Distinguished members of the Subcommittee on PTSD of the Gulf War & Stress: Health Project, Vietnam Veterans of America (VVA) thanks you for the opportunity to present for the record our views on the current state of clinical diagnoses and the disability compensation claims process as accorded our nation's veterans suffering from PTSD.



* First, Vietnam Veterans of America applauds this Committee for its obvious concern about the mental health care of our troops and veterans.

VVA cautions, however, that providing the appropriate PTSD clinical diagnoses and services to assist these women and men requires both an understanding of the stresses and stressors to which they have been exposed and the willingness to commit the financial and personnel resources necessary to help these veterans cope and perhaps eventually recover. Evidence overwhelmingly supports the need for early intervention and treatment of PTSD and related mental health disorders not only for active duty troops and veterans but for their families as well. We must accept that only through early intervention and treatment can we hope for the recovery of our troops and veterans from the mental health diseases caused by the trauma of war.

But as Dr. William Winkenwerder, Assistant Secretary of Defense for Health Affairs observed in his testimony before the House Subcommittee on Military Personnel in October 2005, "no one who goes to war remains unchanged." There is no longer any doubt that the combat experiences of veterans can and often do cause mental health injuries that can be just as debilitating as physical wounds. If left untreated, post-traumatic stress disorder and other psychological traumas can affect combat veterans to the point that, over time, even their daily functions become seriously impaired. This places them at higher risk for self-medication and abuse with alcohol and drugs, domestic violence, unemployment & underemployment, homelessness, incarceration, suicide, and even medical morbidities such as cardiovascular diseases and cancer (1).

No one really knows how many of our troops in Iraq and Afghanistan have been or will be affected by their wartime experiences; despite the early intervention by psychological personnel, no one really knows how serious their emotional and mental problems will become. However, recent reports have suggested that troops returning from service in Afghanistan and Iraq are suffering mental health problems at a rate higher than the levels seen in Vietnam War veterans (2, 3, and 4). In fact, VVA has no reason to believe that the rate of veterans of this war having their lives significantly disrupted at some point in their lifetime by PTSD will be any less than the 37 percent estimated for Vietnam veterans by the National Vietnam Veterans Readjustment Study (NVVRS) conducted some 20 years ago.

Since 1980, when the American Psychiatric Association (APA) added PTSD to the third edition of its "Diagnostic and Statistical Manual of Mental Disorders (DSM-III)" classification scheme, a great deal of attention has been devoted to the development of instruments for assessing PTSD [see Keane et al., (5)], as well as to psychotherapy and pharmacotherapy PTSD treatment modalities [see Foa et al., (6) and the National Center for PTSD's Fact Sheets (7)]. Under intense pressure from Vietnam veterans and their Congressional supporters, the Department of Veterans Affairs subsequently developed a unique range of mental health diagnoses and care services to assist veterans with managing or even overcoming the most troubling of the symptoms associated with PTSD, and the VA disability, compensation, pension, and benefits system was amended to provide appropriate financial redress for the debilitating effects of PTSD or other mental health disability compensation claims related to military service. But the adjudication of PTSD claims continues to be a complex, constantly evolving exercise affected by regulations, legislation, and the latest medical research.

Often the VA orders a compensation examination by a VA clinician or contractor to establish proof of a service-connected PTSD disability. However, by the outset of the "Global War on Terrorism", Congressional investigations and G.A.O. reports noted that the VA was experiencing a chronic and growing claims back log which it has had little success in reducing.

Because of reductions in staff at both the Veterans Benefits Administration (VBA) and the Veterans Health Administration (VHA) -- mental health staff in particular -- and other key organizational capacities in general since 1996, too many clinicians and adjudicators (mis)-placed an emphasis on productivity rather than quality or accuracy and believed that they must see clients quickly, even if their examinations did not yield accurate clinical data or the correct information upon which to adjudicate the claim. Veterans' complaints of 15-minute or 30-minute examinations that were by the very nature of the process grossly inadequate to the point of being malfeasant (with strong pressure to continue these unconscionable practices) became commonplace. Many incorrect diagnoses have undoubtedly occurred as a result.

