical questions from the public. The callers, saying they were relatives or friends of veterans inquiring about possible benefits, made 1,089 calls. Amazingly, 81 percent of the time they received answers that the VA said were either completely incorrect or partly incorrect.

According to an internal VA memo on the mystery-caller program, 22 percent of the answers were “completely incorrect,” 23 percent were “minimally correct,” 20 percent were “partially correct,” 16 percent were “mostly correct,” and only 19 percent were “completely correct.”

The program also found that some VA workers were dismissive of some callers and rude to others. For example, one caller said: “My father served in Vietnam in 1961 and 1962. Is there a way he can find out if he was exposed to Agent Orange?” The VA’s response, according to the VA memo: “He should know if they were spreading that chemical out then. He would be the only one to know. Okay (hung up laughing).”

First Shots Fired In The Claims War

On February 13, VVA presented testimony before the National Academy of Sciences’ Institute of Medicine Gulf War and Health Subcommittee. This is the subcommittee that is looking at the PTSD clinical and diagnostic procedures used in the VA disability claims process.

The subcommittee consists of a group of mental-health professionals not in the employ of the VA, and none of whom are veterans. It also includes the American Enterprise Institute’s Sally Satel—the so-called expert who claims that there’s a “secret underground network which advises veterans where to go for the best chance of being declared disabled.” She could not answer any questions about the science behind PTSD diagnoses, and when questioned in detail about her allegations, kept making outrageous statements that had nothing to do with the day’s proceedings. She left the room after her presentation and did not return.

Seven speakers addressed the subcommittee during the public comment period at the end of the day: VVA’s PTSD/SA Chair and the Director of Government Relations; one of Rep. Lane Evans’s (D-Ill.) staff; a former Veterans Benefits Administration official; and three people from the Vietnam Veterans of America Foundation, two Iraq vets and Bobby Muller. VVA’s written testimony was accepted for the official record.

One of the main points in VVA’s testimony was that by 2002 the Department of Veterans Affairs had prepared a “Best Practices Manual for Post-traumatic Stress Disorder (PTSD) Compensation and Pension Examinations,” containing scientifically validated assessment instruments for the diagnostic evaluation of PTSD and guidelines for the determination of a service-connected disability for PTSD using criteria from the DSM-IV. Several of the VA scientists who wrote this “Best Practices Manual” were present at the subcommittee meeting.

You might be amazed to discover that as of February 2006, the VA had issued no directives to its clinicians and adjudicators to use the Manual, nor had it provided any training on this guide. Copies are not available to staff throughout the VA, nor to anyone else. VVA has good reason to believe there are thousands of copies of the “Best Practices Manual” sitting in a warehouse somewhere—printed with tax dollars— that the VA refuses to make available.

Is there any wonder that there is so much variation among states’ veterans disability compensation payments?

The message that we must continue to press on this issue is: The VA must distribute and train its mental health clinicians and staff in the use of its “Best Practices Manual” for the clinical assessment and diagnoses of PTSD in the disability claims process. We can accept nothing less.

FAMILY MATTERS

For almost 2,300 American families who have lost loved ones since the invasion of Iraq, the visit announcing that death has become a reality. More than 16,000 troops also have been seriously wounded, warranting similar visits or phone calls. According to the Institute for Policy Studies, since 2001 more than one million families have had to learn to adjust to a life without a loved one near—and the constant worry and fear. How do they cope?

Some try to outrun their fears by becoming workaholics. But according to the National Mental Health Association, finding support is imperative in handling stress, although the organization also suggests trying to maintain control over what you can. This can mean sticking to a daily routine, such as having the phone nearby, and having calls forwarded to your cell phone each morning before work.

“It’s support that seems essential to the well-being of families,” says Mark Smaller, director of the Neuro-Psychoanalysis Foundation in Chicago. “The first step in managing these stressful feelings is to acknowledge them and talk of them when they emerge. Just talking to another about these feelings can diffuse intensity, but certainly not make them go away.” Many spouses and parents should acknowledge the importance of connecting, especially with those in similar situations.

Clearly, spouses and parents of those deployed suffer terrible mental anguish. But they are not alone. Children suffer as well. “Children need to feel not alone or isolated with their feelings,” Smaller says. “The more available parents or caretakers are to the child’s fears, anxiety, sadness, and anger, the better the child can integrate these feelings and not feel alone. Kids should be encouraged to talk about their feelings, ideas, thoughts, and fears about a parent leaving or one who is gone. Anything less can leave children feeling as if they have done something wrong to make the parent leave. Any way to maintain some contact through telephone, e-mails, or letters is encouraged.”

When family members go off to war, it is important to remember that they are not the only ones suffering. That is why mental health experts say it is important to be on the lookout for signals that might indicate a military family member is experiencing too much stress: persistent fatigue; inability to concentrate; flashes of anger, lashing out at family and friends; changes in eating or sleeping habits; increased use of alcohol, tobacco, or drugs; repeated tension headaches, lower backaches, stomach problems or other physical ailments; and prolonged feelings of depression, anxiety, or helplessness. If these occur, individuals should seek a support group, or in more serious instances, professional medical attention.