Continued fallout from the release of an email by CREW and VoteVets.org obtained from a Veterans Affairs (VA) employee directing VA staff to refrain from diagnosing soldiers and veterans with Post Traumatic Stress Disorder (PTSD). The email can be seen here. Last week, the Senate Veterans Affairs Committee held hearings on the subject. The Chair of that Committee, Senator Daniel Akaka (D-HI), blasted the VA for its "widespread indifference":

The Veterans Affairs Department seems to have a widespread indifference toward veterans with mental illness, U.S. Sen. Daniel K. Akaka and other Senate Democrats said yesterday.

Their comments came after the Senate Veterans Affairs Committee, which Akaka chairs, heard a VA psychologist deny she was trying to save money when she suggested in an e-mail to her staff that they use other mental illness diagnoses for veterans who may have post-traumatic stress disorder.

"This incident was both disturbing and disappointing," Akaka said. "It reinforced fears among many veterans that the VA's mental health system is not meeting all their needs."

The e-mail, written by Norma Perez, a former PTSD program coordinator for the VA medical center in Temple, Texas, followed another problem where VA officials tried to suppress data on veteran suicides, Akaka said.

"Together, these incidents suggest a possible trend — widespread indifference to the invisible wounds of war," Akaka said. "We are concerned about systemwide problems within VA's mental health system."

Akaka has asked the VA to review and revise its PTSD treatment and compensation guidelines and provide complete data on veterans' suicides. He also has requested a VA inspector general's investigation of the Temple VA medical center.

More fallout from yesterday's hearing in the Senate Veterans Affairs Committee.  The Committee called several staffers from the Department of Veterans Affairs.  Witnesses included Norma Perez, the VA hospital's PTSD program coordinator.   Last month, CREW and VoteVets exposed an email sent by Perez to to a number of VA employees, including psychologists, social workers, and a psychiatrist stating that due to an increased number of “compensation seeking veterans,” the staff should “refrain from giving a diagnosis of PTSD straight out” and they should “R/O [rule out] PTSD” and consider a diagnosis of “Adjustment Disorder.”

At the hearing, Perez tried to explain and defend her actions, but Senators weren't convinced.  From the Honolulu Advertiser:

U.S. Sen. Jon Tester, D-Mont., a committee member, said he "didn't buy" Perez's explanation.

"She sent out an e-mail telling folks not to worry about real diagnoses but to diagnose people with this adjustment disorder," he said. "I just think that is criminal. If people are going to get the help they need in a timely manner, we need to do the best diagnosis we can."

After the hearing, Melanie Sloan, executive director of Citizens for Responsibility and Ethics in Washington, said there is widespread misdiagnosis of veterans with PTSD to cut costs.

"It is unconscionable that administrators like Norma Perez and those higher up the food chain are instituting a process by which our service members are lied to on a regular basis," she said.

Jon Soltz, an Iraq war veteran and chairman of VoteVets.org, said the problem is serious.

"Veterans clearly are having problems getting diagnoses with PTSD, and even when they are diagnosed, cannot get approved for disability claims," he said. "This is shameful treatment of the men and women who fought for our nation in war."

AFP has a report on today's hearing: 

US Senators on Wednesday grilled Veterans Affairs Administration (VA) officials over an email branding soldiers as "compensation-seekers" and urging staff to make fewer diagnoses of post-traumatic stress disorder (PTSD). 

"Citing 'compensation-seeking veterans,' the email in question encourages VA practitioners to avoid diagnosing veterans with PTSD in order to save time and money," Senator Patty Murray told a hearing of the Senate Veterans' Affairs committee.

"This email is a sad reminder that this administration's attempt to hide the true cost of war has begun to affect the way VA employees view their work," Murray said.

Mental health specialist Norma Perez sent out the email in March to staff at the VA medical center in Texas, where she was a coordinator of the PTSD clinical team.

Senators at the hearing cited the email as saying: "Given that we are having more and more compensation-seeking veterans, I would like to see you refrain from giving a diagnosis of PTSD straight out."

