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Post-Traumatic Stress Disorder (PTSD)

From Sticker Shock over Shell Shock, by Mark Benjamin
Salon, 9 August 2005
see Full Article

The U.S. government is reviewing 72,000 cases in which veterans have been diagnosed with severe post-traumatic stress disorder, claiming that misdiagnosis and fraud have inflated the numbers. Outraged vets say the plan is a callous attempt to cut the costs of an increasingly expensive war.

To outraged veterans groups, the review smacks of a convenient way to cut costs during an increasingly expensive war and reflects a reluctance by the department to take PTSD seriously. "The V.A. hopes to trim costs for existing war veterans and recently returning war veterans by targeting PTSD," says Steve Robinson, executive director of the National Gulf War Resource Center, a veterans advocacy organization in Silver Spring, Md. "This is a desperate and despicable move by an administration caught without a plan, the money, or the staff to care for our nation's wounded warriors."

The Department of Veterans Affairs decided to undertake the review after the department's inspector general issued a report last May, showing the agency had been inconsistent in granting a 100 percent PTSD rating to veterans. It found that the likelihood of a veteran's getting the maximum payment varied widely in regions across the country, calling into question the evaluation procedures. For example, in 2004, VA statistics show that an average of 8.9 percent of veterans in New Mexico, Maine, Arkansas, West Virginia, Oklahoma and Oregon received a 100 percent PTSD rating. On the other hand, an average of 2.8 percent of vets received the maximum payment in Indiana, Michigan, Connecticut, Ohio, New Jersey and Illinois.

Once a soldier is out of the military, he can make a claim at the V.A. to receive compensation for wounds, illnesses or mental trauma from service. Doctors perform examinations and make recommendations to adjudicators, who use a ratings system to decide how much money, if any, a veteran will receive. To grant payments to a veteran for PTSD, the agency documents "stressors," the traumatic events that occurred. It examines military records, reviews combat awards like Purple Hearts, and in some cases interviews veterans' war buddies. The V.A. report found that in one out of four cases, agency staff may have failed to fully document the events that triggered trauma from veterans who later got full payments for PTSD. The report expresses concern that the number of veterans receiving payments for PTSD is growing rapidly, from approximately 120,000 cases in 1999 to 216,000 in 2004. PTSD benefit payments, it notes, have soared from $1.7 billion in 1999 to $4.3 billion in 2004.

It also raises the specter that some veterans might be engaging in fraud, stating that 2.5 percent of cases where veterans were getting some money for PTSD were "potentially fraudulent." "We noted an abundance of Web sites providing advice to veterans filing PTSD claims or offering ways to compile less than truthful evidence to obtain approval," the report reads. It notes that one Web site sells a fake Purple Heart for $19.95.

Veterans groups, already enraged that the department might go back and take money from vets, have assailed the accusations of fraud. "It is like accusing somebody of sexual battery or a sexual offense," says Steve Smithson, deputy director for claims services at the American Legion. "Even if that person is later proven innocent, there is still going to be that shadow around him. They are trying to give people the impression that people are gaming the system."

Rick Weidman, director of government relations at Vietnam Veterans of America, says when the department briefed him on the inspector general report, agency officials used the word "fraud" seven times. "They used that as a pretext to find that the whole system was fraudulent and there was insufficient documentation of stressors," Weidman says. "It is outrageous. Say it is 2 percent? I'm willing to guess that the rate of fraud in travel and expenses among high-level V.A. officials is 2 percent. Let's investigate every one of them."

Veterans advocate Robinson, a retired Army Airborne Ranger, who served in the Gulf War, says that in all compensation systems there will always be some individuals who try to pull a fast one on the system. But in this case, he adds, the number of people unfairly being denied compensation "far outweighs" any losses from veterans involved in fraud.

PTSD is a particularly acute problem in Iraq because combat is marked by constant threats that can come from any direction at any time, and the line between civilians and insurgent enemies is blurry at best. A study by the Department of Psychiatric and Behavioral Sciences at Walter Reed Hospital, published in the New England Journal of Medicine in July 2004, showed 17 percent of troops returning from duty in Iraq met the strict screening criteria for mental problems such as PTSD. Nearly 25,000 veterans from Iraq and Afghanistan have been diagnosed with mental-health disorders from war, including PTSD, the V.A. told Congress last month.

By comparison, studies show that up to 30 percent of Vietnam vets, given they were often engaged in guerrilla warfare in jungles, have experienced PTSD. A 1950 study of WW II showed that 10 percent of vets suffered from "traumatic war neurosis," the term that predated PTSD. In any event, the price tag for PTSD from Iraq is going to be steep and will continue to be for decades as veterans collect checks, in some cases for the rest of their lives.

