[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
THE NEXUS BETWEEN ENGAGED IN COMBAT
WITH THE ENEMY AND POST-TRAUMATIC
STRESS DISORDER IN AN ERA OF
CHANGING WARFARE TACTICS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON DISABILITY ASSISTANCE
AND MEMORIAL AFFAIRS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
MARCH 24, 2009
__________
Serial No. 111-9
__________
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
48-423 WASHINGTON : 2009
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
JOHN J. HALL, New York, Chairman
DEBORAH L. HALVORSON, Illinois DOUG LAMBORN, Colorado, Ranking
JOE DONNELLY, Indiana JEFF MILLER, Florida
CIRO D. RODRIGUEZ, Texas BRIAN P. BILBRAY, California
ANN KIRKPATRICK, Arizona
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
March 24, 2009
Page
The Nexus Between Engaged in Combat with the Enemy and Post-
Traumatic Stress Disorder in an Era of Changing Warfare Tactics 1
OPENING STATEMENTS
Chairman John J. Hall............................................ 1
Prepared statement of Chairman Hall.......................... 36
Hon. Doug Lamborn, Ranking Republican Member..................... 3
Prepared statement of Congressman Lamborn.................... 37
WITNESSES
U.S. Department of Defense:
Rear Admiral David J. Smith, M.D., SHCE, USN, Joint Staff
Surgeon, Office of the Chairman of the Joint Chiefs of
Staff, Wounded and Survivor Care Task Force................ 19
Prepared statement of Admiral Smith...................... 53
Colonel Robert Ireland, Program Director, Mental Health
Policy, Office of the Assistant Secretary of Defense for
Health Affairs............................................. 21
Prepared statement of Colonel Ireland.................... 53
U.S. Department of Veterans Affairs:
Bradley G. Mayes, Director, Compensation and Pension Service,
Veterans Benefits Administration........................... 23
Prepared statement of Mr. Mayes.......................... 54
Antonette Zeiss, Ph.D., Deputy Chief Consultant, Office of
Mental Health Services, Office of Patient Care Services,
Veterans Health Administration............................. 24
Prepared statement of Dr. Zeiss.......................... 56
______
American Legion, Ian C. De Planque, Assistant Director, Veterans
Affairs and Rehabilitation Commission.......................... 5
Prepared statement of Mr. De Planque......................... 38
Iraq and Afghanistan Veterans of America, Carolyn Schapper, Repres
entative....................................................... 8
Prepared statement of Ms. Schapper........................... 43
Kilpatrick, Dean G., Ph.D., Distinguished University Professor,
and Director, National Crime Victims Research and Treatment
Center, Medical University of South Carolina, Charleston, SC,
and Member, Committee on Veterans' Compensation for
Posttraumatic Stress Disorder, Institute of Medicine and
National Research Council, The National Academies.............. 13
Prepared statement of Dr. Kilpatrick......................... 44
Murdoch, Maureen, M.D., MPH, Core Investigator, Center for
Chronic Disease Outcomes Research, Minneapolis Veterans Affairs
Medical Center, Veterans Health Administration, U.S. Department
of Veterans Affairs............................................ 26
Prepared statement of Dr. Murdoch............................ 58
Tanielian, Terri, MA, Study Co-Director, ``Invisible Wounds of
War'' Study Team, RAND Corporation............................. 15
Prepared statement of Ms. Tanielian.......................... 47
Vietnam Veterans of America, Thomas J. Berger, Ph.D., Senior
Analyst for Veterans' Benefits and Mental Health Issues........ 7
Prepared statement of Dr. Berger............................. 41
SUBMISSIONS FOR THE RECORD
National Council on Disability, John R. Vaughn, Chairperson,
letter and attachments......................................... 59
Veterans for Common Sense, Paul Sullivan, Executive Director,
statement...................................................... 63
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Ian De Planque, Assistant Director, Veterans
Affairs and Rehabilitation Commission, American Legion,
letter dated April 7, 2009, and response letter dated May
4, 2009.................................................... 68
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Thomas Berger, Ph.D., Senior Analyst for
Veterans' Benefits and Mental Health Issues, Vietnam
Veterans of America, letter dated April 7, 2009, and VVA
responses.................................................. 72
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Carolyn Schapper, Representative, Iraq and
Afghanistan Veterans of America, letter dated April 7,
2009, and IAVA responses................................... 74
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Dean G. Kilpatrick, Ph.D., Member, Committee on
Veterans' Compensation for Posttraumatic Stress Disorder,
Institute of Medicine, and Dr. Kilpatrick's responses...... 75
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Terri Tanielian, Study Co-Director, ``Invisible
Wounds of War,'' RAND Corporation, letter dated April 7,
2009, and Ms. Tanielian and Ms. Eibner's responses......... 78
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Rear Admiral David Smith, M.D., SHCE, USN,
Joint Staff Surgeon, Office of the Chairman of the Joint
Chiefs of Staff, Wounded and Survivor Care Task Force, U.S.
Department of Defense, letter dated April 7, 2009, and DoD
responses.................................................. 81
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Colonel Robert Ireland, Program Director,
Mental Health Policy, Office of the Assistant Secretary of
Defense for Health Affairs, U.S. Department of Defense, and
DoD responses.............................................. 84
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Bradley Mayes, Director, Compensation and
Pension Service, Veterans Benefits Administration, U.S.
Department of Veterans Affairs, letter dated April 7, 2009,
and VA responses........................................... 88
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Antonette Zeiss, Ph.D., Deputy Chief
Consultant, Office of Mental Health Services, Office of
Patient Care Services, Veterans Health Administration, U.S.
Department of Veterans Affairs, letter dated April 7, 2009,
and VA responses........................................... 92
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Maureen Murdoch, M.D., MPH, Core Investigator,
Center for Chronic Disease Outcomes Research, Minneapolis
Veterans Affairs Medical Center, Veterans Health
Administration, U.S. Department of Veterans Affairs, letter
dated April 7, 2009, and VA responses...................... 100
THE NEXUS BETWEEN ENGAGED IN COMBAT
WITH THE ENEMY AND POST-TRAUMATIC
STRESS DISORDER IN AN ERA OF
CHANGING WARFARE TACTICS
----------
TUESDAY, MARCH 24, 2009
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:13 p.m., in
Room 334, Cannon House Office Building, Hon. John J. Hall
[Chairman of the Subcommittee] presiding.
Present: Representatives Hall, Donnelly, and Lamborn.
OPENING STATEMENT OF CHAIRMAN HALL
Mr. Hall. Good afternoon, ladies and gentlemen. The
Veterans' Affairs Disability Assistance and Memorial Affairs
Subcommittee hearing on the topic of ``The Nexus Between
Engaged in Combat with the Enemy and Post-Traumatic Stress
Disorder (PTSD) in an Era of Changing Warfare Tactics'' will
now come to order.
I would ask everyone to rise for the Pledge of Allegiance.
Flags are located at both ends of the room.
[Pledge of Allegiance.]
The task of today's hearing will prove to be both
retrospective and prospective in order to understand Title 38,
section 1154. We must look both backward to the original intent
of Congress and forward to defining it in an era of modern
warfare tactics and counterinsurgency.
I ask that the full text of title 38 U.S. Code, section
1154, be entered into the record.
[The information follows:]
Title 38 U.S.C., Section 1154
Consideration to be accorded time, place, and circumstances of service
(a) The Secretary shall include in the regulations pertaining
to service-connection of disabilities (1) additional provisions
in effect requiring that in each case where a veteran is
seeking service-connection for any disability due consideration
shall be given to the places, types, and circumstances of such
veteran's service as shown by such veteran's service record,
the official history of each organization in which such veteran
served, such veteran's medical records, and all pertinent
medical and lay evidence, and (2) the provisions required by
section 5 of the Veterans' Dioxin and Radiation Exposure
Compensation Standards Act (Public Law 98-542; 98 Stat. 2727).
(b) In the case of any veteran who engaged in combat with the
enemy in active service with a military, naval, or air
organization of the United States during a period of war,
campaign, or expedition, the Secretary shall accept as
sufficient proof of service-connection of any disease or injury
alleged to have been incurred in or aggravated by such service
satisfactory lay or other evidence of service incurrence or
aggravation of such injury or disease, if consistent with the
circumstances, conditions, or hardships of such service,
notwithstanding the fact that there is no official record of
such incurrence or aggravation in such service, and, to that
end, shall resolve every reasonable doubt in favor of the
veteran. Service-connection of such injury or disease may be
rebutted by clear and convincing evidence to the contrary. The
reasons for granting or denying service-connection in each case
shall be recorded in full.
Mr. Hall. So what does it mean to have been ``engaged in
combat with the enemy'' to a sufficient enough degree to prove
a stressor that in turn, warrants service connection for post-
traumatic stress disorder, or PTSD, by the Department of
Veterans Affairs (VA)? And what has been the intent of
Congress?
Congress' commitment originated with the Military Pension
Law of 1776. By the end of the Civil War, Congress recognized,
``every soldier who was disabled while in service of the
Republic, either by wounds, broken limbs, accidental injuries,
or was broken down in the service by the exposure and hardships
incident to camp life and field duty is entitled to an invalid
pension.''
It was believed that those exposures and hardships led to a
malaise at the time known as, ``Soldier's Heart,'' which we now
know as PTSD. I find Soldier's Heart to be more poetic myself.
Shortly after the 65th Congress declared war on Germany, it
passed the War Risk Insurance Act of 1917, which outlined
benefits to World War I veterans. In 2 years, it was amended 22
times. These amendments included the first VA Schedule for
Rating Disabilities and established wartime versus peacetime
rates for pension. The 1933 rating schedule included
instructions to notate the phrase, ``incurred in service and
combat with an enemy of the United States,'' and to list the
period of wartime service. This practice indicated that the
enemy was a foreign government or a hostile force of a nation
and not an individual combatant.
On December 12, 1941, days after the attack on Pearl
Harbor, Congress expressed its desire to, ``overcome the
adverse effect of a lack of an official record,'' and ``the
difficulties encountered in assembling records of combat
veterans.''
Congress further instituted, ``more liberal service pension
laws by extending full cooperation to the veteran.'' The 1945
rating schedule required that wartime service be noted by
including the phrase, ``disability resulted from injury
received in actual combat in an expedition or occupation.''
Importantly, this prerequisite refined the broader 1933
required statement.
Additionally, the 1945 schedule described the onset of
``War Psychosis'' as the result of ``incident in battle or
enemy action or following bombing, shipwreck, imprisonment,
exhaustion or prolonged operational fatigue.'' This diagnosis
was removed when the rating schedule for mental disorders was
revised in 1976, 1988 and 1996.
Some would say that our service men and women are
experiencing prolonged operational fatigue today. But at any
rate, the current rating schedule for PTSD has been described
as vague and subjective. Furthermore, the adjudication process
does not solely accept, as the law prescribes, lay evidence as
sufficient proof as long as it is consistent with the
circumstances, conditions, or hardships of such service,
notwithstanding that there is no official record.
This law should seem self-evident as to the intent of
Congress. So why isn't it? The controversy seems to exist
because of numerous interpretations of Congressional intent.
Leading decisionmakers at VA General Counsel have issued
opinions and court decisions that concluded that if it were the
intent of Congress to specify a combat zone or theater of
combat operations, Congress would have done so as it has in
other provisions of the law under Title 38, but omitted in
section 1154.
So our intention today is to reopen this dialog. The nature
of wartime services changed, as many can agree. Warfare
encompasses acts of terrorism, insurgency, and guerilla
tactics. No place is safe and the enemy may not be readily
identifiable.
Psychiatry has changed also. PTSD is a relatively new
diagnosis, first having appeared in the Diagnostic and
Statistical Manual in 1980, 5 years after the end of the
Vietnam War. Since then, an array of mental health research has
been conducted and assessment techniques have been developed.
Since the world is not the same place it was in 1941, I
have introduced H.R. 952, the ``COMBAT PTSD Act,'' to redefine
section 1154 to include a theater of combat operations during a
period of war or in combat against a hostile force. There
should be a better way for VA, to assist veterans suffering
from PTSD, to adjudicate those claims without it being
burdensome, stressful and adversarial. Veterans still face
issues with stigma, gender and racial disparities in rating
decisions, poorly conducted disability exams, and inadequate
military histories. So, I am eager to hear from the witnesses
today about their experiences with denials, inequities and
variances.
In the last few years, the Institute of Medicine (IOM)
comprehensively reviewed the research on PTSD diagnosis,
assessment and compensation. In 2008, the RAND report on the
``Invisible Wounds of War'' gave us a new perspective on the
costs of war when soldiers are left without treatment or
support. I look forward to hearing more of its witnesses'
analyses.
Finally, the U.S. Department of Defense (DoD) and VA will
share their insights into how they determine combat versus
noncombat and how they have chosen to evaluate PTSD disability.
So I welcome you all. I look forward to all of the
witnesses' testimony and now will yield to Ranking Member
Lamborn for his opening statement.
[The prepared statement of Chairman Hall appears on p. 36.]
OPENING STATEMENT OF HON. DOUG LAMBORN
Mr. Lamborn. Thank you, Mr. Chairman, for yielding. I am
pleased to have the opportunity to discuss the important issue
before us today. I hope that through the collective efforts and
knowledge of the individuals gathered here this afternoon, we
can help ensure that every veteran who has service-related PTSD
is able to access the benefits to which they are entitled.
Chairman Hall, I would also like to commend you for your
compassion toward our veterans. I know it has been a
longstanding issue for you to ensure that no one falls through
the cracks due to unintended consequences of the laws and
regulations pertaining to compensation for PTSD.
You have reintroduced in the 111th Congress a bill to
clarify the meaning of ``combat with the enemy'' for purposes
of service connection. As you and our witnesses are aware,
section 1154(b) of Title 38 already provides special
consideration for veterans attempting to establish service
connection for PTSD or other medical conditions incurred or
aggravated in combat. In short, this means that the VA must
accept a combat veteran's lay testimony as sufficient proof of
service connection for any disease or injury incurred in
combat, even if there is no official record of such incident.
Congress established this broad threshold in recognition of
the chaotic nature of battle and the appropriateness of
resolving every reasonable doubt in favor of the veteran.
Unfortunately, circumstances can conceivably arise in which an
individual who is not a combat veteran under the existing
definition is exposed to an overwhelming stressor but he or she
is unable to prove evidence of the occurrence. This is
especially true for veterans of Vietnam and earlier wars. And
this is the problem we are trying to resolve.
Chairman Hall's proposed solution is the bill which would
essentially redefine ``combat with the enemy'' to include
service on active duty in a theater of combat operations.
As I have stated previously, I am concerned that too broad
of a presumptive threshold would damage the integrity of the
system. I also believe that too loose a definition of
``combat'' would diminish the immeasurable sacrifice and
service of those who actually did engage in battle with the
enemy.
While I understand and appreciate the effort to address
problems regarding the VA claims backlog, I believe that they
generally result from procedural issues and we can and should
address those problems accordingly. In addition to the policy
concerns I have stated, I would also point out that the
mandatory offsets that would be necessary to pass this bill
under existing PAYGO rules would be difficult to find.
Mr. Chairman, as you know it is always a challenge to
identify offsets within our jurisdiction, and the Congressional
Budget Office estimated cost of this measure last year exceeded
$4 billion. I certainly would not be in favor of reducing
existing veterans benefits elsewhere in the VA budget in order
to establish an overly broad definition of ``combat with the
enemy.''
Mr. Chairman, I extend my thanks to you for holding this
hearing and I look forward to hearing the testimony of our
colleagues and witnesses on our panel today. And I yield back.
[The prepared statement of Congressman Lamborn appears on
p. 37.]
Mr. Hall. Thank you, Congressman Lamborn. I would like to
welcome all of our panelists today and other Members of the
Subcommittee as they arrive. Congressman Donnelly.
I will remind all panelists that your complete written
statements have been made a part of the hearing record, so you
can limit your remarks so that we can have sufficient time to
follow up with questions once everyone has had the opportunity
to testify.
On our first panel is Mr. Ian De Planque, Assistant
Director of Veterans Affairs and Rehabilitation Commission at
the American Legion; Dr. Thomas J. Berger, Senior Analyst for
Veterans' Benefits and Mental Health Issues at Vietnam Veterans
of America (VVA); and Ms. Carolyn Schapper, a member of the
Iraq and Afghanistan Veterans of America (IAVA).
Welcome to our first panelists. You may come join us at the
witness table, please.
Mr. De Planque, your statement is entered into the record.
You are now recognized for 5 minutes.
STATEMENTS OF IAN C. DE PLANQUE, ASSISTANT DIRECTOR, VETERANS
AFFAIRS AND REHABILITATION COMMISSION, AMERICAN LEGION; THOMAS
J. BERGER, PH.D., SENIOR ANALYST FOR VETERANS' BENEFITS AND
MENTAL HEALTH ISSUES, VIETNAM VETERANS OF AMERICA; AND CAROLYN
SCHAPPER, REPRESENTATIVE, IRAQ AND AFGHANISTAN VETERANS OF
AMERICA
STATEMENT OF IAN C. DE PLANQUE
Mr. De Planque. Thank you. Good afternoon Mr. Chairman,
Members of the Subcommittee. On behalf of the American Legion,
I would like to thank you for allowing me the opportunity to
present this testimony today.
We are basically here to clarify the concept of engaged in
combat with the enemy in a manner that is consistent with the
realities of warfare in today's world. I think it is important
to note that this is not creating any sort of new benefit. What
is really at issue today is an attempt to clarify the meaning
and intent of the existing statute in section 1154(b). What we
are looking at is something that hopefully fulfills the
original intent of the statute, while at the same time
streamlining some of the red tape involved with one small part
of the claims process.
These provisions were created in recognition of the
recordkeeping abnormalities and difficulties experienced in the
thick of war fighting. They were created to recognize that in
war we don't always have the time to write meticulously
detailed reports. However, these statutes were originally
created in 1941 and the distinctions between being in a combat
zone and being on the frontline were perhaps more cut and dry
than what we are seeing in the age of modern warfare.
As with all things in life, the world changes and we must
evaluate these changes and make sure we adapt to them. In
today's nonlinear battlefield, the frontline is not so clear.
Simply drawing a line on a map and stating that this unit was
present here does not always adequately reflect the extent of
combat situations where servicemembers are in harm's way.
I would like to present an example of two soldiers. Both
soldiers witnessed the exact same event, an event clearly
consistent with the hardships and circumstances of combat as
presented in 1154(b). However, because of the differences in
military occupational speciality (MOS) of the two soldiers, one
faces much more difficult battle when he returns home. Imagine
a convoy traveling through southeastern Afghanistan. An
improvised explosive device (IED) detonates ahead of them on
the road. Fortunately, no American soldiers are injured. No
vehicles are damaged in the blast. However, by the side of the
road, a family of Afghans are struck by the blast and killed
instantly. In the convoy, the soldiers traveling by witness the
aftermath of the explosion.
Subsequent to this event, two soldiers in the convoy
develop post-traumatic stress disorder as a result of what they
have seen. The first veteran is an infantryman, a veteran of
several combat operations prior to this convoy and a recipient
of the Combat Infantryman Badge (CIB). The second veteran is a
mechanic pulled along on the convoy as part of a temporary
assignment and has no decorations of combat.
When they file a claim with the VA, both veterans must
prove and do prove that they have the present condition of PTSD
and that a doctor links the PTSD to the event described above.
Now they must prove the third element of the claim. They
must prove that the alleged incident occurred. Here is where
the two soldiers are then treated differently. The first
veteran, the infantryman, has a combat infantry badge. As long
as his story is consistent with the hardships and circumstances
of combat, which we can all agree that it is, the VA cedes the
existence of the event and a claim is granted.
The second veteran has no combat decoration. In his job he
was fortunate enough to not have been injured or merited a
Purple Heart. His story is the same story, exactly consistent
with the circumstances of war, but he lacks a decoration to say
that he was in combat. This veteran must now prove several
things happened. He must prove that he was on the convoy. This
can be difficult, if not impossible. Temporary details are
assigned in the military all the time, other duties as
assigned. You piece together troops because you have one
overriding goal: Get the job done.
If the veteran is fortunate, morning reports or patrol
reports not only exist for the routine convoy, but they
actually are detailed enough to list all the personnel who went
on it. This is not always the case. Assuming that the veteran
can prove that he was on this particular convoy on this
particular day, he must now prove that this convoy experienced
the incident described above. This is not as easy as it sounds.
