On December 4, 2009, CREW posted documents released by the Department of the Army in respect to CREW’s Freedom of Information Act Request (FOIA) for documents about the diagnosis of Post Traumatic Stress Disorder (PTSD) for Army soldiers. The FOIA request stemmed from a Salon.com article about an Army sergeant who recorded a doctor at an Army medical facility at Fort Carson, Colorado, telling him during an appointment, “clinicians up here are being pressured to not diagnose PTSD and diagnose anxiety disorder [instead.]”

CREW asked for records related to guidance given to army staff and contractors regarding the diagnosis of PTSD. So far we have received about 143 pages, all of which have been posted on www.governmentdocs.org. The documents include an investigative report conducted by the Army into the allegations that medical staffers were pressured to improperly diagnose PTSD at Ft. Carson. Unsurprisingly, the investigator did not find evidence of doctors being pressured or that anyone in the chain of command attempted to influence diagnosis.

What the report did find however, was:

". . .evidence of potential systemic pressures inherent in the Army physical disability evaluation processes that may influence MEDCOM [U.S. Army Medical Command] behavioral health providers in the course of conducting PTSD evaluations. These potential pressures may lead providers to avoid making a diagnosis of PTSD on medical boards contrary to their clinical judgment." (emphasis added)

These pressures seem to spring from two main sources. First, mental health providers interviewed in the report claim that understaffing and overwork have led them to look for, in the words of the report, “more efficient ways to get the job done.” One interviewee commented, “I have heard staff describe that it would be easier to diagnose Anxiety Disorder NOS because the MEB [Medical Evaluation Board] would be less likely to be returned. . .”

Second, the report’s author writes that the “requirements for evaluating PTSD are more strenuous than for any other mental disorder.” Providers need to document years of history for patients and corroborate facts regarding the traumatic event with the patients’ commanders or other sources. (In a December 2009 memo, the Army did slightly back off the requirement that MEBs and soldiers “provide credible supporting evidence of a PTSD stressor” but maintained that a traumatic stressor is required for a proper PTSD diagnosis.) As one interviewee put it, “Documenting the diagnosis of PTSD sufficient to withstand review by the PEB [Physical Evaluation Board] and the US Army PDA [Physical Disability Agency] is at times a challenge.” The same interviewee noted that the Army published an extensive, 20 plus page, guideline on the proper diagnosis of PTSD, but not for any other mental health condition. A different interviewee commented that, “I may have heard that a PTSD diagnosis is reviewed more carefully by the PEB.”

While it remains to be proven if commanders have advocated for a diagnosis cheaper or easier than PTSD, it seems clear, even from the small number of interviews conducted for this report, that Army mental health providers are facing systemic pressure to not diagnose PTSD.

From these documents, it also appears the Army’s mental health doctors are overworked, understaffed, and remain overburdened by bureaucracy and paperwork. The Army and the Defense Department should investigate further and ensure that these factors aren’t denying our soldiers the care they need and deserve.

CREW also requested PTSD documents from the Department of Veterans Affairs, and those can be found here.

In April, Salon printed an article with additional evidence, on tape, of Army medical personnel talking about the pressure to deny the diagnosis of Post-Traumatic Stress Disorder (PTSD) to military personnel. CREW has taken an active role in this issue.

In May, in light of those news reports that the Army has instituted the cost-cutting practice of ordering doctors to misdiagnose soldiers returning from battle with anxiety disorder rather than post traumatic stress disorder (PTSD), CREW and VoteVets.org today asked the chair of the House Armed Services Committee to investigate the extent of this outrageous practice.  Our letter can be found here.

We've been trying to get information from the Army, to no avail. So we're going to court.

Today, CREW filed a lawsuit against the Army, CREW v. Dep't of the Army, challenging the Army's failure to produce records in response to CREW's FOIA request seeking documentation of Army guidance that discourages diagnoses of post traumatic stress disorder (PTSD). The Veterans Affairs has issued similar guidance that CREW also is seeking to document through a FOIA request that is also the subject of pending litigation.

Our CREW's complaint and FOIA request can be found here.

In light of news reports that the Army has instituted the cost-cutting practice of ordering doctors to misdiagnose soldiers returning from battle with anxiety disorder rather than post traumatic stress disorder (PTSD), Citizens for Responsibility and Ethics in Washington (CREW) and VoteVets.org today asked the chair of the House Armed Services Committee to investigate the extent of this outrageous practice.  Our letter can be found here.

As we reported last month, Salon.com reported on a series of conversations at Fort Carson last summer between a sergeant and his psychologist, Dr. Douglas McNinch, during which the doctor admitted he was under pressure from the Army to avoid diagnosing soldiers with PTSD.

The sergeant, who taped his conversations because he suffers from memory problems due to brain injuries, met with Dr. McNinch to learn why the doctor had told the medical evaluation board responsible for the Army’s disability payment system that the sergeant suffered from anxiety disorder rather than PTSD. Dr. McNinch explained, on tape, “I will tell you something confidentially that I would have to deny if it were ever public. Not only myself, but all clinicians up here are being pressured not to diagnose PTSD and diagnose anxiety disorder NOS instead.” Dr. McNinch continued, “yours has not been the only case . . . I and other [doctors] are under a lot of pressure to not diagnose PTSD. It’s not fair. I think it’s a horrible way to treat soldiers . . .” Dr. McNinch has explained he was pressured to misdiagnose PTSD cases by a colonel, who was then head of Fort Carson’s Department of Behavioral Health.

