By Shankar Vedantam
Washington Post Staff Writer
Wednesday, May 9, 2007
The government's methods for deciding compensation for emotionally disturbed veterans have little basis in science, are applied unevenly and may even create disincentives for veterans to get better, an influential scientific advisory group said yesterday.
The critique by the Institute of Medicine, which provides advice to the federal government on medical science issues, comes at a time of sharp increases in cases of post-traumatic stress disorder (PTSD) among veterans and skyrocketing costs for disability compensation. The study was undertaken at the request of the Department of Veterans Affairs amid fears that troops returning from the wars in Iraq and Afghanistan will produce a tidal wave of new PTSD cases.
Between 1999 and 2004, benefit payments for PTSD increased nearly 150 percent, from $1.72 billion to $4.28 billion, the report noted. Compensation payments for disorders related to psychological trauma account for an outsize portion of VA's budget -- 8.7 percent of all claims, but 20.5 percent of compensation payments.
VA officials said they welcomed the report. "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," spokesman Matt Burns said in a statement.
The report suggested changes to VA policies, but the panel could not say whether those changes would result in more or fewer PTSD diagnoses, or in greater or lesser expense for taxpayers. "PTSD has become a very serious public health problem for the veterans of current conflicts and past conflicts," said psychiatrist Nancy Andreasen of the University of Iowa, who chaired the panel. Noting the shortcomings of the VA system, Andreasen added that "a comprehensive revision of the disability determination criteria are needed."
She said the current VA system, in which PTSD compensation is limited to those who are unable to hold a job, places many veterans in a Catch-22.
"You can't get a disability payment if you get a job -- that's not a logical way to proceed in terms of providing an incentive to become healthier and a more productive member of society," she said.
The practice is especially wrong, she added, because it is at odds with VA policies for other kinds of injuries. To determine the compensation a wounded veteran should get, the government assigns one a disability score. Veterans who are quadriplegic, for example, can be assigned a disability level of 100 percent even if they hold a job, whereas veterans with PTSD must show they are unable to work to get compensation.
Andreasen said the policies are "problematic, in the sense that they require the person given compensation to be unemployed. This is a disincentive for full or even partial recovery."
One solution suggested by the panel was to set a minimum compensation level for veterans disabled by PTSD, which would allow those who can seek work to do so.
"This is the report the VA didn't want," said Larry Scott, founder of the group VAWatchdog.org, who applauded the conclusions. If the IOM's recommendations are implemented, he said, they will cost VA "billions of dollars -- more staff, more staff training, more data collection, more clinical evaluations and higher awards."
The report identified problems with both arms of VA's evaluation and compensation procedures: A veteran currently undergoes an evaluation to determine if he or she has PTSD, and the results are used by other raters to determine the level of disability and the amount of compensation.
The Institute of Medicine panel said the scale used to evaluate veterans is outdated and largely designed for people who suffer from other mental disorders. Andreasen and other members also said they had heard from veterans who had received wildly different kinds of evaluations -- some lasting 20 minutes while others took hours. The scientists said VA should standardize the evaluations using state-of-the-art diagnostic techniques.
While VA requires its experts to determine what proportion of a veteran's disabilities were caused by particular traumatic experiences, and to what extent overlapping symptoms are related to particular disorders, the IOM said there is no scientific way to classify symptoms in this manner.
"The VA's disability policies for veterans with PTSD were developed over 60 years ago and now require major, fundamental reform," said Chris Frueh, a former VA clinician who is now a psychologist at the University of Hawaii at Hilo and was not involved with producing the new report. But even though better care is needed for veterans, Frueh said, it is important not to assume that trauma always results in a mental disorder.
"Scientific evidence indicates that resilience is the most common human response to trauma," he said. "Even for the most severe forms of trauma, such as rape or combat, most people do not develop PTSD."