Does every incident get recorded? What if no Americans were
hurt? What if no equipment was damaged?
The provisions of 1154(b) were intended to reflect the
often thin recordkeeping in combat. Detailed notes aren't
always there. Now, keep in mind, all of this sifting through
the records has to be done by VA and the veteran. This is a
colossal amount of effort. Requests must be sent back and forth
to various repositories of records. This problem is compounded
by the fact that Guard and Reserve units often keep their own
records separate from those of active duty, and that the
records don't always mesh up the way that they should. If a
veteran can't find all of these separate pieces in writing,
then the VA must deny the claim because they can't verify the
alleged incident.
Ultimately we have to ask ourselves why we are holding two
soldiers serving in the same military to different standards
when the hardships and circumstances faced by them are so
vastly similar. 1154(b) was never intended nor should it be
used as a means of handing out benefits carte blanche. It only
exists as a means to help sort through the fog of war and
establish the existence of events that might not otherwise be
meticulously documented. It is a means to fill in the last
piece of the puzzle for veterans who have already proved that
they are deserving of a benefit otherwise.
A great deal of things have changed in our understanding of
the realities of modern warfare. This does not mean, however,
that our Nation's duties to aid and assist the brave men and
women who go forth to defend it on the fields of battle should
change. In the modern combat zone the battlefield is
everywhere, and we need to treat all the veterans who serve
with the same hand. Thank you very much.
[The prepared statement of Mr. De Planque appears on p.
38.]
Mr. Hall. Thank you, Mr. De Planque. Mr. Berger, you are
now recognized for 5 minutes.
STATEMENT OF THOMAS J. BERGER, PH.D.
Dr. Berger. Mr. Chairman, Ranking Member Lamborn, and other
distinguished Members of the House Veterans' Affairs Committee,
Subcommittee on Disability Assistance and Memorial Affairs,
Vietnam Veterans of America thanks you for the opportunity to
present our views on the record surrounding the Department of
Veterans Affairs' application of the provisions found in Title
38 U.S.C. 1154, the definition of ``engaged in combat with the
enemy'' and its effect on processing claims for veterans
suffering from post-traumatic stress disorder.
Despite the promises of change from this Administration,
for those most in need of renewed attention are veterans of our
military who have come home from war seeking disability
benefits for post-traumatic stress disorder. While the
dysfunctional state of the VA claims adjudication system has
become a matter of growing public concern, the rhetoric
surrounding our obligation to returning troops still falls
short of actual legislative priorities. Meanwhile, recent
efforts to reform the VA benefits system through litigation
have only affirmed the need for legislative action with courts
repeatedly dismissing the issue as a Congressional matter.
The resulting inertia makes the passage of Congressman
Hall's proposed change to 38 U.S.C. especially vital,
particularly when viewed in conjunction with his proposed
COMBAT PTSD Act. Under current VA policy, disability claims are
effectively presumed fraudulent until proven otherwise. Beyond
establishing their medical condition, claimants must prove,
through elaborate documentation, that their disability stems
from the military service while a veteran was ``engaged in
combat.'' While the disability claims process imposes a toll on
all veterans seeking benefits, this burden falls with
particular weight on those with PTSD who must identify the
specific stressor that triggered their condition, even if they
have already been diagnosed and referred to treatment.
A personal story: A very good friend of mine who served as
a combat medic with the 25th Light Infantry Division in Vietnam
just passed away recently. He suffered hepatitis, had a liver
transplant. All of that he had to fight for, for years with the
VA, because as a combat medic, he did not receive the Combat
Infantryman's Badge. This man died without ever receiving all
the benefits and compensation that was due him.
Under the existing system the VA Clinicians Guide warns
examiners that PTSD symptoms are ``relatively easy to
fabricate'' directing them to supplement treatment records with
elaborate documentation from claimants' family and friends
concerning changes from pre- to post-service status. Despite
the fact that one of the diagnostic criteria for PTSD is an
inability to recall important aspects of a trauma, reviewers
routinely deny or remand claims due to incomplete information.
At the same time, the VA continues to measure employee
productivity by number of cases processed, offering reviewers
an incentive to take any shortcut necessary to clear their
desks of pending claims. The resulting combination of too much
work and too little time ultimately gives rise to premature and
inaccurate determinations, setting in motion years of appeals.
Claimants seeking compensation for military sexual trauma,
for example, are inevitably obstructed by the military's policy
of retaining harassment complaint files for only 2 years,
eliminating critical evidence of the stressor that gave rise to
their condition. Even in the best of circumstances, the
retrieval of military records is a bureaucratic nightmare
requiring protracted negotiation with a central archive in
Missouri, other National Archives facilities, and/or DoD
agencies.
In spite of these inequities, the VA defends its current
system as a precaution against claimant fraud. And even
according to VA spokesperson Kerri Childress, eliminating the
proof requirement, quote, would be a travesty for veterans, an
assault to the pride of honest soldiers when other vets are
scammed by the system.
Establishing service in combat as the presumptive stressor
for the incurrence of PTSD would be a long overdue first step
toward fixing a notoriously broken system. VVA can support the
proposed legislative change because we believe the proposed
change to be well intended and most considerate for those of
our veterans suffering from PTSD and who face interminable
delays and denials in their compensation claims from the VA
under the current claims processes and procedures.
VVA thanks this Committee for the opportunity to submit its
views and testimony on this important veterans issue. Thank
you, sir.
[The prepared statement of Dr. Berger appears on p. 41.]
Mr. Hall. Thank you, Dr. Berger. Ms. Schapper, you are now
recognized for 5 minutes.
STATEMENT OF CAROLYN SCHAPPER
Ms. Schapper. Mr. Chairman and Members of the Subcommittee,
thank you for inviting me to testify today on behalf of Iraq
and Afghanistan Veterans of America, the Nation's first and
largest nonpartisan organization for veterans of the current
conflicts. I would like to thank you all for your unwavering
commitment to our Nation's veterans.
My name is Carolyn Schapper and I am a combat veteran.
While serving as a member of the military intelligence unit in
Iraq from October 2005 to September 2006 with the Georgia
National Guard, I participated in approximately 200 combat
patrols. While many of these patrols included positive
interactions with the local population, I did encounter direct
fire, improvised explosive devices and other threats during
some of my missions. Overall, I valued the opportunity to learn
about the Iraqi people, my country and myself.
However, when I came home from Iraq, I dealt with a wide
range of adjustment issues and symptoms including rage, anger,
withdrawal and depression, high anxiety, agitation, nightmares
and hypervigilance. When you are in this state of mind, it is
difficult to traverse the VA's maze. I might still be lost if I
had not had the good luck of running into another veteran who
had already gotten help and who had pointed out that a Vet
Center could help me start navigating the VA system.
While I was able to receive the appropriate help and rating
from the VA due to the existence of proper paperwork for my
adjustment issues, many of my sisters-in-arms have not been so
lucky. Part of the problem is that because females are excluded
from official combat roles in the military, women veterans have
a greater burden of proof when it comes to establishing combat-
related PTSD. But the reality on the ground in Iraq and
Afghanistan is that there is no clear frontline, and female
servicemembers are seeing combat. Modern warfare makes it
impossible to delineate between combat, combat support, and
combat service support roles. You do not even need to leave the
forward operating base to be exposed to the continual threat of
mortars and rockets. Military personnel are often required to
walk around in, or sleep in, body armor. As one female veteran
told me, life in Iraq and Afghanistan is combat.
Moreover, many female troops in Iraq and Afghanistan have
been exposed to direct fire while serving in support roles such
as military police, helicopter pilots and truck drivers. All of
our troops, whether or not they serve in the combat arms, must
exhibit constant vigilance. And this can take an extreme
psychological toll on all servicemembers.
The traditional understanding of female servicemembers'
military duties has been the biggest hurdle to getting them
adequate compensation for their injury. The nature of PTSD and
other psychological injuries makes it difficult to identify the
exact stressor, and therefore, disability may be determined
based on the claims processor's perception of exposure to
combat.
While service connection for PTSD would seem obvious for a
male infantryman, it can easily come under more scrutiny for a
female intelligence soldier despite how much actual combat
either of them have seen.
Another obstacle that female servicemembers face when
trying to establish presumption of service-connected PTSD
involves collecting the proper paperwork, especially in
instances of military sexual trauma. Some women forgo
documenting their injury, whether combat or sexual trauma,
rather than get official military documentation from a male
commander or doctor. If you are suffering from a mental health
injury, the possibility of having someone question, deride or
expose such a personal and painful experience is often
overwhelming and can lead many female servicemembers to avoid
the process altogether.
H.R. 952, introduced by the Chairman, solves this problem.
It changes Title 38 to presume service connection for PTSD
based solely on a servicemember's presence in the combat zone.
IAVA wholeheartedly endorses this legislation and looks forward
to working with the Subcommittee to see this bill become law.
While this legislation will aid veterans once they have
become diagnosed with a psychological injury and are seeking
disability compensation, we know not every servicemember or
veteran is getting the care they need. To better identify
troops suffering from psychological injuries and help them
receive the appropriate treatment, IAVA recommends mandatory
face-to-face and confidential screenings by a licensed medical
professional for all servicemembers both before and after
combat tour. This is one of the organization's top legislative
priorities for 2009.
To help ensure that veterans seeking access to care and
benefits, particularly those in need of treatment for their
psychological injuries, get the support they need, IAVA has
partnered with the Ad Council to conduct a multiyear public
service announcement (PSA) campaign. The IAVA-Ad Council
Veteran Support PSAs are currently running on television,
radio, print, outdoors and online. The companion campaign,
engaging the family and friends of new veterans will, be
launching later this year.
I will leave you with this final thought. More and more
women are being called upon to serve a more active role in the
combat zone and all too often find themselves in harm's way.
There is no better way to honor the service and sacrifices of
these brave women than to ensure that when they are injured,
they receive the care and compensation they deserve.
Thank you again for the opportunity to testify on this
critical issue. And I think we would all be pleased to take
your questions at this time.
[The prepared statement of Ms. Schapper appears on p. 43.]
Mr. Hall. Thank you Ms. Schapper.
First, Mr. De Planque, in your statement you noted that if
Congress were to change section 1154 it would not be creating a
new benefit, but providing a clarification to the original law
since the veterans' entitlement already existed. Can you expand
upon this contention and how entitlement is already
established?
Mr. De Planque. Yes. Essentially what I am trying to
address with this is that it is not in any sense trying to give
out a golden ticket to PTSD or anything. The problem, what 1154
was created to address, is the problem of establishing
incidents that happen in combat, in the combat area.
I will give a very quick example from my personal
experience. In Afghanistan, my platoon came under fire and
engaged in combat with the enemy. We were an infantry platoon
so we all got CIBs out of the deal and we all--what we said
happened happened. But I compiled all of the reports because
every soldier had to file a contact report and everything. And
I compiled all of those for our platoon and pushed them on. We
had over 20 people involved in that. There were over 20
different stories of what happened. Everybody experiences
things a little bit differently. And when you look at all of
those things, you realize just how hard it is to get an
accurate record of exactly what happened.
I think that that is what 1154(b) was about, is that it is
very, very hard to document and to really capture everything
that is happening in combat, which is a zone-wide exposure when
you look at it in modern warfare. So what 1154(b) is about is
establishing that those things happened.
With the VA claim, it is not just that you establish that
something happened, you still have to have a present diagnosis.
You still have to have a linkage opinion between the two of
those. These aspects of the claims process are not changing at
all, and they haven't changed and they are not affected by
1154(b); 1154(b) is establishing the incident in service. And
that is the difficult part and that is the thing that--when I
talk about what this is doing and clarifying it, it is trying
to create a sense of equity between infantry soldiers, for
example, who have that ticket, that CIB that says, you know,
what you said happened happened, and other soldiers who are
going through exactly the same things and exactly the same
conditions are having their word--they are having a much more
difficult time proving their word because it is not being taken
for granted unless they can say, this combat occurred.
And so in terms of not establishing the benefit, it is more
attempting to deal with the existing facet of benefits, the
sort of nebulous area of confirming something that happened in
combat or in a combat zone.
Mr. Hall. Thank you.
Dr. Berger, at what point would you support VA accepting a
veteran's lay statement as proof of a stressor, instead of
requiring VA to continue to develop a claim by searching for
records and documents that may or may not exist at any of the
centers you mentioned in your statement?
Dr. Berger. Certainly what we call buddy records would seem
very appropriate. As I mentioned, my colleague was a combat
medic with the 25th, had to rely heavily on people that he
served with in order to document his service. And that
particular unit that he served with, the time period took place
in the Michelin rubber plantation area in the Republic of South
Vietnam at the time. A lot of enemy action down there. But as I
said, he did not receive a CIB, so it was very difficult for
him to prove that he had actually been in combat. So certainly
the supporting statements of colleagues who are with you at the
time would help.
I know that in my own personal case, I was in a field
hospital up north, and there weren't many of us Navy corpsmen
there present. In fact, there is only one alive today who could
document my presence there. I would have to go through the
Marines that I served with in order to prove that I was even
there.
Mr. Hall. How accurate would you say veterans are when they
self-report their stressors? In your observations, have you
seen many cases where stressors are exaggerated?
Dr. Berger. I think Bruce Dohrenwend, a Professor at
Columbia University who reevaluated the National Vietnam
Veterans' Readjustment Study (NVVRS) a couple of years ago,
stated it clearly when they looked at the NVVRS data, the PTSD
data from Vietnam veterans, and found very few, very few
instances of fraud, lying in the process that they used to
document their combat service.
Mr. Hall. Thank you, sir.
And, Ms. Schapper, are there situations that the IAVA is
aware of where veterans who served in Iraq or Afghanistan were
not considered to be combat veterans and therefore had their
PTSD claims denied?
Ms. Schapper. I don't have specific instances from IAVA.
But I do have instances of fellow female servicewomen who have
had difficulty. I did not have difficulty supplying the
``burden of proof'' because I was lucky enough that I was
either a convoy commander or a team sergeant and I wrote up all
the reports for the incidents that occurred. But as Mr.
DePlanque was saying earlier, that if you don't happen to have
your name on that report, that you were in that instance, that
combat, that IED, you will be denied. And I do know several
female servicemembers who have been denied because their name
was not on the proper paperwork.
Mr. Hall. I am over my time. But before I turn it over to
the Ranking Member, I wanted to ask one more question, if I
could. What would you suggest the VA do to improve its
assistance to female veterans in order to help develop their
claims?
Ms. Schapper. Personally I would like to see stronger
women's centers in the VA and women's PTSD groups for combat
and/or military sexual trauma. Right now a lot of the PTSD
groups are mixed groups. And although some women do feel open
to speaking in those groups, I do believe most of them hold
back a lot of experiences just because men are in there as
well.
Mr. Hall. Okay. Thank you very much.
Mr. Lamborn.
Mr. Lamborn. Thank you. And Ms. Schapper, I have a question
for you also. If I heard you correctly during your testimony,
you talked about how this bill, if passed, would help in the
case of a woman who has suffered sexual assault or rape. Did I
hear you correctly? And if so, what would the connection be?
Ms. Schapper. This bill wouldn't specifically address
military sexual trauma. I was using that as an instance of how
women often feel more exposed and that people generally
question them more. Whether it is sexual trauma or combat, that
is often more difficult for them to prove they have any sort of
PTSD symptoms at all.
Mr. Lamborn. Okay. Thank you for that clarification. Mr.
Chairman, I would yield back.
Mr. Hall. Thank you. Well first of all, thank you all for
your service to our country. And thank you for your service to
our veterans and for being here to testify today.
We will now excuse you and move on to our second panel,
which consists of Dean G. Kilpatrick, Ph.D., member of the
Committee on Veterans Compensation for Post-Traumatic Stress
Disorder, Institute of Medicine of the National Academies;
Terry Tanielian, Co-Study Director of the ``Invisible Wounds of
War Study'' by the RAND Center for Military Health Policy
Research, accompanied by Christine Eibner, also a Ph.D. and
Economist with the RAND Corporation.
As usual, your full written statement is entered into the
record, so feel free to abridge it if you wish. Mr. Kilpatrick,
you are recognized for 5 minutes.
STATEMENTS OF DEAN G. KILPATRICK, PH.D., DISTINGUISHED
UNIVERSITY PROFESSOR, AND DIRECTOR, NATIONAL CRIME VICTIMS
RESEARCH AND TREATMENT CENTER, MEDICAL UNIVERSITY OF SOUTH
CAROLINA, CHARLESTON, SC, AND MEMBER, COMMITTEE ON VETERANS'
COMPENSATION FOR POSTTRAUMATIC STRESS DISORDER, INSTITUTE OF
MEDICINE AND NATIONAL RESEARCH COUNCIL, THE NATIONAL ACADEMIES;
AND TERRI TANIELIAN, MA, STUDY CO-DIRECTOR, ``INVISIBLE WOUNDS
OF WAR'' STUDY TEAM, RAND CORPORATION, ACCOMPANIED BY CHRISTINE
EIBNER, PH.D., ECONOMIST, RAND CORPORATION
STATEMENT OF DEAN G. KILPATRICK, PH.D.
Dr. Kilpatrick. Thank you very much, Mr. Chairman, Mr.
Ranking Member, and Members of the Committee. I appreciate the
opportunity of being able to testify on behalf of the National
Academy of Sciences' Committee on Veterans Compensation For
Post-Traumatic Stress Disorder.
In June 2007, our Committee completed its report entitled,
``PTSD Compensation and Military Service.'' I am here today to
share with you some of the contents of that report and will
briefly address four issues: the evaluation of traumatic
exposures for VA compensation and pension purposes; the
reliability and completeness of military records for evaluation
of exposure to stressors; what studies say about malingering in
the veteran population; and the means that mental health
professionals use to detect malingering.
In terms of the first issue, VA Compensation and Pension
(C&P) examinations for PTSD consist of a review of medical
history, evaluations of mental status and of social and
occupational functioning, a diagnostic examination and an
assessment of exposure to traumatic events occurred during
military service. To help focus the examination, the VA
Veterans Benefits Administration (VBA) provides examiners with
worksheets that set forth what an assessment should cover. The
PTSD worksheet indicates the elements of a claimant's military
history that should be documented, or it indicates that that
should include military occupational specialty, combat wounds
sustained, citations or medals received, and a clear
description of ``the specific stressor event the veteran
considered to be particularly traumatic, particularly if the
stressor is the type of personal assault including sexual
assault, providing information with examples, if possible.''
It notes that a diagnoses of PTSD cannot be made or
adequately documented or ruled out without obtaining detailed
military history and reviewing the claims folder. This means
that the initial review of the folder conducted prior to
examination, the history and the examination itself, and the
dictation for an examination initially establishing PTSD will
often require more time than for examinations of other
disorders. They recommend that 90 minutes to 2 hours on an
initial exam is normal.
There was also a Best Practices Manual developed by VA that
stated that the initial PTSD compensation basically requires up
to 3 hours. Not withstanding this guidance, our Committee, and
testimony reported to our Committee, indicated that some people
are so pressured that they spend as little as 20 minutes on
these exams. And we concluded that that was an unacceptably
short period of time.
Military records, with respect to the second issue, are
prized because they are thought to be a description or an
unbiased source of evidence to support or refute claims.
However, specifically the conclusion that this is so was really
not supported by our Committee. And in fact, the National
Archives and Research Administration warns that, ``Detailed
information about the veteran's participation in military
battles and engagements is not contained in military service
records and personnel files.'' Studies indicate, instead, that
broad-based research into other indicators of the likelihood of
having experienced traumatic stressors has value. And in fact,
someone just mentioned Dr. Dohrenwend's NVVRS reexamination
study in which they looked at news accounts and a variety of
other things to augment the official records.
Our Committee concluded that the most effective strategy
for dealing with problems with self-reports of traumatic
exposure is to ensure that a comprehensive, consistent and
rigorous process is used throughout the VA to verify veteran-
reported evidence.
What studies say about malingering in veterans populations:
The Committee noted that assessment of malingering--and, I
would add, accusing someone of malingering--is a high-stakes
issue, because it is as devastating to falsely accuse a veteran
of malingering as it is unfair to other veterans to miss
malingered cases.