With a diagnosis of anxiety disorder, the sergeant would receive substantially lower benefits upon a discharge for a disability.

Despite these recorded conversations the Army refused to take any action, relying instead on its own seriously flawed internal investigation.

Salon.com revealed that when Gen. Richard Cody, then vice-chief of staff, met with the sergeant’s legal representatives last July, he stated, “There is no one in leadership telling doctors to do this . . . This is not Army policy.” Two weeks later, the Army formally completed its internal investigation concluding that none of the Army’s medical staff had attempted to influence or coerce the outcome of clinical evaluations. The Army’s investigative report admitted, however, that there are “potential systemic pressures” that “may lead providers to avoid making a diagnosis of PTSD...contrary to their clinical judgment.” Neither the sergeant who taped his conversation with Dr. McNinch, nor the Army officer Dr. McNinch identified as pressuring him to misdiagnose soldiers was interviewed.

CREW and VoteVets.org are asking the House Committee to investigate because the Senate Armed Services Committee refused to do so.

The refusal to diagnose PTSD may be a systemic problem throughout the military. As exposed last year by CREW and VoteVets.org, and through a hearing conducted by the Senate Committee on Veterans’ Affairs, the Department of Veterans Affairs has also pressured health professionals to diagnose adjustment disorder rather than PTSD in soldiers returning from war.

Melanie Sloan, executive director of CREW, said:

It is outrageous that those who are supposed to take care of our service members and veterans will so easily compromise their health. Attempting to cut costs is reasonable, but changing diagnoses is not akin to cutting coupons. Those who serve our nation so heroically deserve better treatment.

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

Talk to anyone who has served recently, and they can tell you they have experienced an issue with a non or under-diagnosis of PTSD, or know someone who has.  This is a problem we’ve all heard of in the Defense Department and Veterans Affairs, and yet, there has yet to be a real investigation of the issue. Chairman Skelton has a chance to do a real service for those who serve in our military by investigating this issue with the scrutiny it deserves.

Salon has an important article about with the latest evidence, this time on tape, of military medical personnel talking about the pressure to deny the diagnosis of Post-Traumatic Stress Disorder (PTSD) to service members:

When Sgt. X went to see McNinch with a tape recorder, he was concerned that something was amiss with his diagnosis. He wanted to find out why the psychologist had told the medical evaluation board that handles disability payments that Sgt. X did not, in fact, have PTSD, but instead an "anxiety disorder," which could substantially lower the amount of benefits he would receive if the Army discharged him for a disability. The recorder in Sgt. X's pocket captured McNinch in a moment of candor. (Listen to a segment of the recording here.)

"OK," McNinch told Sgt. X. "I will tell you something confidentially that I would have to deny if it were ever public. Not only myself, but all the clinicians up here are being pressured to not diagnose PTSD and diagnose anxiety disorder NOS [instead]." McNinch told him that Army medical boards were "kick[ing] back" his diagnoses of PTSD, saying soldiers had not seen enough trauma to have "serious PTSD issues."

"Unfortunately," McNinch told Sgt. X, "yours has not been the only case ... I and other [doctors] are under a lot of pressure to not diagnose PTSD. It's not fair. I think it's a horrible way to treat soldiers, but unfortunately, you know, now the V.A. is jumping on board, saying, 'Well, these people don't have PTSD,' and stuff like that."

Contacted recently by Salon, McNinch seemed surprised that reporters had obtained the tape, but answered questions about the statements captured by the recording. McNinch told Salon that the pressure to misdiagnose came from the former head of Fort Carson's Department of Behavioral Health. That colonel, an Army psychiatrist, is now at Fort Lewis in Washington state. "This was pressure that the commander of my Department of Behavioral Health put on me at that time," he said. Since McNinch is a civilian employed by the Army, the colonel could not order him to give a specific, lesser diagnosis to soldiers. Instead, McNinch said, the colonel would "refuse to concur with me, or argue with me, or berate me" when McNinch diagnosed soldiers with PTSD. "It is just very difficult being a civilian in a military setting."

As the reporters, Michael de Yoanna and Mark Benjamin, noted, CREW has seen evidence of this behavior from the military.  Last year, working with VoteVets, we released an email from a Veterans Affairs (VA) employee directing VA staff to refrain from diagnosing soldiers and veterans with Post Traumatic Stress Disorder (PTSD).  That resulted in a hearing before the Senate Veterans Affairs Committee.   

VoteVets.org and CREW, the two groups who unearthed the V.A. e-mail, reacted viscerally to this new tape obtained by Salon. "This is further evidence our troops are not receiving the mental health treatment they need and deserve," said Melanie Sloan, CREW executive director. "The president and congressional leaders must hold those responsible accountable and make sure the message is sent far and wide that our returning troops are to be diagnosed as their symptoms, not the military's finances, dictate."

"We've heard all kinds of stories from vets who had trouble getting PTSD diagnoses," said VoteVets.org Chairman John Soltz. "It's crucial that we have department-wide investigations at the Departments of Defense and Veterans Affairs to determine if this came from someone high up, and how many troops and veterans were jilted out of a proper diagnosis from the government."

This is really an outrage.  Melanie is right, "The president and congressional leaders must hold those responsible accountable."

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."

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.