Perez said the aim of her email was to urge staff to be "more sensitive to what the veterans are going through." She did not explain how the email was intended to achieve that.

Other VA officials praised the veterans' agency in their testimonies and highlighted the enormous workload that is weighing it down as claims for PTSD snowball.

Last month, CREW and Vote Vets "released an e-mail obtained from a Veterans Affairs (VA) employee directing VA staff to refrain from diagnosing soldiers and veterans with Post Traumatic Stress Disorder (PTSD):

On March 20, 2008 a VA hospital’s PTSD program coordinator sent the e-mail below to a number of VA employees, including psychologists, social workers, and a psychiatrist stating that due to an increased number of “compensation seeking veterans,” the staff should “refrain from giving a diagnosis of PTSD straight out” and they should “R/O [rule out] PTSD” and consider a diagnosis of “Adjustment Disorder” instead.

Congress is now getting involved.

From the Senate Veterans Affairs Committee:

Hearing: Systemic Indifference to Invisible Wounds

June,4,2008

Wednesday, June 4, 2008 9:30am SR-418

Oversight hearing - Systemic Indifference to Invisible Wounds

Click Here to View LIVE Hearing

1-Committee Leadership

• Chairman Daniel K. Akaka

Panel I

• DR. NORMA PEREZ, MENTAL HEALTH INTEGRATION PSYCHOLOGIST, CENTRAL TEXAS VETERANS HEALTH CARE SYSTEM
• MICHAEL J. KUSSMAN, MD, UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS
• REAR ADMIRAL PATRICK W. DUNNE, USN (RET), ACTING UNDER SECRETARY FOR BENEFITS, VETERANS BENEFITS ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

CREW and VoteVets.org requested that the Inspector General for the Department of Veterans Affairs (VA) open an investigation into the process and manner by which the VA makes a diagnosis of post traumatic stress disorder (PTSD) in veterans.  The letter to the VA, which we sent today, can be found here.

In the wake of the disclosure by CREW and VoteVets.org of an internal VA e-mail advising VA mental health staff in Texas to consider a diagnosis of adjustment disorder in place of a PTSD diagnosis as a cost-cutting measure, both organizations have received new information from VA employees and veterans attesting to the fact that this practice is widespread and systemic. VA Secretary James Peake has repudiated the email as not reflecting VA policy. 

The VA has adopted incentive programs that, by rewarding those employees and hospitals that distribute lower levels of compensation to veterans, encourage adjustment disorder diagnoses rather than the most appropriate but also more costly diagnosis of PTSD.

In addition, the VA's internal computer system permits medical files to be changed by health professionals who did not conduct the initial examinations, a practice that appears to have resulted in changed diagnoses from PTSD to adjustment disorder, even where there is no additional medical evidence to support the downgraded diagnoses.

CREW and VoteVets.org also heard from VA employees who suffered retaliation for their failure to support these practices.

Melanie Sloan, executive director of CREW, said:

It is unconscionable that the VA would actively encourage its staff, through monetary incentives, to misdiagnose our veterans’ mental health. Add to that the mind-boggling disclosure that medical files can be altered to downgrade service members’ conditions, and we have a VA that is betraying those it is supposed to serve. The VA Inspector General must spearhead an investigation into these abhorrent practices immediately.

Jon Soltz, Iraq War vet and Chair of VoteVets.org, added this statement:

Despite what Secretary Peake said, the misdiagnoses being encouraged at the Temple, TX VA Center were not an isolated incident. The only question now is: How widespread is this, and how high up does the problem go?  Those of us who served this nation in war deserve to have full confidence in the programs set up to help transition us back to civilian life. These new revelations personally give me zero confidence in the mental health screening and care system the VA oversees.

On May 14th, CREW also sent a Freedom of Information Act request to the VA asking for all records pertaining to any guidance given regarding the diagnosis of PTSD.