Our Committee concluded that while misrepresentation of
combat involvement and traumatic exposure undoubtedly does
occur, the evidence is insufficient to establish how prevalent
this is. And in fact, there is not a lot of evidence that it is
prevalent, or how much effect malingering has on the ultimate
outcome of disability claims. The preponderance of evidence
does not support the notion that receiving compensation for
PTSD makes veterans less likely to
make treatment gains or acknowledge improvement from treatment.
Finally, the means that mental health professionals use to
detect malingering, although there is a need for a reliable
valid way to detect malingering, experts agree that there is no
magic bullet or gold standard for doing so. It would be really
nice if we had a means for determining whether someone is
telling the truth or not or if they are malingering or not.
But, unfortunately, no way exists to do that in a simple
manner.
While some investigators use psychological tests to
indirectly infer the possibility of malingering, these measures
have clear limitations and should not be used as the sole basis
for determining whether a veteran is malingering.
The Committee concluded that in the absence of a definitive
measure, the most effective way to detect inappropriate PTSD
claims is to require a consistent and comprehensive state-of-
the-art examination and assessment that allows the time to
conduct appropriate testing and assessment in these specific
circumstances where it would inform the assessment.
Thank you very much. And I will be happy to take questions.
[The prepared statement of Dr. Kilpatrick appears on p.
44.]
Mr. Hall. Thank you, Mr. Kilpatrick.
Ms. Tanielian, you are now recognized for 5 minutes.
STATEMENT OF TERRI TANIELIAN, MA
Ms. Tanielian. Chairman Hall, Representative Lamborn, and
distinguished Members of the Subcommittee, thank you for
inviting me to testify today. It is an honor and a pleasure to
be here.
Last April, my colleagues and I released findings from a 1-
year project entitled ``Invisible Wounds of War.'' This
independent study focused on three major conditions: post-
traumatic stress disorder, major depression and traumatic brain
injury among Iraq and Afghanistan veterans.
My comments today will focus on our findings about
servicemembers' exposure to trauma during deployment,
prevalence of mental health conditions post deployment and
their associated costs to society as they bear directly on the
issue you are considering today.
First, how is exposure to combat trauma assessed? In
research studies, combat experience has been assessed in a
variety of ways. These include documenting deployment to a
combat zone based on receipt of hostile-fire pay, or assessing
specific experiences during deployment based on self-report.
In our study, combat trauma exposure was assessed using
questions from recent Army studies and included both direct and
vicarious trauma exposure. Rates of reported exposure to
specific types of combat trauma range from 5 to 50 percent in
our study, with close to one-third reporting exposure to two or
more traumatic events. Vicariously experienced traumas, such as
having a friend who was seriously wounded or killed, were the
most frequently reported.
Despite these exposures, most military servicemembers who
have deployed to date will return home from war without
problems and readjust successfully. But many have already
returned or will return with significant mental health
problems.
Among Iraq and Afghanistan veterans, our study found rates
of PTSD and major depression to be relatively high,
particularly when compared with the general population. In late
2007, we conducted a telephone study of about 2,000 previously
deployed individuals. Using well-accepted screening tools, we
estimated substantial rates of mental health problems in the
past 30 days, with 14 percent reporting current symptoms
consistent with a diagnoses of PTSD and 14 percent reporting
current symptoms consistent with a diagnoses of depression; 9
percent of veterans reported symptoms consistent with a
diagnoses of both.
We found that some specific groups previously
underrepresented in studies, including the Reserves and those
who had left military service, may be at higher risk of
suffering from these conditions. We also found that the single
best predictor of reporting current mental health problems was
the number of reported combat traumas while deployed.
From the literature, we know that socioeconomic status,
access to post-deployment social support and transition
services, as well as treatment can mitigate the immediate
consequences of these post-combat mental health problems.
In our study, however, only about half of those with
current PTSD or major depression have sought help from a
physician or other provider in the past year. And of those,
just over half received minimally adequate treatment.
The number who received proven effective care would be
expected to be even smaller. Survey respondents identified many
barriers to getting treatment for their mental health problem.
In particular, they were concerned that treatment would not be
kept confidential and would constrain future job assignments.
The costs of these invisible wounds go beyond the immediate
costs of mental health treatment. Adverse consequences that may
arise from post-deployment mental problems include suicide,
engagement in unhealthy behaviors, substance abuse,
unemployment, homelessness, marital strain and domestic
violence. The costs stemming from these problems are
substantial and include costs related to lost productivity,
reduced quality of life, treatment and premature mortality.
To quantify these costs, RAND used a microsimulation model
to estimate 2-year post-deployment costs associated with PTSD
and depression for military servicemembers returning from Iraq
and Afghanistan. Our analyses used a societal cost perspective
which considers costs that accrue to all members of U.S.
society, including the Government, servicemembers, their
families, employers, private health insurers, taxpayers and
others.
We found that, unless treated, PTSD and depression exact a
high economic toll to society. Our model predicted that the 2-
year post-deployment cost to society for 1.6 million deployed
servicemembers ranged from $4 to $6.2 billion. The majority of
these costs were due to lost productivity; and for a variety of
reasons, the model underestimates the total future costs to
society.
While these costs are high, we also found that providing
evidence-based treatment for PTSD and depression can reduce
societal costs. We estimate that evidence-based treatment for
PTSD and major depression would pay for itself within 2 years,
even without including the many known costs.
Investing in evidence-based care for all those in need can
reduce costs to society by $1.7 billion in just 2 years.
However, ensuring that all veterans with these conditions get
quality care will require addressing the significant gaps that
exist in access to and quality of care for our Nation's
veterans.
Thank you again for the opportunity to testify today and to
share the results of our research. I am joined by my colleague
Christine Eibner, the Health Economist who led these cost
analyses. And together we are happy to answer your questions.
Thank you.
[The prepared statement of Ms. Tanielian appears on p. 47.]
Mr. Hall. Thank you.
So, Ms. Eibner, you have no statement of your own. You are
in a support role?
Ms. Eibner. Right. Exactly.
Mr. Hall. Thank you, Ms. Tanielian. Thank you for your
study. It is an impressive piece of work.
Dr. Kilpatrick, generally speaking, how well can a mental
health provider validate a veteran's self-reported history of
trauma? Do you rule out other diagnoses during the evaluation
period, including malingering?
Dr. Kilpatrick. Well, I think if a mental health
professional is well trained, understands about post-traumatic
stress disorder, understands specifically about not just combat
but war zone exposure, including military sexual trauma, and
looks at the entire picture including the self-report of the
veteran, what we do is we really see how well everything hangs
together.
And, frankly, in terms of post-traumatic stress disorder,
there are things that people write books about it
theoretically, in terms of how to malinger it. And I am not
suggesting that you cannot fool a clinician, because you
probably can fool anybody a little bit. But I do think that for
the most part, by looking at how well the symptoms hang
together and the types of experiences, including things that
many people don't know about and wouldn't know to think of in
order to make something up, that we can tell pretty much
whether people are telling the truth.
The other thing that I would say--and I think our Committee
felt this way, too--is that it is really the stance of people
doing these examinations is important. And if the stance is
that we are going to assume that everybody is lying until they
prove to me that they are not, that we felt was really unfair
and unsupported by the data on how much malingering there
really is.
On the other hand, you can be somewhat skeptical but at the
same time saying, I am going to assume that this person is
telling me the truth until my antenna goes up and I find some
reason to believe that they are not.
Mr. Hall. Along that line of thinking, there has been a
great deal of concern regarding false positives for PTSD. What
about false negatives? Are veterans being denied post-traumatic
stress disorder compensation, in your opinion, who maybe should
not have been?
Dr. Kilpatrick. Well, I think if you look at the whole
picture and you say, all right, how many people--and I think
your study is--the study that we just heard about is very good.
Like how many veterans would we estimate have had, had PTSD,
and then we look at how many of those come forward to the VA,
there is going to be a lot of attrition there for various
reasons.
And then you look at--there is a C&P examination, and how
many of those are denied? I think the group that--one could
make the case that there are a lot of unserved veterans with
PTSD who are unserved and uncompensated. And that would be a
much larger number than a very small number of veterans who
maybe have malingered or exaggerated something and have gotten
a treatment or compensation.
Mr. Hall. Thank you.
Ms. Tanielian, in the model of consequences for post-combat
mental health and cognitive conditions, figure 5.1 in the RAND
report, one of the categories listed as a resource or
vulnerability is social, which includes support, transition,
socioeconomic status and treatment availability. Would you
agree that VA service connection can impact each of those and
transform vulnerabilities into resources?
Ms. Tanielian. Based on the literature, we understand that
an individual has certain resources or vulnerabilities to
whether or not they will actually develop a disorder and then
how they cope and whether or not those consequences can be
mitigated. Access to social support, socioeconomic status and
transition services are associated with being able to mitigate
those consequences. And so to the extent that the eligibility
requirements in place to gain those services make it so that
those services are more available, then they have the
opportunity to promote better outcomes for individuals.
Mr. Hall. Right. You didn't address this directly because
your report was done for the DoD, but as I understand, they are
not in the compensation business.
Ms. Tanielian. Actually, our report was independent of both
the DoD and the VA. We looked specifically at trying to
identify the size and scope of the problem associated with
PTSD, depression and traumatic brain injury among returning
troops.
Mr. Hall. Okay. But it is nonetheless your opinion, as I
understand, that you just stated that compensation would
mitigate some of the negative outcomes from detrimental impact
on social support, life or identity transitions and
socioeconomic status.
Ms. Tanielian. Our study identified several barriers to
getting help for mental concerns reasons and problems. To the
extent that eligibility requirements and structural barriers
are diminished, more veterans would have access to appropriate
care, and thus lower the cost to society associated with PTSD.
Mr. Hall. Thank you. Last I wanted to ask you, RAND
suggested the societal cost of untreated PTSD could run from $4
to $6 billion over a 2-year period just for Iraq and
Afghanistan veterans. I understand that these figures only
somewhat include the cost to VA. If you adjusted for the cost
of disability compensation, do you think the cost to society
would be more or less? And why?
Ms. Tanielian. Sure. I am going to actually ask Dr. Eibner
to address that question.
Ms. Eibner. Sir, we believe this does incorporate the cost
to the VA in terms of disability compensation. And the reason
is, we account for lost productivity in our estimates. So the
lost productivity cost is really what the VA payments are
designed to replace. So it is included in that category.
Mr. Hall. Okay. Thank you very much. Mr. Lamborn.
Mr. Lamborn. Thank you, Mr. Chairman.
Ms. Tanielian, how did you diagnose PTSD among the people
you interviewed? Was there a physician with you? Or what were
the mechanics of that?
Ms. Tanielian. As I mentioned, we conducted a telephone
survey of 2,000 individuals who had been previously deployed.
We used well-accepted screening measures that are used in
conducting epidemiological studies for detecting need for
various different health reasons. Using these screening tools,
we identified current symptoms of PTSD and depression that were
consistent with a diagnoses using DSM-IV scoring criteria for
these screening tools. And so we report the number who were at
the level of consistent symptoms of a diagnosis with PTSD and
depression using these validated screening measures.
Mr. Lamborn. Thank you. And Mr. Chairman, they have done a
good job of explaining themselves. I don't have any further
questions.
Mr. Hall. They sure have. Thank you very much.
We still have--well, this diagram of the immediate
consequences and emergent outcomes and the experience of the
post-combat disorder and what resources and vulnerabilities
there are, that is enough to keep me working for a while. And
it comes in a book. If you haven't seen it, all of you here in
the audience, it is definitely worth reading. It is a serious
contribution and an important contribution to our country's
attempt to help our veterans through this difficult problem. So
I thank you all on this panel for your testimony. You are now
excused.
Moving at breakneck speed, thanks to the fact that there
are no votes being called, and the fact that most of our
Members are not here using their 5 minutes--we will call our
third panel. Rear Admiral David J. Smith, a Joint Staff Surgeon
for the United States Department of Defense; Colonel Robert
Ireland, Program Director of Mental Health Policy for the
Office of the Assistant Secretary of Defense for Health
Affairs, U.S. Department of Defense; Bradley G. Mayes, Director
of the Compensation and Pension Service for the Veterans
Benefits Administration, U.S. Department of Veterans Affairs,
accompanied by Richard Hipolit, General Counsel for the
Department of Veterans Affairs; Antonette Zeiss, Ph.D., Deputy
Chief Consultant, Office of Mental Health Services for the
Veterans Health Administration (VHA); and Maureen Murdoch,
M.D., Core Investigator, Center for Chronic Disease Outcomes
Research of the Minneapolis Veterans Affairs Medical Center,
Veterans Health Administration, U.S. Department of Veterans
Affairs.
As always, your statement is entered into the record as
written. You can feel free to deviate from it.
Mr. Hall. Starting with Rear Admiral Smith, you are
recognized for 5 minutes.
STATEMENTS OF REAR ADMIRAL DAVID J. SMITH, M.D., SHCE, USN,
JOINT STAFF SURGEON, OFFICE OF THE CHAIRMAN OF THE JOINT CHIEFS
OF STAFF, WOUNDED AND SURVIVOR CARE TASK FORCE, U.S. DEPARTMENT
OF DEFENSE; COLONEL ROBERT IRELAND, PROGRAM DIRECTOR, MENTAL
HEALTH POLICY, OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE FOR
HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE; BRADLEY G. MAYES,
DIRECTOR, COMPENSATION AND PENSION SERVICE, VETERANS BENEFITS
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS; ACCOMPANIED BY
RICHARD HIPOLIT, GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL,
U.S. DEPARTMENT OF VETERANS AFFAIRS; ANTONETTE ZEISS, PH.D.,
DEPUTY CHIEF CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES,
OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND
MAUREEN MURDOCH, M.D., MPH, CORE INVESTIGATOR, CENTER FOR
CHRONIC DISEASE OUTCOMES RESEARCH, MINNEAPOLIS VETERANS AFFAIRS
MEDICAL CENTER, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF
REAR ADMIRAL DAVID J. SMITH, M.D., SHCE, USN
Admiral Smith. Mr. Chairman, distinguished Members of the
Subcommittee, I am privileged to appear before you today and
report on wounded-warrior issues and specifically those
associated with post-traumatic stress disorder.
In my capacity as the Joint Staff Surgeon, I serve as the
Chief Medical Advisor to the Chairman of the Joint Chiefs of
Staff and as a Senior Member of the Chairman's Warrior and
Survivor Care Task Force.
On behalf of the Chairman, let me emphasize to you that
wounded warrior issues, particularly including post-traumatic
stress, continue to be a top priority for the Chairman and the
Department of Defense as a whole.
Working in concert with the respective services, we
continue to focus on revitalizing and reconstituting the force,
actively identifying the needs of and giving support to our
servicemembers' families and removing the stigma associated
with post-traumatic stress within the DoD.
I make the statement of revitalizing and reconstituting the
force, because those are the terms the Chairman uses when
speaking of the top issues and, specifically, his imperative
concern.
I, along with the task force, continuously focus on
improving current programs, while inviting the creation of new
ones. And we are strongly focused on teaming with the Veterans
Affairs and nongovernmental organizations to ensure our
veterans and their families receive care that they so aptly
deserve after they leave active duty.
In regards to doctrine definitions and terminology
associated with post-traumatic stress, let me say that the
Department evaluates definitions for their use in doctrine, but
we do not evaluate definitions for the potential implications
on benefit determination.
DoD's definitions and terminologies may be used, but are
not replacements for policy and law in determination matters.
The doctrine and definitions are tools we use to provide a
common starting point across the Department, but compensation
will continue to be dictated by policy and law rather than
terms of reference for post-traumatic stress.
The DoD and the VA use the Diagnostic and Statistical
Manual for Mental Disorders, 4th edition, frequently referred
to as the DSM-IV, for the diagnosis of post-traumatic stress
disorder, and CFR 38 outlines the necessary prerequisites for
eligibility.
With these rule sets, the medical community then applies
professional judgment to interpret and diagnose individual
cases, and the DoD continuously monitors changes within the
medical community of terms of reference, research findings, and
new treatment modalities and improvements to ensure we stay in
touch with changes that do occur.
Now, let me take a moment of your time to identify one area
of concern related to the treatment of post-traumatic stress
and other issues related to the care of our servicemembers and
veterans. The disability evaluation and compensation system, in
its current state, is clearly too complex and burdensome for
even the most tolerant of our servicemembers and veterans.
The time associated with working through the system has
been identified as a significant additional stressor to our
servicemembers and their families that we want to fix. And in
contrast to the stop-gap efforts, which have been employed in
the past, I believe that the disability evaluation and
compensation system requires revolutionary, systemic overhaul.
DoD is working closely with our representatives from the
Veterans Affairs counterparts to begin this process. Both
Secretary Gates and Admiral Mullen have identified this issue
as an important focus area for DoD and VA.
I identified this issue to the Committee and its Members to
let you know we are keenly aware of the problem, and at some
time in the future DoD and VA may ask for assistance from the
Legislative Branch to help streamline and correct deficiencies
that may require adjustments to current law.
DoD will continue to keep your Committee and the Congress
at whole apprised of the situation as we work through the
nuances to help fix the disability evaluation system.
Now, I would like to reemphasize the point to you: Congress
and the DoD have committed hundreds of millions of dollars to
improve our understanding of combat and operational stress,
psychological health, the resilience of our personnel, as well
as to diagnose and treat post-traumatic stress and related
conditions, including mild traumatic brain injury.
We continue to face many challenges and are working closely
with the Veterans Affairs, the National Institute of Mental
Health, and academic centers across the country to better
improve our services for veterans and their families. We will
continue to focus on post-traumatic stress until we feel every
servicemember is optimally prepared to cope with combat stress
and, when needed, is receiving the treatment he or she has
earned through their service.
Mr. Chairman, thank you again for the invitation to appear
here this afternoon, and I am pleased to respond to any
questions you or the Subcommittee Members may have.
[The prepared statement of Admiral Smith appears on p. 53.]
Mr. Hall. Thank you, Admiral. I am pleased to hear you
talk, as does Secretary Shinseki, about his ongoing and
evolving work with Secretary Gates and the two Departments
working together, because there is so much of this that is a
continuum that starts with entry into active duty and continues
on into one's later years as a veteran. Many of these problems
can best be solved if the two Departments work together.
And when you talk about, I think you said, revolutionary
and systematic overhaul of the disability evaluation system,
you may be aware that last year we passed a bill that was
passed by the Senate also and signed into law to do just that.
So it will take a while to do it, but we have started the ball
rolling and hopefully that revolutionary and systematic
overhaul will happen. Colonel Ireland, you now have the floor
for 5 minutes.
STATEMENT OF COLONEL ROBERT IRELAND
Colonel Ireland. Chairman Hall, Ranking Member Lamborn, and
distinguished Members of the Subcommittee, thank you for this
opportunity to discuss the Department of Defense approach to
diagnosing PTSD and defining related stressors and the use of
the servicemember's record.
In many ways, due to the complexities we have heard earlier
today, it may seem quite simple on the DoD clinical side. When
servicemembers' medical conditions do require further medical
evaluation in order to assess whether they are retainable in
their service to perform their duties, military treatment
facility clinicians perform an evaluation, write a summary and
submit it for review by a medical evaluation board, or MEB.
This consists simply of two or three clinicians in the
treatment--medical treatment facility. And when it is a mental
health issue it should include--must include--a psychiatrist.
So if there is an MEB review of the psychiatric condition,
there should be a sign-off by a psychiatrist on that report.
The report is to confirm the diagnosis and document
thoroughly the medical condition of the member and to review
each case based on relevant facts. The local MEB simply
determines whether the servicemember meets the retention
standards and can be returned to duty, or whether the member
fails to meet those standards and would require either a waiver
to continue in service or has to go to a Physical Evaluation
Board (PEB) for further consideration to look at whether they
should be retained with that waiver, separated with or without
severance pay, or retired.
All of these fall outside of the clinical processes at the
local level and are a service matter with the Personnel
Physical Evaluation Board system.
With respect to PTSD, military providers do use the same
criteria as their civilian counterparts to diagnose PTSD, using
the American Psychiatric Association's (APA's) DSM-IV criteria.
And I will skip going through those criteria to avoid
duplication and save some time.