Veterans Affairs says it wants to make sure that vets getting payments for mental wounds deserve the money. "We have a responsibility to preserve the integrity of the rating system and to ensure that hard-earned taxpayer dollars are going to those who deserve and have earned them," Daniel L. Cooper, the V.A.'s undersecretary for benefits, tells Salon in a written statement. He says the V.A. will look into 72,000 cases, dating from 1999 to 2004, where veterans received the maximum payment for mental trauma from war.

Cooper says the department will work hard to make sure that "the veteran is treated consistently and fairly" during the process. "There is no focus on fraud," Cooper writes. "The focus is on proper justification and consistency in all cases." But, he adds, "If there is fraud found, that case will be immediately referred to the [inspector general] for resolution." During the review, Cooper says the department will go through each case to make sure that stressors from war have been "properly validated" and proved.

What that boils down to, says Robinson, is that veterans caught in the V.A. review are going to have to prove they were hurt all over again. "If you had a claim granted during this time period, you better get out your [military records] and start calling your buddies for evidence of your combat exposure," he says. Ironically, the inspector general report was instigated in response to a request from a slate of elected officials from Illinois, including Democratic Sen. Barack Obama, who asked the department to look into payments to veterans in his state because they might be too low.

But the agency will focus this new review of 72,000 cases solely on veterans who are getting the maximum monthly payments for PTSD. It will obviously include soldiers with the most insidious mental problems following combat: homicidal rage, suicidal thoughts, nightmares, anxiety, sleeplessness, hallucinations and paranoia.

Weidman says the department's pursuit of vets with PTSD only exacerbates the stigma attached to mental trauma. "There is flat-out discrimination against PTSD on the part of many people, both in the military and it carries over to the V.A.," he says. He calls the V.A. review "a biased and bigoted view of neuropsychiatric wounds."

However, veterans groups say the V.A. simply has failed to train its own staff to evaluate PTSD consistently. They explain that this is one reason why the V.A. inspector general report in May showed that the department was so inconsistent in deciding under what conditions veterans should get maximum payments for mental trauma. "The V.A. places the blame for these variances squarely on the veteran, with only minimal discussion about V.A. doctors not doing proper medical exams or unified claims rating processes across the nation," says Robinson. "If the V.A. really wants to solve this problem, then they should look at their systems for medical screening."

If the V.A. properly examines its medical screening practices, say veterans advocates, it is bound to find that many soldiers were wrongly denied medical benefits for PTSD in the first place. In fact, they say, that is a far more widespread and insidious problem. "They have never looked at their erroneous denials," says Smithson. "What is happening is they are looking at ways to save money. If they looked at denials, that would cost them money."

In a statement to Salon, Obama says it is "wrong for the V.A. to choose only to reevaluate cases where veterans received 100 percent PTSD ratings and not review the cases of those veterans who may have received a rating that was unfairly low or unjustly denied," he writes. "We shouldn't cut costs at the V.A. on the backs of these veterans -- it is our moral obligation to make sure each of them is being treated fairly." Obama recently drafted an amendment, passed by the Senate Veterans Affairs Committee, that would require the V.A. to standardize procedures for assessing PTSD and better train staff.

Veterans groups say the Bush administration's sticker shock from the Iraq war is behind the review. To them, the review of 72,000 PTSD cases is part of the administration's larger strategy to manage a budget that is already making it harder for veterans to get benefits or healthcare.

Last month, the V.A. admitted that veterans healthcare will be $1 billion more this year and $2.6 billion more next year than the agency previously claimed. The department says it underestimated the number of troops coming back from war, but critics say the agency was trying to low-ball the V.A. budget. After beating back Democrats' efforts to give the agency more money, embarrassed Republicans quickly began moving $1.5 billion in emergency funds to the department. (Former House Veterans Affairs Committee chairman and New Jersey Republican Rep. Christopher H. Smith long sought more funds for the department. Veterans groups and Democrats think that the GOP removed him from that post in favor of Indiana Republican Rep. Steve Buyer, who might be more amenable to cost cuts.)

In June, the V.A. issued an order that would have made it more difficult to grant veterans 100 percent disability for PTSD by requiring further review of those cases before granting payments. It was rescinded a week later in the face of intense criticism from veterans groups, who wanted equal scrutiny on cases where the department decided to deny a PTSD claim.


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