Subsequent VA attempts to address the problem led to significant variations in disability ratings by region and adjudicators for PTSD-related claims and other mental health disorders. Although post-traumatic stress disorder is a commonly compensated condition (i.e., awarded PTSD claims constitute about half of all awarded claims and about a quarter million veterans are currently compensated), it is important to note that PTSD is NOT the most variably rated disability; there are other disabilities for which ratings differ far more drastically, infectious diseases, for example. But this misconception has led to extravagant claims by some that the majority of PTSD-related claims are fraudulent and that a "secret underground network advises veterans where to go for the best chance of being declared disabled."

In any case, by 2002 the Department of Veterans Affairs had prepared a "Best Practice Manual for Posttraumatic Stress Disorder (PTSD) Compensation and Pension Examinations" (8) containing scientifically validated assessment instruments for the diagnostic evaluation of PTSD and guidelines for the determination of a service-connected disability for PTSD. In fact, several of the distinguished scientists who co-authored this Best Practice Manual sit before us today.

Members of this Subcommittee, however, might be astonished to discover that by February 2006, the VA not only has issued no directives to clinicians and to adjudicators to use the Manual, nor provided any training on this guide, but that even copies of it are not available to staff throughout the VA, nor to anyone else for that matter. VVA has good reason to believe that there are thousands of hard copies of the Best Practices Manual sitting in a warehouse somewhere, printed with tax dollars from you and me, that they refuse to make available.

With that said, VVA offers the following comments specific to the mental health clinical diagnostic practices currently being offered our nation's veterans seeking rightful disability compensation claims for their PTSD suffering --

* VA Central Office must formally direct the distribution and use of its "Best Practice Manual for Posttraumatic Stress Disorder" throughout the VA healthcare system.

The Best Practice Manual includes the following statement on page 6: "The VHA encourages use of this protocol when examining veterans for compensation purposes to ensure that a detailed history is obtained from the veteran and a comprehensive evaluation is performed and documented".

An unhurried, scientifically validated diagnostic assessment mechanism utilizing current DSM-IV checklists must be uniformly applied to obtain the correct type of clinical data necessary to provide accurate PTSD diagnoses. The Best Practice Manual contains not only a standardized assessment protocol, but also includes appropriately validated diagnostic and psychometric assessment tools and a recommended initial examination time of at least three hours to perform the series of psychological evaluations needed to best decide and rate the claim, along with a 90-minute follow-up examination. And according to the Manual, assessment for PTSD must also include the client's military history.

* The VA must also provide the resources for appropriate, in-depth training for the VA mental health clinicians, staff and adjudicators to properly and effectively implement the Manual's protocol and guidelines.

Training in the use of the "Best Practice Manual" is, in the parlance of today's world, a "no brainer." But adequate training is also necessary for looking for, identifying, and assessing PTSD clients within the framework of their particular war-related trauma and to ensure sensitivity using non-invasive methods of inquiry, such as motivational interviewing. In addition, a staff that is thoroughly knowledgeable with the Manual will become familiar with both asking appropriate questions and recognizing physiological symptoms that may better assist in accurate diagnoses and effective evaluations.

* The VA mental health leadership in cooperation with the Veterans Benefits Administration must change the way PTSD and other disability claims are adjudicated.

In addition to increasing the number of adjudicators (as well as providing much better training, competency based testing, and much better supervision), VVA proposes a pilot project in which the most experienced adjudicators at a VARO "triage" incoming claims, rather than simply handling them by docket number. Relatively simple claims can then be fast-tracked; there is no reason why a veteran who files a claim along with the appropriate paperwork for, say, tinnitus, cannot be adjudicated within 60 days. Claims that need additional documentation can be returned to the veteran or the veteran's service officer. Difficult or complicated cases can be routed to the most experienced adjudicators. Because the adjudication of PTSD claims historically seems to have resulted in significant disparities in adjudication decisions, these might be sent to a special group of adjudicators well-trained and well-versed in the VA's Best Practices Manual. VVA believes this proposed change can improve productivity as well as morale in both the VA and VBA systems and be welcomed by the veterans community.

* The VA should develop and launch an internal mental health anti-stigma campaign that focuses on PTSD.

The stigma associated with seeking help for PTSD will not decrease without a system wide campaign to change perceptions and attitudes among staff and leadership. Educational programs for VA mental health staff, veterans and their families should be strongly encouraged, and the programs should present symptoms and descriptions of combat-related PTSD and other mental health problems, publicize available resources, encourage veterans to come forward, and guarantee that seeking assistance for PTSD within the VA system will not be held against the individual.

Thank you.