With regard to comments on stressors, there is a long
history of how that word is used and the development of theory
related to it. But to simply to refer to well, that was an
appropriate stressor, is probably an oversimplification in
assessing what someone has experienced, what they have
witnessed. And then we also need to consider how that caused a
physiologic reaction within them and an emotional reaction--and
then for human beings, usually there is some form of self-
assessment of that experience or that event and one's own
perception of one's own reaction to it, and one's sense of
whether they can meet the demand. And when they can't, that is
usually when they show up to mental health. So a stressor is a
complex thing to speak about, and simply checking off the
stressors of what would cause PTSD may be an
oversimplification.
To conclude, the importance of such records of these
evaluations and PEB recommendations and conclusions to
transitioning servicemembers cannot be overemphasized. We do
encourage servicemembers to request copies of their medical and
mental health records upon separation from the military to
assure continuity of care, irrespective of where they receive
their care in the future.
Those utilizing the VA have the added advantage of VA
provider visibility of their medical and their mental health
records through the use of the Bidirectional Health Information
Exchange, which is functional and is receiving military medical
records.
Thank you, again, for allowing the opportunity to appear
before you and to discuss these issues.
[The prepared statement of Colonel Ireland appears on p.
53.]
Mr. Hall. Thank you, Colonel.
Mr. Mayes, welcome back. It is always good to see you. You
are now recognized for 5 minutes.
STATEMENT OF BRADLEY G. MAYES
Mr. Mayes. Thank you.
Mr. Chairman, Ranking Member Lamborn, I would like to thank
you for the opportunity to testify on this important topic of
post-traumatic stress disorder. Mr. Dick Hipolit, from the
Department of Veterans Affairs, Office of General Counsel,
accompanies me today.
The number of veterans receiving service-connected
compensation for PTSD from VA has grown dramatically. From
fiscal year 1999 through fiscal year 2008, the number increased
from 120,000 to more than 345,000.
We all share the goals of preventing this disability,
minimizing its impact on our veterans, and providing those who
suffer from it with just compensation for their service to our
country. Consequently, VA has expanded its efforts to assist
veterans with the claims process and keep pace with the
increased number of claims.
Today, I will briefly describe the PTSD claims process and
explain how VA applies the statutory requirements of 38 U.S.C.,
section 1154, to the processing of these claims. Section 1154,
which, as we heard earlier, was enacted by Congress in 1941,
requires that VA consider the time, place and circumstances of
a veteran's service in deciding a claim for service connection.
Section 1154(b) provides for reliance on certain evidence
as a basis for service connection of disabilities that result
from a veteran's engagement in combat with the enemy. As a
result, veterans who engaged in combat with the enemy and filed
claims for service-connected disability related to that combat
are not subject to the same evidentiary requirements as
noncombat veterans. Their lay statements alone may provide the
basis for a service-connected disability without additional
factual or credible supporting evidence.
In PTSD claims, a combat veteran's personal stressor
statement can serve to establish the occurrence of the
stressor.
The processing of PTSD claims is governed by our
regulations at 3.304(f). Specifically this regulation states
that in order for service connection for PTSD to be granted,
there must be, first of all, medical evidence diagnosing the
condition.
Second of all, medical evidence establishing a link between
current symptoms and an in-service stressor.
And then, third, credible supporting evidence that the
claimed in-service stressor occurred.
As I said, the first two requirements involve medical
assessments, while the third requirement may be satisfied by
nonmedical evidence.
PTSD is defined as a mental disorder that results from a
stressor. That third requirement of the regulation emphasizes
the importance of the stressor and the obligation of the
Department of Veterans Affairs to seek credible evidence
supporting the occurrence of that stressor.
In PTSD claims where the stressor is not combat related,
VBA personnel conduct research and develop for credible
evidence to support the claimed stressor.
However, we have incorporated into our regulations the
1154(b) provisions, so that when there is evidence of combat
participation and the stressors related to that combat, no
stressor corroboration is required. The veteran's lay statement
alone, as stated, is sufficient to establish the occurrence of
the stressor.
Through the years, VA has made changes to our regulations
at 3.304(f) based on the requirement at section 1154 of the
statute that mandates us to consider the time, place and
circumstance of a veteran's service. The definition and
diagnostic criteria for PTSD evolved to a great extent from the
psychiatric community's attempt during the seventies to explain
the psychological problems of some Vietnam War veterans. Once
the medical community recognized this mental disorder, VA added
it as a disability to the schedule. VA then moved to
incorporate PTSD diagnostic criteria from the APA's DSM-IV into
the PTSD claim evaluation process.
Given the delay that may occur between the occurrence of
that stressor and the onset of PTSD, and the subjective nature
of a person's response to an event, VA concluded when it first
promulgated the regs in 1993, that it was reasonable to require
corroboration of the in-service stressor.
However, as the military incorporated more female members
into its ranks, VA recognized that PTSD could result from
personal assault and sexual trauma.
To meet this evolving situation, VA added a section at
3.304(f), which provides for acceptance of evidence for
stressor corroboration in such cases from multiple sources
other than the veteran's service records. The evidence may
include local law enforcement records, hospital or rape crisis
center records, or testimony from family, friends or clergy
members.
Although the combat participation provisions of section
1154 have been in effect for many years, the VA has recently
provided a regulatory change that further extends the intent of
that statute and recognizes the changing conditions of modern
warfare.
A new section, 3.304(f)(1), now provides for service
connection of PTSD when there is an in-service diagnosis of the
disability. In such cases, the veteran's lay stressor statement
and the medical examiner's association of PTSD with a stressor
is sufficient to establish service connection where PTSD is
diagnosed.
This liberalization of regulatory requirements is due to
the recognition by VA of the heightened awareness of PTSD among
military medical personnel, resulting in the increasing numbers
and reliability of PTSD diagnoses for personnel that are still
on active duty.
These descriptions of PTSD-related initiatives make it
clear that VA is committed to following the mandate of the
provisions of section 1154, and adjusting the PTSD claims
process as necessary to serve our veterans.
This concludes my testimony, and I would be happy to answer
any questions that the Members may have.
[The prepared statement of Mr. Mayes appears on p. 54.]
Mr. Hall. Thank you, Mr. Mayes.
Dr. Zeiss.
STATEMENT OF ANTONETTE ZEISS, PH.D.
Dr. Zeiss. Good afternoon, Chairman Hall and Members of the
Subcommittee.
Thank you for the opportunity to discuss the diagnosis of
PTSD by Veterans Health Administration health clinicians,
particularly in the context of a compensation and pension
claim.
The Department of Veterans Affairs is recognized for its
outstanding PTSD treatment and research programs, the quality
of VA health care in this area is outstanding, and we improve
as we learn more. All VA clinicians, including those
responsible for completing compensation and pension
evaluations, adhere to the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition, Text Revision, DSM-IV-TR of the
American Psychiatric Association.
According to these clinical criteria, PTSD can follow
exposure to a severely traumatic stressor that involves
personal experience of an event involving actual or threatened
death or serious injury. It also can be triggered by witnessing
an event that involves death, injury or a threat to the
physical integrity of another. This would meet criterion A in
the DSM-IV criteria for PTSD.
The person's response to the event, also to meet criterion
A, must involve intense fear, helplessness or horror. If
criterion A is met, then symptoms characteristic of PTSD to
fully establish the diagnosis would be explored, including
persistent reexperiencing of the traumatic event, persistent
avoidance of stimuli associated with the trauma, along with
numbing of general responsiveness and persistent symptoms of
increased arousal.
No single individual would display all these symptoms, and
a diagnosis requires a combination of a sufficient number of
symptoms, while recognizing that individual patterns will vary.
PTSD also can be experienced in many ways. Symptoms must
last for more than 1 month to receive the diagnosis, and the
disturbance must cause clinically different distress or
impairment in social, occupational or other important areas of
functioning.
Military combat certainly creates situations that fit the
DSM-IV-TR description of a severe stressor event that could
result in PTSD. The likelihood of developing PTSD is known to
increase as the proximity to, intensity of, and number of
exposures to such stressors increase.
PTSD is associated with increased rates of other mental
health conditions and can directly or indirectly contribute to
other medical conditions. Symptoms may be brief or persistent.
The course of PTSD may ebb and return over time, and PTSD can
have delayed onset. Clinicians use these criteria in
discussions with patients to identify cases of PTSD.
VA seeks to ensure that we offer the right diagnosis in all
clinical settings, whether for C&P examinations or part of the
standard mental health assessment. In the C&P context, only
psychiatrists and psychologists may conduct an initial C&P
examination in which a diagnosis of PTSD is being considered in
response to a claim by a veteran.
In addition, any psychiatrist or psychologist who will
conduct a PTSD C&P exam must complete specific training on that
process and receive certification in conducting C&P
examinations in relation to diagnostic criteria of PTSD.
We recognize that many individuals with symptoms of combat
stress or PTSD may find it difficult to discuss the details of
those experiences. Without the patient disclosing the source of
the stress, it is impossible for a clinician to diagnose PTSD
according to the clinical criteria of DSM-IV-TR. This is part
of why only doctoral-level providers are allowed to conduct
initial exams and to have the sensitivity and expertise to
enable a full description of the concerns being presented.
VHA clinicians who conduct the clinical interview for the
diagnosis of PTSD in the context of a claim do not ask for
external corroborating evidence for the described stressful
event. That would be really determined by the clinician's
experience of the description of the veteran of their stressful
experience, and how that led to the symptoms that they also
would describe.
Apart from issues of determining diagnosis in the C&P
context, identifying and treating patients with PTSD and other
mental health conditions is, of course, of paramount concern
for Veterans Health Administration, and we provide mental
health care in many different environments, including Vet
Centers.
And I might add that while the RAND study showed about 14
percent returning with possible PTSD, in VA we are serving over
20 percent of those veterans who have returned and sought care
from VA, and have been diagnosed with possible PTSD. So we are
very much trying to identify cases and ensure delivery of care
as well as, in the appropriate context, support for claims.
So I have submitted my written statement, and just convey
that any veteran with a mental health condition we hope will
seek care from VA, will receive treatment and counseling for
mental health conditions, and we are ready to help.
Thank you for the opportunity to speak, and I am prepared
to answer questions.
[The prepared statement of Dr. Zeiss appears on p. 56.]
Mr. Hall. Thank you, Dr. Zeiss.
Dr. Murdoch, you are now recognized for 5 minutes.
STATEMENT OF MAUREEN MURDOCH. M.D., MPH
Dr. Murdoch. Thank you. Mr. Chair and Members of the
Subcommittee, thank you for the opportunity to appear before
you today to present findings from my team's research on post-
traumatic stress disorder disability awards.
I must note that the views presented here are mine and
don't necessarily represent the view of the Department of
Veterans Affairs; and they reflect the results of my studies,
not necessarily other studies that have been done. And I must
emphasize that this research was done more than 10 years ago
and may not reflect experiences of new cohorts of veterans.
So I am sure you know that PTSD is the most common
psychiatric condition for which veterans seek VA disability
benefits. Between 1998 and 2000, my colleagues and I conducted
three studies looking at differences in PTSD disability awards.
The first study was a historical administrative database
evaluation of all 180,039 veterans who applied for disability
benefits between 1980 and 1998. The second was a mailed survey
of about 5,000 veterans who applied for disability benefits
between 1994 and 1998. And then, finally, we did a claims audit
of about 345 veterans who also responded to the survey.
These studies had several objectives, but the most relevant
to today's proceedings included identifying the role of combat
experience on receiving disability benefits for PTSD and
understanding how claiming combat versus military sexual trauma
influenced gender differences in receiving PTSD service
connection.
From the historical database study, we learned that rates
of service connection increased over time between 1980 and
1998. And across all time periods, men and women who were
documented as being combat-injured in the database had a rate
of service connection of greater than 90 percent.
By 1998, the observed rate of service connection for men
without combat injuries was 64 percent, and the rate for women
without combat injuries was 57 percent. From the survey's study
which, again, covered the time period between 1994 and 1998, we
again saw that more than 90 percent of men and women who had
documented combat injury in the database received service
connection for PTSD.
Of those who did not, who were not identified as being
combat injured, 52 percent of women and 64 percent of men
received PTSD service connection. However, this gender
difference was almost completely explained by the men and
women's different rate of combat experience. Regardless of
gender, veterans with more combat experiences were more likely
to receive service connection than veterans with fewer or no
combat experiences.
Since men were more likely to report combat experiences,
they were also more likely to be service connected for PTSD. I
would also like to point out that in this study, 30 percent of
the women reported some kind of combat experience.
In our claims audit of 345 veterans who participated in the
mailed survey, we found that 85 percent of men received a
diagnosis of PTSD from a qualified clinician, compared to 76
percent of women.
Veterans who were selected for chart audits did not get
service connection for PTSD unless his or her examining
clinician made a diagnosis of PTSD. About a third of veterans
with PTSD diagnosis did not receive service connection.
Veterans diagnosed with PTSD at the time of their clinical
examination reported an average of two more combat experiences
at the time of survey, compared to men who were not diagnosed
with PTSD.
Women who were diagnosed with PTSD were as likely to report
a military sexual assault on the survey as were those not
diagnosed. So, put another way, reporting more combat
experiences was associated with greater odds of PTSD diagnosis,
but reporting sexual assault was not.
The factor most strongly associated with veterans receiving
a diagnosis of PTSD was having a stressor documented in their
claims file.
Mr. Chairman, Subcommittee Members, this concludes my
statement, and I am pleased to respond to any questions you may
have. Thank you.
[The prepared statement of Dr. Murdoch appears on p. 58.]
Mr. Hall. Thank you, Doctor.
I will begin my questioning with Admiral Smith. In its
testimony in an earlier panel, the IAVA referred to ``combat
support'' and ``combat service support.'' Can you describe
these terms and how they function in a combat zone or combat
theater of operations?
Admiral Smith. I am not sure that I am the expert that can
answer that but--and I said in my testimony--the doctrine that
we set up is primarily based on needs of what we need within
the military.
For example, in doctrine we don't have a definition for
``combat,'' because it is clear from Webster's Dictionary what
that is. There is a DoD Instruction that talks about benefits,
that actually does define, based on CFR, various aspects of
combat, and that is DoD-I 1332.38 that I have with me.
Mr. Hall. Okay, and this question would be to you and
Colonel Ireland both. Given the circumstances in Iraq and
Afghanistan, would you say that it is distinguishable in terms
of who is engaged in combat with the enemy and who is not?
Let me elaborate? As one Member of Congress who went and
slept in the Green Zone for one night and was told, if you hear
a siren in the middle of the night, jump out of bed and run
over to that bunker because last week we lost two soldiers to
incoming mortar rounds; now if that was my one-night experience
in the Green Zone, the safest place in the country, then
presumably supply sergeants, nurses, cooks, servicemembers who
are there on a break from being out in the countryside working
at their regular duties, are all subject to a nightly
possibility of incoming rounds impacting close to them and
injuring or killing members of our forces.
Obviously, there are different degrees of combat. You can't
compare that to being attacked or ambushed on the road and hit
with an IED and so on or so forth. But nonetheless, it is the
kind of thing that repeated experience might cause--in some
people--might cause symptoms.
Admiral Smith. Yes, sir. As far as combat, clearly that is
where the history becomes so important; because as you aptly
pointed out, it varies dramatically by the location you are in,
the particular jobs that you are assigned and what your
experiences are there.
Over the course of the last 10 years, a number of combat
badges have actually been developed and the definitions of
those are defined by each one of the services. And then it is
dependent on the particular commander of the units as to who
gets allocated that designation.
Mr. Hall. Colonel Ireland, do you care to add to that?
Colonel Ireland. From the clinical perspective, it doesn't
matter much whether we were involved in offensive or defensive
or no operations whatsoever at the time of attack. So that is
not part of my expertise to comment, sir.
Mr. Hall. Does the Post-Deployment Health Reassessment
(PDHRA) program screen for PTSD, Colonel Ireland, and what
happens with those PDHRA results?
Colonel Ireland. The results of the assessment are made
available to the VA, and then clinicians can pull them up off
their screen and look at them when they see a patient.
From our standpoint, the servicemember is evaluated by a
designated health care member to review their physical and
mental health concerns on the health assessment, and discuss
with them the nature of them--to determine how badly they are
bothered by them--to make a brief functional assessment, but
not a formal one, and make a determination as to whether
further evaluation or treatment may be necessary, and then
discuss with the member various options they may have, both
clinical and preclinical, and help them influence the
direction, dependent on the number of endorsements, the
severity of what they are perceiving and the member's
willingness to engage in care.
So the member may go to a chaplain but not necessarily go--
but refuses to go to a clinic for evaluation, we start there
with preclinical care.
If they don't want to see anyone, we might refer them to
http://afterdeployment.org--our Web site, so we will try to
work with a member based on the severity of their condition and
what they are willing to do.
Mr. Hall. Can you tell us more about the DoD BATTLEMIND
program and how it identifies potentially traumatic events. And
is BATTLEMIND mandatory for all servicemembers before and after
deployments?
Colonel Ireland. BATTLEMIND is a unique Army program, sir,
and it is using mostly Army contexts to display its messages.
Those types of messages are included in other types of
programs.
For example, the Air Force is utilizing LANDING GEAR, a
similar-type program, but using more of the experiences
familiar to Air Force members. It is my understanding, though,
that other services are using BATTLEMIND for certain situations
and are certainly free to do so. As in suicide prevention, we
encourage the sharing and stealing of good ideas wherever they
are found.
Mr. Hall. Thank you.
Mr. Mayes, as you have acknowledged, the language in
section 1154 that was enacted by Congress in 1941--and VA, of
course, has to base its rulemaking on it--if Congress broadened
the definition, would VA change its requirements?
Mr. Mayes. Well, certainly, if Congress passed legislation
that changed the language, for example, that is in section 1154
right now, then we would engage in rulemaking to comport with
the law.
Mr. Hall. Thank you. I am going to turn it over to Ranking
Member Lamborn.
Mr. Lamborn. I thank the Chairman.
Admiral Smith, what type of recourse does a non-combat
veteran have if the traumatic event he or she experienced is
not expressly written down in their service record?
Admiral Smith. I am not sure that I can answer from a DoD
perspective. Within the DoD, it would be reliant on their
history and in trying to document it by talking to members of
their unit, et cetera. But we primarily are relying on the
medical information that we received during the encounter.
I think I am going to have to defer to the VA relative to
how one would document that or how they would deal with that
from a benefits point of view.
Mr. Lamborn. Okay, let's turn that over--if someone wants
to address that.
Mr. Mayes. Ranking Member, could you repeat the question? I
am sorry; you caught me there.
Mr. Lamborn. What type of recourse would a noncombat
veteran have if the traumatic event they experienced is not
expressly written down in their service record?
Mr. Mayes. Well, as I said in my testimony, we will go
ahead and develop for that stressor, that would then
substantiate or could be used to support a diagnosis of post-
traumatic stress disorder. So we are required by statute, as
stipulated in section 5107, to go out and secure any evidence
that the veteran might have available or presented to us or
indicated that they have in their possession.
We would go out and look at service records. Potentially we
would ask for buddy statements. And so we would begin to
assemble a picture that would begin to try and corroborate the
stressor that is asserted by the claimant. And with that
evidence that we had collected--if it was sufficient, if there
was sufficient corroboration and there was an indication that
the veteran was suffering from symptoms related to PTSD--then
we would send that documentation along with a request to our
colleagues in VHA for a C&P exam so that they could then
provide the other two elements--and that is the diagnosis and
the medical link between that diagnosis and the stressor that
is asserted by the claimant.
Mr. Lamborn. Okay. Thank you.
Admiral Smith, back to you. How would a servicemember's
record reflect their temporary assignments while in theater?
For example, would a record show that a helicopter mechanic was
temporarily assigned to a convoy, and would their records show
that they saw potentially traumatic events while part of the
convoy?
Admiral Smith. I think I am going to have to take that for
record, sir. Sorry.
Mr. Lamborn. Okay. Well, we could maybe get a written
response at another time.
Admiral Smith. Sure.
[The DoD subsequently provided the following information:]
Currently there is no uniform recording of the exposure to
traumatic events within a service member's records when they
are assigned to temporary duties described by Congressman
Lamborn such as convoy duty or patrol.
This is a problem identified recently by a task force formed
by the Chief of the Army National Guard Bureau as well as by a
team of investigators sent by the Chairman of the Joint Chiefs
of Staff to Iraq and Afghanistan in February. Currently, these
combat events are recorded in CIDNE (Combined Information Data
Network Exchange) and SIGACT (Significant Activity) Reports.