Last week, CREW and Vote Vets "released an e-mail obtained from a Veterans Affairs (VA) employee directing VA staff to refrain from diagnosing soldiers and veterans with Post Traumatic Stress Disorder (PTSD):

On March 20, 2008 a VA hospital’s PTSD program coordinator sent the e-mail below to a number of VA employees, including psychologists, social workers, and a psychiatrist stating that due to an increased number of “compensation seeking veterans,” the staff should “refrain from giving a diagnosis of PTSD straight out” and they should “R/O [rule out] PTSD” and consider a diagnosis of “Adjustment Disorder” instead.

The fallout continues.  Today, NPR is reporting that more members of Congress are asking for an investigation into this matter:

In an e-mail, a psychologist at the Olin E. Teague Veterans' Center in Temple, Texas, advised her staff to stop diagnosing veterans with PTSD to save money. The e-mail became public last week.

The head of the Department of Veterans Affairs insists that's not VA policy.

Psychologist Norma Perez was hired last summer to help coordinate a PTSD program at the center, which draws a lot of veterans. Not long afterward, Perez announced she would disband a dozen or so PTSD therapy groups, in which about 140 veterans met monthly with a clinical counselor. Perez wanted to replace the long-term groups with short-term plans — lasting no longer than three months — that focus on coping skills and cognitive processing therapy. The VA uses a broad range of therapies for PTSD, including group therapy.

Some veterans in the program said Perez told them that long-term group therapy doesn't work. Some vets accused Perez of personally trying to destroy their groups.

But Kim Larsen, a former Army medic and Vietnam vet with PTSD, who attended two VA forums about the plan to disband the groups, had a different impression. He thought Perez was simply the messenger. Then he saw an e-mail from Perez to her staff, advising them to "refrain from giving a diagnosis of PTSD straight out...." It was dated March 20.

Incensed, Larsen shared the e-mail and it wound up with Citizens for Responsibility and Ethics, a watchdog group, and VoteVets.org, a veterans advocacy group. Last week, the groups posted the e-mail on the Internet, setting off a tempest.

Congressional leaders and Democratic presidential candidate Sen. Barack Obama called for an investigation, and the inspector general of the VA has begun one.

Rep. Bob Filner, a California Democrat who heads the House Veterans Affairs Committee, said of Perez: "I can't believe that someone at that level position is doing this on her own. Somewhere in the hierarchy people are saying, 'It's costing us too much with these PTSD diagnoses. Cool it.'"

Brandon Friedman from VoteVets reports in a diary at DailyKos:

Senator Barack Obama involved himself in the VA email situation today by sending a letter to VA Secretary James Peake demanding an investigation into whether or not the Department of Veterans Affairs is under-diagnosing combat-related PTSD as a cost-cutting measure.  Obama then requested hearings on the matter and, within hours, those requests were granted by the chairmen of the House and Senate Veterans Affairs Committees.

This move by Obama comes after VoteVets.org and CREW produced an email on Thursday from a VA official--Norma Perez--in which she advised a number of VA employees, including psychologists, social workers, and a psychiatrist that, due to an increased number of "compensation seeking veterans," the staff should "refrain from giving a diagnosis of PTSD straight out" and they should "R/O [rule out] PTSD" and consider a diagnosis of "Adjustment Disorder" instead.

The story has now been picked up by the AP, the Washington Post, CBS News, the New York Daily News, MSNBC, CNN, the Politico, and the Military Times.

In his letter to Peake today, Obama called on the VA Secretary

to launch an investigation into the incident to evaluate whether Perez was advised to send this e-mail or give this instruction at the urging of her superiors; whether staff members at the Teague Center followed Perez's advice, and if so, how many veterans were affected by incorrect diagnoses; whether officials at other veterans centers have given some similar admonitions to staff members charged with diagnosing PTSD; whether affected veterans have been given immediate re-diagnoses and; whether this is an incident or a trend through the VA system.

You can read the full text here.

Washington Post:

A psychologist who helps lead the post-traumatic stress disorder program at a medical facility for veterans in Texas told staff members to refrain from diagnosing PTSD because so many veterans were seeking government disability payments for the condition.

