Study Shows VA Must Change How it Handles PTSD

More veterans make mental health claims than before
by Rick Rogers 

Left, Bill Rider Jr., president of the American Combat Veterans of War in San Diego County, seeks a uniform disability rate schedule. 

A federal study released yesterday urges the most sweeping changes since World War II on how veterans are diagnosed with and compensated for post traumatic stress disorder.  

The Department of Veterans Affairs needs to replace its narrowly defined and unevenly applied criteria for PTSD screening with broader standards based on the latest knowledge about psychiatry, the Institute of Medicine and the National Research Council said in their joint report. The agencies also called on the VA to jettison its current rating scale for disability payments and establish a system of fixed, long-term benefits…

“As the increasing number of claims to the VA shows, PTSD has become a very significant public-health problem,” said Nancy Andreasen, who led the committee of mental-health experts that conducted the yearlong study. “Comprehensive revision is needed.”

Rep. Bob Filner, D-San Diego, said the report had “some really good ideas for what we should be doing” and hoped VA officials were paying attention.

Filner, chairman of the House Veterans' Affairs Committee, agreed with the report's recommendations for improving PTSD screening practices. But he did not promise to seek additional money for the overhaul, which includes hiring more mental-health professionals to diagnose and treat patients.

“I think we've given them the resources,” Filner said, referring to Congressional proposals to boost VA funding by more than $6 billion in the next fiscal year. “The question is, are they being used properly?”

A Veterans Affairs statement confirmed that the agency requested the study and paid $840,000 for it.

“VA is studying the findings, conclusions and recommendations of the report to determine actions that can be taken to further enhance the services we provide,” the statement said.

But there was no getting around the fact that VA leaders also hoped to control skyrocketing compensation for PTSD. Three of their four goals for the federal study committee dealt with compensation – and for good reason.  

From 1999 to last year, the national VA system's number of PTSD claims rose from 120,265 to about 233,000. Its disability payments for PTSD more than doubled between 1999 and 2004 – from $1.72 billion to $4.28 billion.

Comparable numbers for the San Diego VA system weren't immediately available.

In the past year, VA leaders have acknowledged that they were unprepared for the flood of new PTSD claims. While their overall budget has increased dramatically, the amount designated for mental-health care remains relatively flat.

The result is a shortage of psychologists, psychiatrists and nurses trained to deal with PTSD and other mental-health conditions. Several VA and independent review panels have concluded that burnout is high among VA mental-health specialists because of their overwhelming workload.

The situation won't likely improve for them.

The new report shows that Vietnam War veterans made up most of the recent spike in applications for PTSD benefits. The study's authors expect hundreds of thousands of troops from the Persian Gulf, Iraq and Afghanistan wars to seek similar payments in the decades to come.

“There likely will be many more claims . . . so how this issue (of diagnosis and compensation) is resolved now will eventually affect many active-duty personnel,” the researchers wrote in their conclusions.

In a report released last month, the VA said 39,243 veterans out of 686,000 who have served in Iraq or Afghanistan since 2002 have been diagnosed with PTSD as their primary health problem.

Studies by the agency, the Pentagon and several universities have estimated that 17 percent to 33 percent of Iraq and Afghanistan veterans will file a claim for PTSD or other psychological problems during their lifetimes. If these veterans resemble their Vietnam War predecessors, many of their mental-health disability claims will come in their latter years – when their overall health fails or when another war reminds them of the ones they fought.

The report released yesterday also found that:

 The VA must do a better job of gathering, analyzing and publishing information about PTSD.

 To operate an effective PTSD program, the VA must use only experienced mental-health professionals to diagnose patients claiming to have the disorder. Currently, some of the evaluations last only 20 minutes while others run for three hours.

 VA officials must update the criteria they use to determine the severity of PTSD and thus the level of compensation. The study's authors described the present standards as crude and too general.

 VA leaders need to model their PTSD program after guidelines set by the American Psychiatric Association. They also should establish certification programs for workers who deal with PTSD claims.

 The VA should base PTSD disability payments on how much the disorder affects all aspects of a veteran's life, not just his or her ability to be gainfully employed.

 PTSD can be triggered by trauma other than combat, such as sexual assault. Female veterans are less likely to receive compensation for PTSD, which may partly be due to the difficulty of substantiating exposure to traumatic events unrelated to combat, including sexual harassment or assaults that occurred during military service.

The study's authors did not address how much it would cost to carry out their recommendations or how long the overhaul might take.

Nevertheless, leaders of several veterans groups praised the report.

“It's a step forward. It insists on training and accountability and more thorough examinations – a lot of the things we've been seeking for a long time,” said Dave Gorman, executive director for Disabled American Veterans, a national organization with 1.2 million members.

He and other advocates for veterans said the VA system needs standardized disability rates, better training for its compensation evaluators and more thorough screenings for PTSD.

“The VA should uniformly apply the disability rate schedule for everyone,” said Bill Rider Jr., president of the American Combat Veterans of War in San Diego County.

“In some places in the country, you get higher ratings of disability compensation versus other regions,” he said. “Some military services also get a higher rate than others.”

The veterans' representatives are wary of VA leaders' intentions for commissioning the new study. They're concerned that the report will serve as a Trojan horse for military and VA officials who want to reduce PTSD benefits because they believe the disorder doesn't affect many veterans or because they foresee a shortage of funds to deal with the swelling caseload.

“There are some people in Congress, the Bush administration and the VA who keep saying that all these entitlement programs are out of control and that something has to be done in the name of saving taxpayer money,” said Dave Autry, a spokesman for Disabled American Veterans.

“What they forget is that this is an earned entitlement,” Autry said.

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