CIDNE and SIGACT reporting are used for battlefield
intelligence. There are no direct linkages, however, of
personnel data to these reports. In some cases, these exposures
to traumatic events are recorded in the service member's
medical record if they report for medical evaluation or
treatment. In other cases, the service member may report the
exposure in their Post Deployment Health Assessment or Post
Deployment Re-assessment (PDHA and PDHRA) long after the event.
The Office of the Surgeon General of the Army is working in
conjunction with the Chief of the National Guard Bureau in the
development of a joint application for associating service
member identification numbers with CIDNE and SIGACT reporting.
The Chairman of the Joint Chiefs of Staff has formally listed
this tracking program as one of his top wounded warrior
priorities.
Mr. Lamborn. Mr. Mayes, can the definition of combat under
section 1154 be improved on, short of making everyone in the
combat theater fall under the definition?
Mr. Mayes. My sense is--let me back up and say, first of
all, any veteran can be service-connected for PTSD. They don't
have to be a combat veteran. So let's start from that premise.
I believe, and we have looked to the legislative history on
section 1154, regarding section 1154, that the intent of
Congress was to reduce the evidentiary burden on those veterans
who engaged in combat with the enemy. And they were very
specific. Congress was very specific in selecting that language
when you look at the bills that were being contemplated at the
time.
If the intent is to address the evidentiary burden to prove
the stressor for a noncombat veteran, I believe you can get at
that by looking at section 1154, but you can also get there
possibly by looking at the regulations that we have codified at
3.304(f), 38 CFR, 3.304(f).
And we have done that over the years. That is what I was
saying. We have reduced the evidentiary burden for female
veterans suffering from post-traumatic stress disorder due to
personal assault.
We have reduced the evidentiary burden for American ex-
POWs. We have reduced the evidentiary burden for veterans
diagnosed with post-traumatic stress disorder when they are
diagnosed while still on active duty.
And we would certainly be willing to work with the
Committee to explore avenues for achieving what I think it is
that is being attempted here, as I understand it. However, it
is not a legislative hearing. We didn't come over to talk about
the proposed bill, but I extend my offer to work with the
Committee.
Mr. Lamborn. May I have one followup question, Mr.
Chairman?
Mr. Hall. Yes.
Mr. Lamborn. My time has expired, but as a followup to this
important line of reasoning that we are all discussing here,
you maybe were able to hear the example earlier from the
American Legion representative about two people in the same
convoy but they had differing burdens of proof afterward.
Do you have any reflections on that particular scenario
based on what you just said?
Mr. Mayes. Well, I do, Mr. Lamborn. As a matter of fact, I
made a note of it. Mr. De Planque, I thought, did an
outstanding job of laying out the issue.
And the truth is that if we could place the servicemember--
or the veteran who was not in the combat MOS--if we could place
them in that area at the time that those events were occurring,
then our procedures, where we are today, would allow us to
grant service connection in that case as long as the evidence
that corroborated the stressor was used by the clinician as the
stressor that supported the diagnosis of post-traumatic stress.
So that was my point. There is a way to reach the noncombat
veteran right now in our existing procedures, and I would say
that on its face, we have seen a dramatic increase in the
number of veterans that are on the rolls for PTSD. It is a 188
percent increase in the last 10 years, as opposed to a 10-
percent increase on the rolls for all disabilities.
So the things that we have done along the line to reduce
that evidentiary burden, I believe, are part of the reason, not
all of the reason, but part of the reason that we are seeing
that dramatic increase in veterans receiving compensation for
PTSD.
Mr. Lamborn. Okay. Thank you all for your answers and for
being here today.
Mr. Hall. Thank you, Mr. Lamborn.
I would like to follow up, if I may, by noting, Mr. Mayes,
that you testified there are 345,520 veterans who are service-
connected for PTSD. Dr. Zeiss testified that she is treating
442,862 veterans, which is an almost 100,000 different number.
What do you attribute that difference to? Or I could ask Dr.
Zeiss the same thing.
Mr. Mayes. Well, I can't definitively say why every
veteran--I mean, there is no way for me to know why a veteran
might be treated for PTSD, yet not file a claim for post-
traumatic stress disorder. I mean, I can only offer you
conjecture.
But, certainly, it is possible that some veterans are
seeking counseling and treatment to get healthy, and aren't
interested in proceeding to VBA to file a claim for disability
compensation.
Mr. Hall. Dr. Zeiss?
Dr. Zeiss. I would say the same, and say that we are very
grateful to Congress that you have offered the 5-year window
where all veterans returning from the current conflicts can
come to VA and have eligibility to receive care. So it is not
necessary to establish a service-connected diagnosis of PTSD
for these returning veterans in order to be diagnosed and
receive care on the VHA side of the house.
Clearly there are many veterans who are receiving care with
the diagnosis of PTSD. And what their individual reasons for
perhaps not submitting a claim, or what the data is about how
many of them have submitted a claim that has not been accepted,
we don't have that data on the VHA side of the house.
Mr. Hall. Or maybe the treatment is so successful that they
don't feel that they are in need of assistance.
In your testimony, Dr. Zeiss, you noted that safety and
trust are important issues when discussing these traumatic
events. Patients need to be comfortable, examiners need to be
sensitive.
The IOM recommends exams take at least 90 minutes and
perhaps up to 3 hours, but noted that VA exams frequently can
take as little as 20 minutes. How can you achieve safety, trust
and comfort in that short a time to elicit a complete military
history and develop an understanding of the patient stressors?
Dr. Zeiss. Our guidelines and part of the training for
those who are going to conduct C&P exams would support what has
been said by IOM. And the recommendation is that the exams
should take at least 2 hours, I believe, was the final
decision.
It is certainly the case that for some repeat exams, where
the only question is what the current level of disability is,
and there is not a diagnosis being established, a much shorter
interview might be very appropriate.
But for a diagnostic exam, we have been at pains to stress
and to try to set up a system in which full interviews would be
done in a timeframe that supports the recommendation of IOM and
our own VHA recommendations, and we continue to follow up to
try to ensure that that is the standard.
Mr. Hall. How good are you, do you think, at detecting
veterans who might claim to have PTSD who don't actually have
it?
Dr. Zeiss. Well, I thought that Dr. Kilpatrick covered that
beautifully, and so I will simply echo some of the things that
he said. Everyone would love it if we had a simple test that
could establish malingering or a simple blood test that
established PTSD, and many of these issues would be moot. We
don't. This is a much more complex and experiential kind of
decision and clinical process.
And so clinicians need to be sensitive, as Dr. Kilpatrick
said. We should start with the assumption that people are
telling us the truth. But if there are red flags in what they
are saying, if there are different stories at different points,
or contradictory things being said, the clinician may want to
slow down and take additional time.
We actually have in the established practices for doing a
C&P exam for PTSD, and in the training, the idea that if there
is such a concern, the clinician has the option of setting up a
second interview or an opportunity for psychological testing.
No psychological testing, as Dr. Kilpatrick said, could give a
definitive answer, but it might inform whether or not there is
some malingering.
It also might inform whether the appropriate diagnosis is
not PTSD but some other mental health problem.
So we have tried to build into the process clinically
sensitive ways to ensure that the clinician is really attending
to all the information they are getting and making staged
decisions about how much additional evaluation should occur
prior to making the diagnosis.
Mr. Hall. And you are using the Best Practices Manual for
PTSD and C&P exams?
Dr. Zeiss. That is part of the training evaluation, and
there is also a study going on looking at the CAPS process, the
Best Practices Manual, to see whether or not in fact it does
lead to superior quality of diagnosis.
Mr. Hall. Are worksheets for the PTSD C&P exams mandated?
Dr. Zeiss. Yes. We have developed those in collaboration
with the VBA. All clinicians who are doing the C&P interview
would complete that information to provide to VBA. And if they
don't, it comes back from VBA, and they will not make a
decision until they have that complete information.
Mr. Hall. A couple more quick ones. When the Compensation
Pension Examine Program (CPEP) has reviewed VHA records for
PTSD, how accurate have those records have been?
Dr. Zeiss. I am sorry, I couldn't hear.
Mr. Hall. When the CPEP has reviewed VHA records for PTSD,
how accurate have those exams been?
Dr. Zeiss. I would defer the answer to that to Mr. Mayes.
CPEP is a part of VBA, and that data would be evaluated
internally within the VBA side.
Mr. Mayes. I don't have that data with me today, but we can
certainly take that back and provide it for the record. Just so
I am clear, you are looking for the accuracy of only PTSD
exams; is that correct, Mr. Chairman?
Mr. Hall. Yes, please.
Mr. Mayes. Okay.
[The VA provided the information in response to Question #5
of the post-hearing questions and responses for the record,
which appears on p. 91.]
Mr. Hall. I understand that primary care providers have
been instructed to screen Iraq and Afghanistan veterans for
traumatic brain injury and PTSD. I guess this could go to Mr.
Mayes and Dr. Zeiss.
Why not screen all combat veterans for both?
Dr. Zeiss. We are mandated to screen all veterans, not just
the currently returning veterans. And in addition, there is
mandatory screening for depression, military sexual trauma and
problem drinking.
Mr. Hall. Let me just close by posing a--we heard a couple
of hypotheticals before when one of the earlier panels was
here.
This is an actual case that we are aware of that a veterans
service organization (VSO) representative is working on for a
Vietnam veteran who was trained as a cook and--deployed to a
forward base in Vietnam.
When he arrived there, according to the veteran, the
commander looked at his papers and said, ``I don't know what
you were sent here for. We don't have a mess hall. Here is a
rifle, you are doing perimeter duty.''
And so he spent his tour in Vietnam doing perimeter guard
duty, taking incoming fire at night, and finished his tour and
came back to the United States and was discharged and has, I
understand, the classic symptoms of PTSD. Let's assume for the
sake of argument that is true. Now, obviously, none of you have
seen him. This is not a case where we have examined the person
in question. But the VSO rep who is working with him is himself
a veteran, obviously, a Vietnam veteran. Because of the fact,
so far, that this veteran's record says he was a cook, he is so
far being denied PTSD classification, which would accord him a
disability compensation.
Does a change such as that, which we are considering to
provide a presumed stressor, once there is a diagnosis--you
have to have the diagnosis from a doctoral-level person--but
once you have that service in uniform in a combat zone, would
provide this stressor to allow disability assistance?
Does that sound like that would solve that kind of problem,
Admiral, starting with you? Or would it be necessary? Is it
necessary to solve that problem?
Admiral Smith. Well, from the testimony that I have heard
and looking over what the CFR actually says, it would appear
that it could be documented that he was not doing mess work. If
there is no documentation for that, that is where the conundrum
comes in.
Mr. Hall. Colonel?
Colonel Ireland. It sounds like what you are proposing may
apply and be helpful to that person.
Mr. Hall. Mr. Mayes?
Mr. Mayes. Two comments. The first comment is, I believe,
that if we could gather sufficient corroborating evidence that
we could service-connect that veteran--for example, evidence
that he participated in hostile activities, the types of
activities that would support a diagnosis of PTSD. And then we
would need, as I said, the diagnosis and the medical evidence
establishing the link between that stressor and that diagnosis.
That is my first comment.
So I think we are reaching veterans with similar fact
patterns.
My second comment is if, hypothetically, you relaxed the
evidentiary burden for that veteran, then their lay testimony
alone would serve as sufficient evidence for the stressor. It
would also, if they claimed a low-back condition, their lay
testimony alone would establish the injury to the lower back or
any disability, because changing their evidentiary threshold at
1154 is going to apply across the board, not just to
neuropsychiatric disabilities.
Those are the two comments that I would offer.
Mr. Hall. Dr. Zeiss?
Dr. Zeiss. I don't think that from the VHA examiner's
perspective, a change in the law would change our approach,
because we are not looking at the evidentiary burden.
Mr. Hall. Right.
Dr. Zeiss. The person would have the same kind of
evaluation and that information would be evaluated by VBA.
Mr. Hall. Dr. Murdoch?
Dr. Murdoch. I don't think I have anything to add.
Mr. Hall. Okay. Well, there are many more variations on
that theme.
I commend you all for the work that you are doing and your
service to our veterans.
And just the fact that the numbers, as Mr. Mayes among
others have noted, numbers are going up of the veterans who are
being treated for PTSD is a sign that at the very least the
outreach is working better, and that hopefully some of the
stigma is being removed. Veterans are realizing that help is
available, and that asking for it doesn't place them in some
kind of dubious category that will make it harder for them as
they continue. On the contrary, it should make the rest of
their lives more successful and easier.
So we are looking at some success already that I think is
good, and our aim here is to try to make that--to maximize that
success, if we can, if it is helpful to provide this presumed
stressor.
I thank you all for your testimony. If we have any further
questions, we will send them to you in writing. Admiral Smith,
Colonel Ireland, Mr. Mayes, Mr. Hipolit--sorry I didn't ask you
a question directly, I am sure you will get over it.
Mr. Hipolit. Maybe next time.
Mr. Hall. Right. We will think of one. Dr. Zeiss and Dr.
Murdoch, thank you all. This hearing is now adjourned.
[Whereupon, at 4:08 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. John J. Hall, Chairman,
Subcommittee on Disability Assistance and Memorial Affairs
Good Morning Ladies and Gentleman:
The task of today's hearing will prove to be both retrospective and
prospective; for in order to understand title 38 section 1154, we must
look both backward to the original intent of Congress, and forward to
defining it in an era of modern warfare tactics and counterinsurgency.
I ask that the full text of title 38 United States Code section 1154 be
entered into the record.
So, what does it mean to have been ``Engaged in Combat with the
Enemy'' to a sufficient enough degree to prove a stressor that in turn
warrants service connection for Post-Traumatic Stress Disorder--or
PTSD--by the Department of Veterans Affairs and what has been the
intent of Congress?
Congress' commitment originated with the Military Pension Law of
1776 and by the end of the Civil War, Congress recognized that ``every
soldier who was disabled while in service of the Republic, either by
wounds, broken limbs, accidental injuries, . . . or was broken down in
the service by the exposure and hardships incident to camp life and
field duty . . . is entitled to an invalid pension.'' It was believed
that those exposures and hardships led to a malaise known as
``Soldier's Heart''--what we now know as PTSD.
Shortly after the 65th Congress declared war on Germany, it passed
the War Risk Insurance Act of 1917, which outlined benefits to WWI
veterans. In 2 years, it was amended 22 times. These amendments
included the first VA Schedule for Rating Disabilities and established
wartime versus peacetime rates for pension.
The 1933 Rating Schedule included instructions to notate the phrase
``incurred in service in combat with an enemy of the United States''
and to list the period of wartime service. This practice indicated that
the enemy was a foreign government or a hostile force of a nation, and
not an individual combatant.
On December 12, 1941, days after the attack on Pearl Harbor,
Congress expressed its desire to ``overcome the adverse effect of a
lack of an official record . . .'' and ``the difficulties encountered
in assembling records of combat veterans.'' Congress further instituted
``more liberal service pension laws . . . by extending full cooperation
to the veteran.''
The 1945 Rating Schedule required that wartime service be noted by
including the phrase ``disability resulted from injury received in
actual combat in an expedition or occupation.'' Importantly, this
prerequisite refined the broader 1933 required statement. Additionally,
the 1945 schedule described the onset of ``War Psychosis'' as the
result of an ``incident in battle or enemy action, or following
bombing, shipwreck, imprisonment, exhaustion, or prolonged operational
fatigue.'' This diagnosis was removed when the Rating Schedule for
mental disorders was revised in 1976, 1988, and 1996.
The current Rating Schedule for PTSD has been described as vague
and subjective. Furthermore, the adjudication process does not solely
accept, as the law prescribes, lay evidence as sufficient proof as long
as it is consistent with the circumstances, conditions, or hardships of
such service, notwithstanding that there is no official record. This
law should seem self-evident as to the intent of Congress! So why isn't
it? The controversy seems to exist because of numerous interpretations
of Congressional intent. Leading decisionmakers at VA General Counsel
have issued opinions and Court decisions concluded that if it were the
intent of Congress to specify a combat zone or a theater of combat
operations, Congress would have done so as it has in other provisions
of the law under title 38, but omitted in section 1154.
My intention today is to re-open this dialog. The nature of wartime
service has changed as many can agree. Warfare encompasses acts of
terrorism, insurgency, and guerilla tactics. No place is safe and the
enemy may not be readily identifiable.
Psychiatry has changed too. PTSD is a relatively new diagnosis;
first having appeared in the Diagnostic and Statistical Manual in
1980--5 years after the end of the Vietnam War. An array of mental
health research has been conducted and assessment techniques have been
developed. Since the world is not the same place it was in 1941, I have
introduced H.R. 952, the Combat PTSD Act to redefine section 1154 to
include a theater of combat operations during a period of war or in
combat against a hostile force.
There should be a better way for VA to assist veterans suffering
from PTSD adjudicate those claims without it being burdensome,
stressful and adversarial. Veterans still face issues with stigma,
gender and racial disparities in rating decisions, poorly conducted
disability exams, and inadequate military histories. So, I am eager to
hear from the witnesses today about their experiences with denials,
inequities, and variances. In the last few years, the IOM
comprehensively reviewed the research on PTSD diagnosis, assessment,
and compensation. In 2008, the RAND Report on the Invisible Wounds of
War gave us a new perspective on the costs of war when soldiers are
left without treatment or support and I look forward to hearing more of
its witness' analysis. Finally, DoD and VA will share their insights
into how they determine combat vs. noncombat and how they have chosen
to evaluate PTSD disability.
Prepared Statement of Hon. Doug Lamborn, Ranking Republican Member,
Subcommittee on Disability Assistance and Memorial Affairs
Thank you, Chairman Hall for yielding.
I am pleased to have the opportunity to discuss the important issue
before us today.
I hope that through the collective efforts and knowledge of the
individuals gathered here this afternoon, we can help ensure that every
veteran who has service-related PTSD is able to access the benefits to
which they are entitled.
Chairman Hall, I would also like to commend you for your compassion
toward our veterans.
I know it has been a longstanding issue for you to ensure no one
falls through the cracks due to unintended consequences of the laws and
regulations pertaining to compensation for PTSD.
You've reintroduced in the 111th Congress, a bill to clarify the
meaning of ``combat with the enemy'' for purposes of service-
connection.
As you and our witnesses are aware, section 1154(b) of title 38,
United States Code, already provides special consideration for veterans
attempting to establish service-connection for PTSD or other medical
conditions incurred or aggravated in combat.
In short, this means that the VA must accept a combat veteran's lay
testimony as sufficient proof of service-connection for any disease or
injury incurred in combat, even if there is no official record of such
incident.
Congress established this broad threshold in recognition of the
chaotic nature of battle, and the appropriateness of resolving every
reasonable doubt in favor of the veteran.
Unfortunately, circumstances could conceivably arise in which an
individual, who is not a combat veteran under the existing definition,
is exposed to an overwhelming stressor, but he or she is unable to
provide evidence of the occurrence.
This is especially true for veterans of Vietnam and earlier wars.
This is the problem we are trying to resolve.
Chairman Hall's proposed solution is his bill, which would
essentially redefine ``combat with the enemy'' to include service on
active duty in a theater of combat operations.
As I've stated previously, I am concerned that too broad of a
presumptive threshold would damage the integrity of the system.
I also believe that too loose of a definition of combat would
diminish the immeasurable sacrifice and service of those who actually
did engage in battle with the enemy.
While I understand and appreciate the effort to address problems
regarding the VA claims backlog, I believe that they generally result
from procedural issues and we should address those problems
accordingly.
In addition to the policy concerns I have stated, I would also
point out that the mandatory offsets that would be necessary to pass
this bill under existing PAYGO rules, would be difficult to find.
Mr. Chairman as you know, it is always a challenge to identify
offsets within our jurisdiction, and the CBO estimated cost of this
measure last year exceeded $4 billion.
I would not be in favor of reducing existing veterans' benefits in
order to establish an overly broad definition of combat with the enemy.
Mr. Chairman I extend my thanks to you for holding this hearing and
I look forward to hearing the testimony of our colleagues and the
witnesses on our panel today. I yield back.