"Given that we are having more and more compensation seeking veterans, I'd like to suggest that you refrain from giving a diagnosis of PTSD straight out," Norma Perez wrote in a March 20 e-mail to mental-health specialists and social workers at the Department of Veterans Affairs' Olin E. Teague Veterans' Center in Temple, Tex. Instead, she recommended that they "consider a diagnosis of Adjustment Disorder."

VA staff members "really don't . . . have time to do the extensive testing that should be done to determine PTSD," Perez wrote.

Adjustment disorder is a less severe reaction to stress than PTSD and has a shorter duration, usually no longer than six months, said Anthony T. Ng, a psychiatrist and member of Mental Health America, a nonprofit professional association.

Veterans diagnosed with PTSD can be eligible for disability compensation of up to $2,527 a month, depending on the severity of the condition, said Alison Aikele, a VA spokeswoman. Those found to have adjustment disorder generally are not offered such payments, though veterans can receive medical treatment for either condition.

Perez's e-mail was obtained and released publicly yesterday by VoteVets.org, a veterans group that has been critical of the Bush administration's policies in Iraq and Afghanistan, and Citizens for Responsibility and Ethics in Washington (CREW), a nonprofit government watchdog group.

"Many veterans believe that the government just doesn't want to pay out the disability that comes along with a PTSD diagnosis, and this revelation will not allay their concerns," John Soltz, chairman of VoteVets.org and an Iraq war veteran, said in a statement.

Melanie Sloan, executive director of CREW, said in a statement: "It is outrageous that the VA is calling on its employees to deliberately misdiagnose returning veterans in an effort to cut costs. Those who have risked their lives serving our country deserve far better."

Veterans Affairs Secretary James B. Peake said in a statement that Perez's e-mail was "inappropriate" and does not reflect VA policy. It has been "repudiated at the highest level of our health care organization," he said.

"VA's leadership will strongly remind all medical staff that trust, accuracy and transparency is paramount to maintaining our relationships with our veteran patients," Peake said.

Peake said Perez has been "counseled" and is "extremely apologetic." Aikele said Perez remains in her job.

This is an outrage.

CREW and VoteVets.org released an e-mail obtained from a Veterans Affairs (VA) employee directing VA staff to refrain from diagnosing soldiers and veterans with Post Traumatic Stress Disorder (PTSD).

On March 20, 2008 a VA hospital’s PTSD program coordinator sent the e-mail below to a number of VA employees, including psychologists, social workers, and a psychiatrist stating that due to an increased number of “compensation seeking veterans,” the staff should “refrain from giving a diagnosis of PTSD straight out” and they should “R/O [rule out] PTSD” and consider a diagnosis of “Adjustment Disorder” instead:

This week, CREW sent a Freedom of Information Act (FOIA) request to the VA asking for all records pertaining to any guidance given regarding the diagnosis of PTSD. The FOIA request can be found here.

Melanie Sloan, executive director of CREW, said today:

It is outrageous that the VA is calling on its employees to deliberately misdiagnose returning veterans in an effort to cut costs. Those who have risked their lives serving our country deserve far better. First and foremost, they have a right to expect that they receive diagnoses and treatment based on their symptoms and not on the VA’s budget. The VA should immediately reverse this and any other similar directives.

Jon Soltz, an Iraq War Veteran and Chairman of VoteVets.org, added:

This is an issue I take personally. I know of many people who received a diagnosis of ‘Adjustment Disorder,’ who strongly felt they had PTSD, many of whom confirmed that suspicion with an independent diagnosis. Many veterans believe that the government just doesn’t want to pay out the disability that comes along with a PTSD diagnosis, and this revelation will not allay their concerns. It is crucial that we quickly get to the bottom of this, and ensure that misdiagnosing veterans is not part of some cost-cutting policy.

Last month, the RAND Corporation released a report that found that approximately 300,000 U.S. troops are suffering from major depression or post traumatic stress from serving in the wars in Iraq and Afghanistan, and only about half have sought treatment.