Prepared Statement of Ian C. De Planque Assistant Director,
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present the American Legion's
views on ``The Nexus between Engaged in Combat with the Enemy and Post-
Traumatic Stress Disorder (PTSD) in an Era of Changing Warfare
Tactics.'' The progression of modern warfare through the end of the
20th century and the beginning of the 21st century has seen fundamental
changes in how we must view the battlefield. We must give recognition
to the unique exigencies of the modern battlefield. As we examine the
modern day state of war fighting, it becomes clear that old models of
clear cut boundaries have given way to nonlinear battlefields, where
simply defined lines of battle are no longer present. In recognition of
this state of asymmetrical warfare, we must look at assumptions of how
combat operations are defined and recorded by the Nation's military.
The American Legion commends the Subcommittee for holding a hearing to
discuss this extremely important and topical issue.
Combat veterans have a huge advantage when attempting to establish
service-connection for PTSD or other medical conditions incurred or
aggravated in combat. Claims for service-connection of a combat-related
condition receive special treatment under law and regulation
administered by Department of Veterans Affairs (VA). They receive
favorable treatment because war is, and has always been, a chaotic
endeavor. It can be difficult to record every detail of operations in
the heat of battle. There are so many unrecorded nuances to the
activity of military forces that Congress has specifically directed
that the special circumstance of combat merit special circumstances in
the establishment of incidents during military service in the
conditions of war. Therefore, if a combat veteran states that he or she
suffered a disease, injury, or stressor event during combat, VA must
generally accept that statement as fact. This is true even if there are
no service records that support the statement.
Specifically, section 1154(b) of title 38, United States Code
(USC), provides:
In the case of any veteran who engaged in combat with the
enemy in active service with a military, naval, or air
organization of the United States during a period of war,
campaign, or expedition, the Secretary shall accept as
sufficient proof of service-connection of any disease or injury
alleged to have been incurred in or aggravated by such service
satisfactory lay or other evidence of service incurrence or
aggravation of such injury or disease, if consistent with the
circumstances, conditions, or hardships of such service,
notwithstanding the fact that there is no official record of
such incurrence or aggravation in such service, and, to that
end, shall resolve every reasonable doubt in favor of the
veteran. Service-connection of such injury or disease may be
rebutted by clear and convincing evidence to the contrary. The
reasons for granting or denying service-connection in each case
shall be recorded in full.
As a point of clarification, the special provisions in section
1154(b) lower the burden on the veteran to show that the injury,
disease or event during service, which the veteran claims led to the
current medical condition, in fact happened. Section 1154(b) does not,
however, remove the need to prove the other two requirements for
service-connection: medical evidence of current disability and medical
evidence of a relationship between the current medical condition and
the in-service precipitating injury, disease or event. Medical
evidence, not lay evidence, is nearly always needed to satisfy those
two requirements for a grant of service-connection. For example, if a
combat veteran seeking service-connection for a shoulder disability
states that ``he landed with great force on the shoulder after being
knocked to the ground by a shell blast,'' then under section 1154(b),
his statement is likely to be sufficient proof that the incident
happened. For service-connection to be granted, however, the veteran
will also need to present medical evidence of a current shoulder
disability and medical evidence of an etiological link between the
current shoulder problem and the combat injury. Section 1154(b) does
not help the veteran meet those two requirements. It should also be
noted that the relaxed evidentiary standards in section 1154(b) only
apply to incidents that are combat-related. They do not apply to
veterans who did not engage in combat and they do not apply when combat
veterans are trying to prove the occurrence of noncombat incidents.
Unfortunately for many veterans, the most difficult burden is
establishing themselves as a combat veteran in order to benefit from
the advantages afforded by statute. In order to determine whether VA is
required to accept a particular veteran's ``satisfactory lay or other
evidence'' as sufficient proof of service incurrence under section
1154(b), an initial determination must be made as to whether the
veteran ``engaged in combat with the enemy.'' The United States Court
of Appeals for Veterans Claims (CAVC) has held that this determination
is not governed by the specific evidentiary standards and procedures in
section 1154(b), which only apply once combat service has been
established. See Cohen v. Brown, 10 Vet. App. 128, 146 (1997).
The Veterans Benefits Administration's (VBA) Adjudication
Procedures Manual M21-1MR PART III, SUBPART 4, CHAPTER 4, section H,
Par., 29b states that ``Engaging in combat with the enemy means
personal participation in events constituting an actual fight or
encounter with a military foe or hostile unit or instrumentality. It
includes presence during such events either as a combatant, or
servicemember performing duty in support of combatants, such as
providing medical care to the wounded'' (emphasis added). In Sizemore
v. Principi, 18 Vet. App. 264, 272 (2004), the CAVC concluded that a
determination whether a veteran was in combat must be made on a case-
by-case basis, and the definition of ``engaged in combat with the
enemy,'' as used in section 1154(b) of title 38, USC, requires that the
veteran has ``personally participated in events constituting an actual
fight or encounter with a military foe or hostile unit or
instrumentality.''
Unless a veteran was wounded or received a specific combat
decoration or badge (such as the Combat Infantryman Badge or Combat
Action Ribbon) or award for valor, it is often very difficult to
establish that a veteran engaged in combat with the enemy in order to
trigger the combat presumptions under section 1154(b). Despite the
various narrow, and in our opinion outdated, interpretations of combat
as discussed above, we must recognize, however, that the very meaning
of the term ``engaged in combat with the enemy'' has taken on a whole
new meaning as the nature of warfare in today's world has changed. This
is especially true of service in the combat zones of Iraq and
Afghanistan.
Due to the fluidity of the modern battlefield and the nature of the
enemy's tactics, there is no defined frontline or rear (safe) area. It
is simply a reality of today's warfare that servicemembers in
traditional non-combat occupations and support roles are subjected to
enemy attacks such as mortar fire, sniper fire, and improvised
explosive devices (IED) just as their counterparts in combat arms-
related occupational fields. Unfortunately, such incidents are rarely
documented making it extremely difficult, if not impossible in some
instances, for many veterans to verify in order to prove that they
``engaged in combat with the enemy,'' to the satisfaction of VA, to
trigger the combat presumptions of section 1154(b).
Servicemembers, who received a combat-related badge or award for
valor, trigger the combat-related presumptions of section 1154(b), but
a clerk riding in a Humvee, who witnessed the carnage of an IED attack
on a convoy, and later develops PTSD, does not automatically trigger
such a presumption. Proving that the incident happened or that clerk
was involved in the incident, in order to benefit from the presumption
afforded under section 1154(b), can be extremely time consuming and
difficult. In some instances, it may even be impossible to submit
official documentation or records of the incident because such records
do not exist. A good example of this is a soldier stationed in the
Green Zone in Iraq who falls and injures his or her knee while running
for cover during a mortar attack and later develops a chronic knee
condition, but never received treatment after the initial injury. Since
the soldier didn't think he or she was hurt that bad and never sought
treatment for the knee, the only proof the soldier has to offer that he
or she injured his or her knee during an enemy attack on his or her
base is his or her word. Since the soldier was stationed in a ``safe''
area and did not receive a combat decoration or award or participate in
any combat operations, establishing that he or she ``engaged in combat
with the enemy'' in order to satisfy the current narrow interpretation
of the phrase just to trigger the provisions of section 1154(b) will be
extremely difficult, if not impossible. Adding to this already
difficult burden is the VA General Counsel decision ruling that ``the
absence from a veteran's service records of any ordinary indicators of
combat service may, in appropriate cases, support a reasonable
inference that the veteran did not engage in combat.'' This means that,
according to the General Counsel, records supporting such an inference
may be considered as negative evidence even though they do not
affirmatively show that the veteran did not engage in combat. See
VAOPGCPREC 12-99, dated October 18, 1999.
In addressing the definition of ``engaged in combat with the
enemy,'' the VA General Counsel noted that the phrase is not defined by
any applicable statute or regulation. In offering its interpretation,
the General Counsel examined the legislative history surrounding the
1941 enactment of the provisions now provided in section 1154(b). The
General Counsel noted that there had been several bills considered in
the House of Representatives that contained varying criteria for
invoking the special evidentiary requirements now contained in section
1154(b). These bills used phrases such as ``in a combat area'' (H.R.
4737, 77th Cong., 1st Sess. 1941; H.R.2652, 77th Cong., 1st Sess. 1941)
and ``within the zone of advance'' (H.R. 1587, 77th Cong., 1st Sess.
1941; H.R. 9953, 76th Cong., 3d Sess. 1940). Language addressing
veterans who were subjected to ``arduous conditions of military or
naval service'' in a war, campaign, or expedition was also used (H.R.
6450, 76th Cong., 3d Sess. 1940). The General Counsel surmised that, in
light of these various proposed standards, Congress' choice of the
language ``engaged in combat with the enemy'' must be ``viewed as
purposeful.'' The General Counsel concluded that, ``[c]onsistent with
the ordinary meaning of that phrase, therefore, section 1154(b)
requires that the veteran have actually participated in combat with the
enemy and would not apply to veterans who served in a general ``combat
area'' or ``combat zone'' but did not themselves engage in combat with
the enemy.'' See VAOPGCPREC 12-99, dated October 18, 1999. It is
important to point out that even if VA's view of Congress' intent in
1941 is correct, today's battles, as has been emphasized throughout
this statement, no longer take place on a linear battlefield. Defined
lines of battle are no longer present and ``general'' combat areas or
combat zones no longer exist. Therefore, it is essential that a statute
based in a forties reality of combat adapt to the realities of combat
in the 21st century.
Given the evolving nature of modern warfare, as reflected in the
enemy's unconventional tactics on today's battlefields, and the
outdated and overly restrictive interpretations of combat by both the
courts and VA, it not only makes sense to clarify the definition of
``engaged in combat with the enemy'' under section 1154(b) in a manner
consistent with the new realities of modern warfare, it is essential
that we do so, not just for those serving now, but for those who have
served in the past and those who will serve in the future. Such a
clarification would also benefit the VA by negating extensive
development, and in some cases overdevelopment, of the combat-related
stressor verification portion of a PTSD claim or the incident in
service requirement of claims for other combat-related conditions and,
in doing so, reduce the length of time it takes to adjudicate such
claims. To this end, Congress must examine the manner in which combat
is defined for the purposes of the statute. It is not a matter of
drastically changing the existing law or creating a new benefit, but
simply clarifying how it must be construed. Under the provisions of
section 1154(b) soldiers, sailors and airmen are still required to
detail alleged incidents. The only question that arises is when do the
provisions of this subsection apply and how is combat to be judged on
this modern, nonlinear battlefield?
The American Legion is well aware that these alleged incidents must
still be consistent with the conditions and actions of a combat
situation, indeed that combat or combat conditions must be alleged.
Furthermore, we are aware that simply accepting the occurrence of these
occurrences in combat is not a magic wand to grant service-connection
for any condition, as a veteran must still show evidence of a present
condition and of a medical linkage between the incident and present
condition.
Mr. Chairman, the American Legion reinforces the belief that we as
a Nation must reexamine how we view many aspects of war and war
fighting. While many things have changed, there are and will always be
some consistencies. This Nation has a long tradition of extending its
hand to those who have sacrificed to protect and serve. We have never,
nor should we ever, veered from the promises to ``. . . care for him
who shall have borne the battle and for his widow and his orphan . .
.'' as was ably stated by President Abraham Lincoln.
It is our hope that the information we have presented on what is at
issue here will provide some insight into this challenging topic. The
American Legion stands ready to assist this Subcommittee and VA in the
examination of the criteria which must be met to trigger the provisions
of section 1154(b) of title 38, USC. Thank you again for this
opportunity to provide testimony on behalf of the members of the
American Legion.
Prepared Statement of Thomas J. Berger, Ph.D., Senior Analyst for
Veterans' Benefits and Mental Health Issues, Vietnam Veterans of
America
Mr. Chairman, Ranking Member Lamborn, Distinguished Members of the
House Veterans' Affairs Committee's Subcommittee on Disability
Assistance & Memorial Affairs, and honored guests, Vietnam Veterans of
America (VVA) thanks you for the opportunity to present our statement
for the record surrounding the Department of Veterans Affairs (VA)
application of the provisions found in Title 38 United States Code
1154, the definition of ``engaged in combat with the enemy'' and its
effect on processing claims for veterans suffering from Post-
Traumatic Stress Disorder (PTSD).
Background: VVA reminds the Chairman and the distinguished Members
of this Subcommittee that the Veterans Claims Assistance Act (VCAA)
became effective in November 2000. Designed to codify VA's longstanding
practice of assisting veterans (at least in theory) in developing their
claims for benefits, Congress promulgated this statute ``to reaffirm
and clarify the duty of the Secretary of Veterans Affairs to assist
claimants for benefits under laws administered by the Secretary . . .''
In other words, the enactment of the VCAA in November 2000, in
conjunction with its implementing regulations, was supposed to render
mandatory assistance to all veteran-claimants upon submission of a
claim, and in this way, it ``defined VA's obligation to fully develop
the record. . . .'' And while the VCAA imposes a substantial duty on
the VA to assist the veteran-claimant in obtaining evidence in support
of a claim, it also obliges the claimant to aid in this process by
providing ``enough information to identify and locate the existing
records including the custodian or agency holding the records; and the
approximate timeframe covered by the records. . . . ''
VA fought proper implementation of the VCAA for several years, and
only after losing in court did they move to at least in theory
implement the VCAA according to the Congressional intent and eliminate
the usually misapplied requirement to present a ``well-grounded'' claim
before the VA would assist a veteran with his or her claim. Prior to
passage of the VCAA, 38 U.S.C.S. 5107(a) stated:
Except when otherwise provided by the Secretary in accordance
with the provisions of this title, a person who submits a claim
for benefits under a law administered by the Secretary shall
have the burden of submitting evidence sufficient to justify a
belief by a fair and impartial individual that the claim is
well grounded. The Secretary shall assist such a claimant in
developing the facts pertinent to the claim. Section 5107 as
revised by the VCAA eliminates the words well-grounded and
simply states: CLAIMANT RESPONSIBILITY Except as otherwise
provided by law, a claimant has the responsibility to present
and support a claim for benefits under laws administered by the
Secretary.
Enactment of the VCAA ended the confusion, unnecessary expenses,
premature denials and improper adjudications caused by the
interpretation of the words ``well-grounded claim.'' Essentially, 10
years of CAVC and U.S. Court of Appeals for the Federal Circuit case
law dealing with the well-grounded claim requirement no longer has
relevance because that requirement has been eliminated by the 2000 VCAA
law.
It is clear now that the intent of the Congress is for the VA to
assist almost every claimant with the development of their claim,
except for those who have no reasonable possibility of obtaining
benefits. (In effect, the well-grounded claim requirement has been
replaced with the no reasonable possibility standard.) It is also clear
that the VA is obligated to explain to all claimants just what evidence
is necessary to substantiate their claims before a final adjudication
can be promulgated.
The VCAA does not however change any of the rules governing what a
claimant needs to prove to be granted a VA benefit. Nor does the VCAA
change the burden of proof or the standard of proof that the VA must
apply to a claim. The burden of proof is generally on the claimant and
the rule in existence both before and after the VCAA requires the VA to
grant a claim if either (1) a preponderance of the evidence supports
the claim or (2) the weight of the evidence in support of the claim is
approximately equal to the weight of the evidence against the claim.
In filing a PTSD claim the veteran is required to have proof that
he or she experienced a ``stressor'' event in service; that is, a
traumatic event that involves experiencing, witnessing, or confronting
an event or events that involve actual or threatened death and/or
serious injury, or encountering a threat to the physical integrity of
others, and responding with intense fear, helplessness or horror.
Subsequently, the medical evidence must reflect a diagnosis of PTSD at
any time during or after service and a link between the current
diagnosis and the in-service stressor event, which may involve combat
or non-combat-related events.
While the veteran need not prove that s/he incurred an in-service
disease or physical injury, the record must nevertheless contain
``credible supporting evidence'' to establish the existence of the
claimed stressor event, with the only exceptions being if the veteran
engaged in combat or was a prisoner of war and the claimed stressor was
related to that combat or captivity. Combat exposure verification is
based on the receipt of certain military decorations verified within
service personnel records, and the VA has recognized that a ``number of
citations appear to be awarded primarily or exclusively for
circumstances related to combat,'' including for example, the Medal of
Honor, Navy Cross, and Combat Infantryman's Badge. In addition, the
United States Court of Appeals for Veterans Claims (CAVC) has also
eased the burden on veterans by finding that personal participation in
combat need not be established.
Therefore, although the veteran with verified combat service has no
burden to verify his or her claimed stressor (having instead only the
burden to verify that s/he participated in combat), the veteran for
whom combat participation is not established in the record is not so
fortunate. His or her claim must have ``credible supporting evidence''
or face denial. Non-combat stressors typically include, but are not
limited to, exposure to or involvement in aircraft crashes, vehicle
crashes, ship wrecks, explosions, rape or assault, witnessing a death,
duty on a burn ward, and/or service with a graves registration unit.
The non-combat stressor may be experienced alone or with a group of
people and is not necessarily limited to just one single episode. In
addition, in personal trauma cases such as in-service sexual assault,
alternative sources may be used to verify the stressful event and can
include documents from rape crisis centers, counselors, clergy, health
clinics, civilian police reports, medical records immediately following
the incident, and/or diaries or journals, or other credible evidence.
Herein lies a major problem in our view, because the VA does not
necessarily accept or apply these criteria uniformly and consistently.
In addition, if the veteran provides sufficient detail, the VA can
submit a referral to the U.S. Army and Joint Services Records Research
Center (JSRRC) to conduct a records search to verify the in-service
stressor. These requests are supposed to be sent through the VA's
Personnel Information Exchange System (PIES) using codes. Once the
request is submitted through PIES, there is an interface process from
the Defense Personnel Records Information Retrieval System to the
appropriate military service records information management system
(which may utilize a completely different coding system) whereupon it
is then sent to the JSRRC electronically.
The JSRRC does not search through records in an attempt to identify
an in-service stressor, but rather to verify the stressor. Some of the
difficulties with the JSRRC include the fact that not every event that
occurred during the course of the veteran's service is recorded, and
service records do not typically chronicle the specific experiences of
individual servicemembers. In addition, most of the records searched by
the JSRRC are not stored electronically and must be searched manually.
Typically, the staff will bring out one to a dozen boxes of written
material, and the JSRRC staff member has 30 minutes to go through this
mass of material. Obviously, more often than not, the majority of the
data available is not combed, even in a cursory manner, because there
is not time to so. The Committee should be aware that reportedly there
are only 13 staff members to do this work, and they are more than 4,000
requests in arrears. Moreover, there is no master index of subjects or
names, and military records are often incomplete. The JSRRC is under
the control of DoD, as are all the unit and individual records.
Therefore the VA cannot control this essential step in the current
process.
If the Congress is looking for very useful ways to stimulate the
economy, and to accomplish much needed work at the same time, then
working with your colleagues on the Armed Services Committee to start
the long needed process of computerizing and indexing these key
military records would be a most useful thing to do. The DoD can
utilize the Temporary (up to 1 year) Schedule A hiring authority issued
by the President earlier this month to hire disabled young veterans to
start this work immediately. We would note that the latest Bureau of
Labor Statistics (BLS) reported that the unemployment figure for our
youngest veterans is 11.2%, which in and of itself cries out for
immediate meaningful action by the Congress.
In summary, an appropriate process already exists for VA PTSD
claims processing as mandated by the Congress back in 2000. However, it
doesn't work, because the VA has again failed to provide for the
consistency, uniformity and efficiency that are necessary to ensure
that this process works in a timely fashion for all veteran-claimants.
Further, DoD has been dilatory in doing its part to supply needed
information in a complete, thorough, and timely manner.
Obviously, something needs to be done to render what has become an
intolerable chronic problem for veterans who are legitimately seeking
service connection compensation and access to quality medical services
for their very real neuro-psychiatric wounds.
VVA Position on H.R. 952
VVA can support the proposed legislative change as outlined in H.R.
952 if the intent is that it be applied to veterans with a valid
diagnosis (i.e., in the manner called for as noted in the 2006 I.O.M.
report at http://iom.edu/CMS/3793/32410.aspx) of PTSD, and if the
intent is that any veteran who served in a combat zone be taken at
their word that the event or incident which occurred in service gave
rise to their disability. The criteria recommended by the Institute of
Medicine or the National Academies of Sciences should be taken as the
definitive methodology. Incidentally, that methodology, which includes
testing and intense analysis largely mirrors that contained in the
``Best Practices'' PTSD manual. The problem, of course, is that VA does
not do it, despite the 3,800 new clinicians they have hired ostensibly
to better treat PTSD. VVA has come to learn that a similar legislative
change has been proposed on the Senate side by Senator Charles Schumer
of New York.
It would of course be useful if VA used their own ``Best
Practices'' manual in the adjudication of PTSD claims . . . but they do
not. In fact, the only place that one can get a copy of that 2002
manual, produced at great expense, is from VVA. So the VA does not
properly train their physicians nor do they properly train the folks
who are adjudicators.
If need be, VVA offers its assistance in developing clearer
language in the proposed legislative change because we believe the
proposed H.R. 952 to be well-intended and most considerate for those of
our veterans suffering from PTSD and who face interminable delays and
denials in their VA compensation claims under the current claims
process and procedures. VVA thanks this Committee for the opportunity
to submit its views and testimony on this important veterans' issue.
Prepared Statement of Carolyn Schapper, Representative
Iraq and Afghanistan Veterans of America
Mr. Chairman and Members of the Subcommittee, thank you for
inviting me to testify today. On behalf of Iraq and Afghanistan
Veterans of America, the Nation's first and largest non-partisan
organization for veterans of the current conflicts, I would like to
thank you all for your unwavering commitment to our Nation's veterans.
My name is Carolyn Schapper, and I am a combat veteran. While
serving as a member of a Military Intelligence unit in Iraq from
October 2005 to September 2006 with the Georgia National Guard, I
participated in approximately 200 combat patrols. Whether it was
interacting with the local population or extracting injured personnel,
I encountered direct fire, Improvised Explosive Devices (IEDs), and the
constant threat from insurgents.
When I came home from Iraq, I dealt with a wide range of adjustment
issues/Post-Traumatic Stress Disorder (PTSD) symptoms; rage, anger,
revenge-seeking, increased alcohol use, withdrawal from friends and
family, depression, high anxiety, agitation, nightmares and hyper-
vigilance. I could barely stay focused at work, let alone traverse the
VA maze. I might still be lost if I had not had the dumb luck of
running into another veteran who already had gotten help, and who
pointed out that a Vet Center could help me start navigating the VA
system. While I was able to find help and receive the appropriate
disability compensation for my psychological injury, many of my
sisters-in-arms have not been so lucky.
Part of the problem is that, because females are excluded from
official ``combat roles'' in the military, women veterans have a
greater burden of proof when it comes to establishing combat-related
PTSD. But the reality on the ground in Iraq and Afghanistan is that
there is no clear front line, and female servicemembers are seeing
combat.
Modern warfare makes it impossible to delineate between combat,
combat-support, and combat service support roles. You do not even need
to leave the Forward Operating Base to be exposed to the continual
threat of mortars and rockets. Military personnel are often required to
walk around in or sleep in body armor. As one female veteran told me,
``Life in Iraq and Afghanistan is combat.'' Moreover, many female
troops in Iraq and Afghanistan have been exposed to direct fire while
serving in support roles, such as military police, helicopter pilots,
and truckdrivers. All of our troops, whether or not they serve in the
combat arms, must exhibit constant vigilance, and this can take an
extreme psychological toll on our servicemembers.
The traditional understanding of female servicemembers' military
duties has been the biggest hurdle to getting them adequate
compensation for their injury. The nature of PTSD and other
psychological injuries makes it difficult to identify the exact
stressor, and therefore, disability may be determined based on the
claims processor's perception of exposure to combat. While a service-
connection for PTSD would seem obvious for a male infantryman, it could
easily come under more scrutiny for a female intelligence soldier
despite how much actual contact either of us had with enemy forces.
Another issue that female servicemembers face when trying to
establish presumption of service-connected PTSD involves collecting the
proper paperwork. Especially in instances of Military Sexual Trauma,
some women would rather forgo documenting their injury, rather than get
official military documentation from a male commander or doctor. If you
are suffering from a mental health injury, the possibility of having
someone question, deride or expose such a personal and painful
experience is often overwhelming, and can lead many female
servicemembers to avoid the process altogether.
H.R. 952, introduced by the Chairman, solves this problem by
changing Title 38 to presume service-connection for PTSD based solely
on a servicemember's presence in a combat zone. IAVA wholeheartedly
endorses this bill, and looks forward to working with the Subcommittee
to see this legislation become law.
While this legislation will aid veterans once they have been
diagnosed with a psychological injury and are seeking disability
compensation, we know that not every servicemember or veteran is
getting the care they need. This is why IAVA has partnered with the Ad
Council to conduct a multiyear Public Service Announcement campaign to
help ease the transition and readjustment challenges facing Iraq and
Afghanistan veterans when they return home. The campaign also helps
ensure that veterans seeking access to care and benefits, and
particularly those who need treatment for their psychological injuries,
get the support they need. Ad Council is responsible for many of the
Nation's most iconic and successful PSA campaigns in history, including
``Only You Can Prevent Forest Fires,'' ``A Mind is a Terrible Thing to
Waste,'' and ``Friends Don't Let Friends Drive Drunk.'' The IAVA-Ad
Council Veteran Support PSAs are currently running on television,
radio, in print, outdoors and online. A companion campaign engaging the
family and friends of new veterans will be launching later this year.
I will leave you with this final thought. More and more, women are
being called upon to serve a more active role in the combat zone, and
all too often find themselves in harm's way. There is no better way to
honor their service and sacrifices than to ensure that when they are
injured, they receive the care and compensation they deserve. Thank you
again for the opportunity to testify on this critical issue, and I
would be pleased to take your questions at this time.
Respectfully,
Carolyn Schapper
Prepared Statement of Dean G. Kilpatrick, Ph.D.,
Distinguished University Professor, and Director,
National Crime Victims Research and Treatment Center,
Medical University of South Carolina, Charleston, SC, and
Member, Committee on Veterans' Compensation for Posttraumatic
Stress Disorder, Institute of Medicine and National Research Council,
The National Academies
The Institute of Medicine and National Research Council Report
``PTSD Compensation and Military Service'' Findings Regarding the
Evaluation of Traumatic Exposures and Malingering in
Veterans Seeking PTSD Compensation
Good afternoon, Mr. Chairman, Mr. Ranking Member, and Members of
the Committee. My name is Dean Kilpatrick and I am Distinguished
University Professor in the Department of Psychiatry and Behavioral
Sciences and Director of the National Crime Victims Research and
Treatment Center at the Medical University of South Carolina. Thank you
for the opportunity to testify on behalf of the Members of the
Committee on Veterans' Compensation for Post-Traumatic Stress Disorder.
This Committee was convened under the auspices of the National Research
Council and the Institute of Medicine of the National Academy of
Sciences. Our Committee's work--which was conducted between March 2006
and July 2007--was requested by the Department of Veterans Affairs,
which provided funding for the effort.
In June 2007, our Committee completed its report, entitled PTSD
Compensation and Military Service. I am pleased to be here today to
share with you some of the content of that report, the knowledge I've
gained as a clinical psychologist and researcher on traumatic stress,
and my experience as someone who previously served as a clinician at
the VA.
I will briefly address four issues in this testimony:
The evaluation of traumatic exposures for VA compensation
and pension purposes,
The reliability and completeness of military records for
evaluation of exposure to stressors,
What studies say about malingering in the veterans
population, and
The means that mental health professionals use to detect
malingering.
Evaluation of traumatic exposures for VA compensation and pension
purposes
VA compensation and pension (C&P) examinations for PTSD consist of
a review of medical history; evaluations of mental status and of social
and occupational function; a diagnostic examination, which may include
psychological testing; and an assessment of the exposure to traumatic
events that occurred during military service.
To help focus the examination, the Veterans Benefits Administration
(VBA) provides examiners with worksheets that set forth what an
assessment should cover. These worksheets are designed to ensure that a
rating specialist receives all the information necessary to rate a
claim.
The PTSD worksheet provides guidance on the elements of a
claimant's military history that should be documented. These include
Military Occupational Specialty (MOS), combat wounds sustained,
citations or medals received, and a clear description of the ``specific
stressor event(s) the veteran considered to be particularly traumatic,
particularly if the stressor is a type of personal assault, including
sexual assault, [providing] information, with examples, if possible.''
The worksheet notes:
. . . Service connection for post-traumatic stress disorder
(PTSD) requires medical evidence establishing a diagnosis of
the condition that conforms to the diagnostic criteria of DSM-
IV, credible supporting evidence that the claimed in-service
stressor actually occurred, and a link, established by medical
evidence, between current symptomatology and the claimed in-
service stressor. It is the responsibility of the examiner to
indicate the traumatic stressor leading to PTSD, if he or she
makes the diagnosis of PTSD.
A diagnosis of PTSD cannot be adequately documented or ruled
out without obtaining a detailed military history and reviewing
the claims folder. This means that initial review of the folder
prior to examination, the history and examination itself, and
the dictation for an examination initially establishing PTSD
will often require more time than for examinations of other
disorders. Ninety minutes to 2 hours on an initial exam is
normal. (emphasis added)
A Best Practice Manual developed by VA practitioners also offers
guidance on assessing trauma exposure, and recommends tests that can be
administered to help elicit information. The Manual states that
``[i]nitial PTSD compensation and pension evaluations typically require
up to 3 hours to complete, but complex cases may demand additional
time.'' It estimates that 30 minutes of that time would be used for
records review and an additional 20 minutes for orientation to the
interview, review of the military history, and conduct of the trauma
assessment.
Notwithstanding this guidance, testimony presented to the Committee
indicated that clinicians often feel pressured to severely constrain
the time that they devote to conducting a PTSD C&P examination--
sometimes to as little as 20 minutes.
The reliability and completeness of military records for evaluation of
exposure to stressors
VA's statutory ``duty to assist'' includes helping veterans gather
evidence to support their claims, including the provision of VA records
and facilitation of requests for information from the Department of
Defense (DoD) and other sources. Military personnel records--which
document duty stations and assignments, MOS, citations, medals, and
related administrative information--are valued in this regard because
they are perceived as unbiased evidence that can corroborate or refute
claimants' accounts. One study reviewed by the Committee found that
less than half of treatment-seeking Vietnam veterans reporting combat
involvement had objective evidence of combat exposure documented in
their publicly available military personnel records. It concluded that
a ``meaningful'' number of treatment-seekers ``may be exaggerating or
misrepresenting their involvement [and combat exposure] in Vietnam and,
by inference, they attributed this to ``the disability benefit
incentive'' and compensation-seeking.
However, this conclusion is not supported by other research that
the Committee examined, calling into question whether the information
available in the military personnel files is always adequate to
evaluate trauma exposure. The National Archives and Research
Administration, the Nation's conservator of the military personnel
records, offers the following caveat for users of these data:
``Detailed information about the veteran's participation in military
battles and engagements is NOT contained in the record''. Studies
indicate, instead, that broad-based research into other indicators of
the likelihood of having experienced traumatic stressors has value.
This may be especially important in cases of PTSD related to sexual
assault. Available information suggests that female veterans are less
likely to receive service connection for PTSD and that this is a
consequence of the relative difficulty of substantiating exposure to
noncombat traumatic stressors like military sexual assault.
The Committee concluded that the most effective strategy for
dealing with problems with self-reports of traumatic exposure is to
ensure that a comprehensive, consistent, and rigorous process is used
throughout the VA to verify veteran-reported evidence.
What studies say about malingering in the veterans population
The Committee noted that assessment of malingering is a high stakes
issue because it is as devastating to falsely accuse a veteran of
malingering as it is unfair to other veterans to miss malingered cases.
The most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV) defines malingering as ``the intentional
production of false or grossly exaggerated physical or psychological
symptoms motivated by external incentives . . . such as obtaining
financial compensation''.
Combat veterans who are evaluated for PTSD frequently exhibit
elevations across various assessment measures, including elevations on
tests used to detect symptom overreporting. Concerns have thus been
raised regarding the accuracy of veterans' accounts of their
psychological functioning, which in turn poses significant challenges
for diagnostic assessment and treatment. While some research and
commentary suggests that this pattern may reflect, at least in part,
symptom over reporting by a subset of veterans who are motivated by
possible receipt of financial compensation, access to treatment, and
other incentives, the Committee found that literature examining the
relationship between compensation seeking and reported levels of
psychopathology has in fact yielded mixed results.
The Committee's review of the literature concluded that, while
misrepresentation of combat involvement and trauma exposure undoubtedly
does happen among veterans seeking treatment and compensation for PTSD,
the evidence currently available is insufficient to establish how
prevalent such misrepresentations are and how much effect they have on
the ultimate outcome of disability claims. Further, while some veterans
do drop out of mental-health treatment once they obtain service-
connected disability compensation for PTSD, the currently available
data suggest that this concern may not apply to the majority of
veterans who seek and obtain such awards. Although more research is
needed, the Committee concluded that the preponderance of evidence does
not support the notion that receiving compensation for PTSD makes
veterans less likely to make treatment gains or acknowledge improvement
from treatment.
The means that mental health professionals use to detect malingering
Although there is a need for a reliable, valid way to detect
malingering, experts agree that there is no magic bullet or gold
standard for doing so. Several investigators have used scales from such
tests as the Minnesota Multiphasic Personality Inventory (MMPI) and
MMPI-2 to indirectly infer the possibility of malingering, and the Best
Practice Manual notes that they are useful in identifying the test-
taking style of veterans and in assessing service-connected PTSD
status. However, these measures have clear limitations and should not
be used as the sole basis for assessing whether a veteran is
malingering with respect to PTSD status. The Committee concluded that,
in the absence of a definitive measure, the most effective way to
detect inappropriate PTSD claims is to require a consistent and
comprehensive state-of-the-art examination and assessment that allows
the time to conduct appropriate testing in those specific circumstances
where the examining clinician believes it would inform the assessment.
Our Committee also reached a series of other findings and
recommendations regarding the conduct of VA's compensation and pension
system for PTSD that are detailed in the body of our report. The
National Academies previously provided the Subcommittee with copies of
this report and would happy to fulfill any additional requests for it.
Thank you for your attention. I'm happy to answer your questions.
Publications referenced in this testimony
American Psychiatric Association. 2000. Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).
Washington DC: APA.
Frueh BC, Elhai JD, Grubaugh AL, Monnier J, Kashdan TB, Sauvageot
JA, Hamner MB, Burkett BG, Arana GW. 2005. Documented combat exposure
of U.S. veterans seeking treatment for combat-related post-traumatic
stress disorder. British Journal of Psychiatry 186(6):467-472.
Institute of Medicine. 2007. PTSD Compensation and Military
Service. Washington, DC: National Academies Press. [Online]. Available:
http://www.nap.edu/
catalog.php?record_id=11870 [accessed 20 March 2009].
U.S. National Archives and Records Administration. 2009. Military
Service Records and Official Military Personnel Files. [Online].
Available: http://www.archives.gov/veterans/military-service-records/
[accessed 20 March 2009].
Watson P, McFall M, McBrine C, Schnurr PP, Friedman MJ, Keane T,
Hamblen JL. 2002. Best Practice Manual for Post-Traumatic Stress
Disorder (PTSD) Compensation and Pension Examinations. [Online].
Available: http://www.avapl.org/pub/PTSD%20Manual%20final%206.pdf
[accessed 20 March 2009].
Prepared Statement of Terri Tanielian,* MA, Study Co-Director,
Invisible Wounds of War Study Team, RAND Corporation
Assessing Combat Exposure and Post-Traumatic Stress Disorder in Troops
and Estimating the Costs to Society Implications from the
RAND Invisible Wounds of War Study \1\
Chairman Hall, Representative Lamborn, and distinguished Members of
the Subcommittee, thank you for inviting me to testify today. It is an
honor and pleasure to be here. I will discuss the findings from our
study ``Invisible Wounds of War'' as they relate to the topic of your
hearing today. More specifically, my testimony will briefly review the
findings from our study related to assessing exposure to combat and
prevalence of post-traumatic stress disorder and depression among
servicemembers returning from Operations Enduring Freedom and Iraqi
Freedom; as well as the societal costs associated with these
conditions. The full findings and recommendations from our study were
also presented in the testimony to the full House Committee on Veterans
Affairs on June 11, 2009.
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* The opinions and conclusions expressed in this testimony are the
author's alone and should not be interpreted as representing those of
RAND or any of the sponsors of its research. This product is part of
the RAND Corporation testimony series. RAND testimonies record
testimony presented by RAND associates to Federal, State, or local
legislative Committees; Government-appointed commissions and panels;
and private review and oversight bodies. The RAND Corporation is a
nonprofit research organization providing objective analysis and
effective solutions that address the challenges facing the public and
private sectors around the world. RAND's publications do not
necessarily reflect the opinions of its research clients and sponsors.
\1\ This testimony is available for free download at http://
www.rand.org/pubs/testimonies/CT321/.
---------------------------------------------------------------------------
Background
Since October 2001, approximately 1.7 million U.S. troops have
deployed as part of Operation Enduring Freedom (OEF; Afghanistan) and
Operation Iraqi Freedom (OIF; Iraq). The pace of the deployments in
these current conflicts is unprecedented in the history of the all-
volunteer force (Belasco, 2007; Bruner, 2006). Not only are a higher
proportion of the armed forces being deployed, but deployments have
been longer, redeployment to combat has been common, and breaks between
deployments have been infrequent (Hosek, Kavanagh, and Miller, 2006).
At the same time, episodes of intense combat notwithstanding, these
operations have employed smaller forces and have produced casualty
rates of killed or wounded that are historically lower than in earlier
prolonged wars, such as Vietnam and Korea. Advances in both medical
technology and body armor mean that more servicemembers are surviving
experiences that would have led to death in prior wars (Regan, 2004;
Warden, 2006). However, casualties of a different kind have emerged in
large numbers--invisible wounds, such as post traumatic stress
disorder.
As with safeguarding physical health, safeguarding mental health is
an integral component of the United States' national responsibilities
to recruit, prepare, and sustain a military force and to address
service-connected injuries and disabilities. But safeguarding mental
health is also critical for compensating and honoring those who have
served our Nation.
In April 2008, my colleagues and I released the findings from a 1-
year project entitled ``Invisible Wounds of War. This independent study
focused on three major conditions--post-traumatic stress disorder
(PTSD), major depressive disorder, and traumatic brain injury (TBI).
Unlike the physical wounds of war that maim or disfigure, these
conditions remain invisible to other servicemembers, to family members,
and to society in general. All three conditions affect mood, thoughts,
and behavior; yet these wounds often go unrecognized and
unacknowledged. Our study was guided by a series of overarching
questions about the prevalence of mental health conditions, costs
associated with these conditions, and the care system available to meet
the needs of servicemembers afflicted with these conditions. In my
comments today, I will focus on our findings about servicemembers'
exposure to trauma during deployment, prevalence of mental health
conditions post deployment among OEF/OIF veterans, and the costs to
society associated with these conditions among veterans, as they bear
directly on the issue you are considering today. Specifically, I will
address several related questions:
Deployment Related Experiences and Exposure to Trauma: How is
exposure to combat trauma assessed among OEF/OIF troops in research
studies?
Prevalence of PTSD and Depression: What is the scope of mental
health conditions that troops experience when returning from deployment
to Afghanistan and Iraq?
Societal Costs of PTSD and Depression Among Veterans: What are the
costs of these conditions, including treatment costs and costs stemming
from lost productivity and other consequences? What are the costs and
potential savings associated with different levels of medical care--
including proven, evidence-based care; usual care; and no care?
How is exposure to combat trauma assessed among OEF/OIF troops in
research studies?
In research studies, combat experience has been assessed using a
variety of different means, including documenting deployment to a
combat zone based on receipt of hostile-fire pay or assessing specific
experiences during deployment based on self-report. Most of the prior
research has evaluated the relationship between these exposures and the
development of post-combat adjustment difficulties such as post-
traumatic stress disorder. Scholarly interest in exposure to combat-
related traumas emerged following the official designation of PTSD as a
psychiatric disorder by the American Psychiatric Association in 1980
(APA, 1980). The PTSD diagnosis replaced earlier terms such as ``battle
fatigue'' and ``war neurosis.'' Among other changes, the PTSD diagnosis
required a ``catastrophic stressor that was outside the range of usual
human experience'', and this requirement spurred the need to assess
such experiences. The definition of what constitutes a trauma has
changed over time, but the requirement that PTSD be linked to specific
experiences remains. Researchers studying veteran populations since
that time have used different scales to assess (using mainly self-
report) specific details about a variety of exposures that military
personnel may experience when deployed to a war zone.
In our study, combat trauma exposure was assessed using 24
questions that were adapted from Hoge et al. (2004) and includes both
direct and vicarious trauma exposure (e.g., witnessing a traumatic
event that occurred to others). However, we found that many questions
were empirically redundant with one another, and thus used only a
subset of exposures (11 questions) to form a combat exposure measure
that formed two indices: (1) a one-question measure that assessed
whether the servicemember had ever experienced an injury or wound that
required hospitalization while deployed (this may or may not have
required medical evacuation from theater), and (2) a scale derived by
counting the number of ten specific trauma exposures that occurred
during any of the servicemember's OEF/OIF deployments.
Rates of reported trauma exposures on these 11 items are presented
in Table 1. As shown, rates of exposure to specific types of combat
trauma ranged from 5 to 50 percent, with high reporting levels for many
traumatic events. Vicariously experienced traumas (e.g., having a
friend who was seriously wounded or killed) were the most frequently
reported. About 10-15 percent of OEF/OIF veterans reported NO trauma
exposures, and about 15-20 percent reported exposure to just ONE event
(largely death or injury of a friend), so most (close to 75 percent)
reported multiple exposures.
Table 1. Rates of Trauma Exposure in OEF/OIF (N=1965)
------------------------------------------------------------------------
Weighted 95% CI 95% CI
Percentage LL UL
------------------------------------------------------------------------
Having a friend who was seriously 49.6 45.7 53.6
wounded or killed
------------------------------------------------------------------------
Seeing dead or seriously injured non- 45.2 41.3 49.1
combatants
------------------------------------------------------------------------
Witnessing an accident resulting in 45.0 41.1 48.9
serious injury or death
------------------------------------------------------------------------
Smelling decomposing bodies 37.0 33.3 40.7
------------------------------------------------------------------------
Being physically moved or knocked 22.9 19.6 26.1
over by an explosion
------------------------------------------------------------------------
Being injured, not requiring 22.8 19.2 26.3
hospitalization
------------------------------------------------------------------------
Having a blow to the head from any 18.1 15.1 21.1
accident or injury
------------------------------------------------------------------------
Being injured, requiring 10.7 8.2 13.1
hospitalization
------------------------------------------------------------------------
Engaging in hand-to-hand combat 9.5 7.3 11.6
------------------------------------------------------------------------
Witnessing brutality toward 5.3 3.3 7.3
detainees/prisoners
------------------------------------------------------------------------
Being responsible for the death of a 5.2 3.0 7.4
civilian
------------------------------------------------------------------------
Source: Schell and Marshall, 2008, in Tanielian and Jaycox (eds).
Invisible Wounds of War: Psychological and Cognitive Injuries, Their
Consequences, and Services to Assist Recovery. RAND Corporation, MG-
720CCF.
Note: CI = Confidence Interval; LL = Lower Limit; UL = Upper Limit.
Percentages are weighted to reflect the full population of 1.64
million servicemembers who had deployed to OEF/OIF as of October 31,
2007.
What is the scope of mental health issues faced by OEF/OIF troops
returning from deployment?
Most of the military servicemembers who have deployed to date in
support of OIF or OEF will return home from war without problems and
readjust successfully, but many have already returned or will return
with significant mental health conditions. Among OEF/OIF veterans, our
study found rates of PTSD and major depression to be relatively high,
particularly when compared with the general U.S. civilian population.
In late fall 2007, we conducted a telephone study of 1,965 previously
deployed individuals sampled from 24 geographic areas. Using well-
accepted screening tools for conducting epidemiological studies, we
estimated substantial rates of mental health problems in the past 30
days among OEF/OIF veterans, with 14 percent reporting current symptoms
consistent with a diagnosis of PTSD and 14 percent reporting symptoms
consistent with a diagnosis of major depression (9 percent of veterans
reported symptoms consistent with a diagnosis of both PTSD and major
depression). Major depression is often not considered a combat-related
injury; however, our analyses suggest that it is highly associated with
combat exposure and should be considered in the spectrum of post-
deployment mental health consequences.
Assuming that the prevalence found in this study is representative
of the 1.64 million servicemembers who had been deployed for OEF/OIF as
of October 2007, we estimate that as of April 2008 approximately
303,000 OEF/OIF veterans were suffering from PTSD or major depression.
We also found that some specific groups, previously underrepresented in
studies--including the Reserve Components and those who have left
military service--may be at higher risk of suffering from these
conditions. But the single best predictor of reporting current mental
health problems consistent with a diagnosis of PTSD or depression was
the number of combat traumas reported while deployed. It is important
to note that these data were cross-sectional in nature, that is, they
provide a snapshot of the scope of mental health need among OEF/OIF
veterans. These estimates may change as more individuals return from
deployments or more individuals begin to suffer post-combat related
difficulties that rise to a level of meeting diagnostic criteria.
Seeking and Receiving Treatment. Military servicemembers with
probable PTSD or major depression seek care at about the same rate as
the civilian population, and, just as in the civilian population, many
of the afflicted individuals were not receiving treatment. About half
(53 percent) of those who met the criteria for current PTSD or major
depression had sought help from a physician or mental health provider
for a mental health problem in the past year. Even when individuals
receive care for their mental health condition, too few receive quality
care. Of those who have a mental disorder and also sought medical care
for that problem, just over half received a minimally adequate
treatment. The number who received quality care (i.e., a treatment that
has been demonstrated to be effective) would be expected to be even
smaller. Focused efforts are needed to significantly improve both
accessibility to care and quality of care for these groups. The
prevalence of PTSD and major depression will likely remain high unless
greater efforts are made to enhance systems of care for these
individuals. Survey respondents identified many barriers to getting
treatment for their mental health problems. In general, respondents
were concerned that treatment would not be kept confidential and would
constrain future job assignments and military-career advancement. About
45 percent were concerned that drug therapies for mental health
problems may have unpleasant side effects, and about one-quarter
thought that even good mental health care was not very effective. These
barriers suggest the need for increased access to confidential,
evidence-based psychotherapy, to maintain high levels of readiness and
functioning among previously deployed servicemembers and veterans.
What are the costs of these mental health and cognitive conditions to
the individual and to society?
The costs of these invisible wounds go beyond the immediate costs
of mental health treatment. Adverse consequences that may arise from
post-deployment mental and cognitive impairments include suicide,
reduced physical health, increased engagement in unhealthy behaviors,
substance abuse, unemployment, poor performance while at work,
homelessness, marital strain, domestic violence, and poor parent-child
relationships. The costs stemming from these consequences are
substantial, and may include costs related to lost productivity,
reduced quality of life, substance abuse treatment, and premature
mortality.
To quantify these costs, RAND undertook an extensive review of the
literature on the costs and consequences of post-traumatic stress
disorder (PTSD) and depression. Our analysis included the development
and use of a micro-simulation model to estimate 2-year post-deployment
costs associated with PTSD and depression for military servicemembers
returning from OEF and OIF. Our analyses use a societal cost
perspective, which considers costs that accrue to all members of U.S.
society including Government agencies (e.g., DoD and VA),
servicemembers, their families, employers, private health insurers,
taxpayers, and others. In conducting the micro-simulation analysis for
PTSD and depression, we also estimated the costs and potential savings
associated with different levels of medical care, including proven,
evidence-based care, usual care, and no care.
We found that unless treated, PTSD and depression have wide-ranging
and negative implications for those afflicted and exact a high economic
toll to society. The presence of any one of these conditions can impair
future health, work productivity, and family and social relationships.
Individuals afflicted with any of these conditions are more likely to
have other psychiatric diagnoses (e.g., substance use) and are at
increased risk for attempting suicide. They have higher rates of
unhealthy behaviors (e.g., smoking, overeating, unsafe sex) and higher
rates of physical health problems and mortality. Individuals with any
of these conditions also tend to miss more days of work or report being
less productive. There is also a possible connection between having one
of these conditions and being homeless. Suffering from these conditions
can also impair relationships, disrupt marriages, aggravate the
difficulties of parenting, and cause problems in children that may
extend the consequences of combat experiences across generations.
Below, we summarize some of the key negative outcomes that have been
linked to PTSD and depression in prior studies. For a more thorough
discussion of these issues, please see Tanielian and Jaycox [Eds.],
2008, Chapter Five.
Suicide: Depression and PTSD both increase the risk for suicide, as
shown by evidence from studies of both military and civilian
populations. Psychological autopsy studies of civilian suicides have
consistently shown that a large number of civilians who committed
suicide had a probable depressive disorder. One study showed that
approximately 30 percent of veterans committing suicide within 1-year
had a mental health disorder such as depression, as did approximately
40 percent of veterans attempting suicide. Although not as strongly
associated with suicide as depression, PTSD is more strongly associated
with suicidal thoughts and attempts than any other anxiety disorder and
has also been linked to elevated rates of suicide among Vietnam
veterans.
Physical Health: Depression and PTSD have been linked to increased
morbidity. With respect to physical health, cardiovascular diseases are
the most frequently studied morbidity outcome among persons with
psychiatric disorders. Both PTSD and depression have been linked to
higher rates of heart disease in military and civilian populations.
Depression also affects conditions associated with aging, including
osteoporosis, arthritis, Type 2 diabetes, certain cancers, periodontal
disease, and frailty.
Health-compromising Behaviors: The link between depression and PTSD
and negative physical health outcomes may be partly explained by
increases in health-risk behaviors that influence health outcomes. For
example, research on civilian populations has shown a clear link
between PTSD and depression and smoking, as well as a link between
symptoms of depression and PTSD and sexual risk taking.
Substance Abuse: Rates of co-occurring substance use disorders with
PTSD and depression, are common and are often associated with more-
severe diagnostic symptoms and poorer treatment outcomes. Several
studies have examined the relationship between mental disorders and
alcohol and drug abuse. The results have varied, depending on the
specific condition studied. Studies of Vietnam veterans showed that
PTSD increases the risk of alcohol and substance abuse, while other
studies of civilian populations have found that depression tends to be
a consequence of substance abuse rather than a cause.
Labor Market Outcomes: PTSD and depression influence labor-market
outcomes as well. Specifically, there is compelling evidence indicating
that these conditions will affect servicemembers' return to employment,
their productivity at work, and their future job prospects. Studies of
Vietnam veterans have also found that those with a diagnosis of
depression or PTSD had lower hourly wages than Vietnam veterans without
a diagnosis.
Homelessness: Few studies have examined the rates of homelessness
among individuals with PTSD or depression; rather, most studies have
studied the prevalence of mental disorders among homeless individuals.
Compared with non-homeless persons in the general population, homeless
people have higher rates of mental disorder and are more likely to
experience a severe mental disorder. One study found that 75 percent of
homeless individuals with PTSD had developed the condition prior to
becoming homeless. However, evidence in this area is not strong, and
the prevalence of mental disorders among homeless people may be
overstated, possibly the consequence of studies relying on poor
sampling methods or flawed assumptions.
Marriage and Intimate Relationships: The effects of post-combat
mental and cognitive conditions inevitably extend beyond the afflicted
servicemember. As servicemembers go through life, their impairments
cannot fail to wear on those with whom they interact, and those closest
to the servicemember are likely to be the most severely affected.
Studies of Vietnam veterans, whose results parallel those among
civilian populations, have linked PTSD and depression to difficulties
maintaining intimate relationships, and these deficits account for a
greatly increased risk of distressed relationships, intimate-partner
violence, and divorce among those afflicted.
Child Outcomes: In addition, the interpersonal deficits that
interfere with emotional intimacy in the romantic relationships of
servicemembers with these PTSD and depression may interfere with their
interactions with their children. In particular, interviews with
spouses of veterans from several conflicts (World War II, Korea, and
Vietnam) have all revealed a higher rate of problems among children of
veterans with symptoms of PTSD. Rates of academic problems, as well as
rates of psychiatric treatment, were also higher in children of
veterans with PTSD compared to children of veterans without PTSD. The
implications of a parent's depression on children's outcomes has not
been studied directly in military populations, but numerous studies of
civilian populations have shown that the children of depressed parents
are at far greater risk of behavioral problems and psychiatric
diagnoses than children of non-depressed parents.
A limitation of the research summarized above is that virtually
none of the studies we reviewed were randomized controlled trials, and
thus may not be able to detect causal relationships between these
disorders and subsequent adverse consequences such as homelessness,
substance abuse, or relationship problems. Further, the majority of
studies reviewed drew from data on Vietnam-era veterans or from data on
civilians. Nevertheless, these studies are important for understanding
the range of co-morbidities and behavioral outcomes likely to be
associated with PTSD and depression, and this information is relevant
for determining the required resources for treating veterans with these
conditions. Effective treatments for PTSD and depression exist
(Tanielian and Jaycox [Eds.), 2008, Chapter 7), and can greatly improve
functioning. With adequate treatment and support, some veterans may
avoid negative outcomes altogether.
What are the associated economic costs to society?
To understand the consequences of these conditions in economic
terms, we developed a microsimulation model. Using data from the
literature (which had limited information on specific populations and
costs), we estimated the costs associated with mental health conditions
(PTSD and major depression) for a hypothetical cohort of military
personnel deployed to Afghanistan and Iraq.
We defined costs in terms of lost productivity, treatment, and
suicide attempts and completions, and we estimated costs over a 2-year
period (see Tanielian and Jaycox [Eds.], 2008, Chapter Six). For this
analysis, we focus specifically on the costs of PTSD and depression,
and we considered the costs associated with different types of
treatment and different patterns of comorbidity, allowing for remission
and relapse rates to be influenced by treatment type. The data
available to conduct this type of detailed analysis for specific mental
health conditions, however, did not support projecting costs beyond a 2
year time horizon.
For each condition, we generated two estimates--one that included
the medical costs and the value of lives lost due to suicide, and one
that excluded such costs. We were unable to estimate the costs
associated with homelessness, domestic violence, family strain, and
substance abuse because reliable data are not available to create
credible dollar figures for these outcomes. If figures for these
consequences were available, the costs of having these conditions would
be higher. Our estimates represent costs incurred within the first 2
years after returning home from deployment, so they accrue at different
times for different personnel. For servicemembers who returned more
than 2 years ago and have not redeployed, these costs have already been
incurred. However, these calculations omit costs for servicemembers who
may deploy in the future, and they do not include costs associated with
chronic or recurring cases that linger beyond 2 years. (Details of our
model assumptions and parameters can be found in Tanielian and Jaycox
[Eds.], 2008, Chapter Six).
Our microsimulation model predicts that 2-year post-deployment
costs to society resulting from PTSD and major depression for 1.64
million deployed servicemembers (as of October 2007) could range from
$4.0 to $6.2 billion (in 2007 dollars), depending on how we account for
the costs of lives lost to suicide. For PTSD, average costs per case
over 2 years range from $5,904 to $10,298; for depression, costs range
from $15,461 to $25,757; and for PTSD and major depression together,
costs range from $12,427 to $16,884. The majority of the costs were due
to lost productivity. Because these numbers do not account for future
costs that may be incurred if additional personnel deploy and because
they are limited to 2 years following deployment, they underestimate
total future costs to society.
Providing Evidence-Based Treatment for PTSD and Depression Can
Reduce Societal Costs. Certain treatments have been shown to be
effective for both PTSD and major depression, but these evidence-based
treatments are not yet available in all treatment settings. We estimate
that evidence-based treatment for PTSD and major depression would pay
for itself within 2 years, even without considering costs related to
substance abuse, homelessness, family strain, and other indirect
consequences of mental health conditions. Evidence-based care for PTSD
and major depression could save as much as $1.7 billion, or $1,063 per
returning veteran; the savings come from increases in productivity, as
well as from reductions in the expected number of suicides. Given these
numbers, investments in evidence-based treatment would make sense, not
only because of higher remission and recovery rates but also because
such treatment would increase the productivity of servicemembers. The
benefits to increased productivity would outweigh the higher costs of
providing evidence-based care. These benefits would likely be even
higher had we been able to capture the full spectrum of costs
associated with mental health conditions. However, a caveat is that we
did not consider additional implementation and outreach costs (over and
above the day-to-day costs of care) that might be incurred if DoD and
the VA attempted to expand evidence-based treatment beyond current
capacity.
Summary
Our study found high rates of exposures to combat trauma during
deployment and revealed serious prevalence (18.5 percent) of current
PTSD and depression among servicemembers who had returned from OEF or
OIF. In our analyses (not presented in this testimony), we also found
significant gaps in access to and the quality of care provided to this
population. Too few of those with PTSD and depression were getting
help, and among those that were getting help too few were getting even
minimally adequate care. If left untreated or under-treated, these
conditions can have negative cascading consequences and result in a
high economic toll. Investing in evidence based care for all of those
in need can reduce the costs to society in just 2 years. Ensuring all
veterans afflicted with these conditions will require addressing the
significant gaps that exist in access to and quality of care for our
Nation's veterans.
Thank you again for the opportunity to testify today and to share
the results of our research. Additional information about our study
findings and recommendations can be found at: http://veterans.rand.org.
References
American Psychiatric Association, Diagnostic and Statistical Manual
For Mental Disorders, Third Edition. Washington, DC. American
Psychiatric Association, 1980.
Belasco, A. The Cost of Iraq, Afghanistan, and Other Global War on
Terror Operations Since 9/11. Washington, D.C.: Congressional Research
Service, 2007.
Bruner, E.F. Military Forces: What Is the Appropriate Size for the
United States? Washington, D.C.: Congressional Research Service, 2006.
Hoge, C.W., C.A. Castro, S.C. Messer, D. McGurk, D.I. Cotting, and
R.L. Koffman. Combat duty in Iraq and Afghanistan, mental health
problems, and barriers to care. New England Journal of Medicine, Vol.
351, No. 1, July 2004, pp. 13-22.
Hosek, J., J. Kavanagh, and L. Miller. How Deployments Affect
Service Members. Santa Monica, Calif.: RAND Corporation, MG-432-RC,
2006. As of March 13, 2008: http://www.rand.org/pubs/monographs/MG432/.
Institute of Medicine, Committee on Treatment of Post-traumatic
Stress Disorder, Board on Population Health and Public Health Practice.
Treatment of Post-traumatic Stress Disorder: An Assessment of the
Evidence. Washington, D.C.: National Academies Press, 2007.
Regan, T. Report: High survival rate for U.S. troops wounded in
Iraq. Christian Science Monitor, November 29, 2004.
Tanielian, T. and L.H. Jaycox (Eds). Invisible Wounds of War:
Psychological and Cognitive Injuries, Their Consequences and Services
to Assist Recovery. Santa Monica, California. RAND Corporation MG 720-
CCF, 2008.
Warden, D. Military TBI during the Iraq and Afghanistan wars.
Journal of Head Trauma Rehabilitation, Vol. 21, No. 5, 2006, pp. 398-
402.
Prepared Statement of Rear Admiral David J. Smith, M.D., SHCE, USN,
Joint Staff Surgeon, Office of the Chairman of the Joint Chiefs of
Staff,
Wounded and Survivor Care Task Force, U.S. Department of Defense
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to appear before you today. In my capacity as the Joint
Staff Surgeon, I serve as the medical advisor to the Chairman of the
Joint Chiefs of Staff, the Joint Staff and Combatant Commanders and
coordinate operational medicine, force health protection and readiness
issues among the Combatant Commands, the Office of the Secretary of
Defense and the services. I am a board-certified Occupational Medicine
physician with 27 years of service and additional background in medical
management and undersea medicine.
I serve as the senior ranking member of the Chairman's Wounded and
Survivor Care Task Force. Under the direction of the Chairman, the Task
Force has been actively engaged in focused efforts to implement
necessary change and reinforce successful efforts to improve the health
of the force and to ensure the appropriate care and support is provided
for our wounded servicemembers, their families, and the families of
those killed in action so they can effectively manage the physical and
mental challenges incurred during military service.
Mr. Chairman, thank you again for the invitation to appear here
this afternoon. I am pleased to respond to any questions you or the
Subcommittee Members may have.
Prepared Statement of Colonel Robert Ireland, Program Director,
Mental Health Policy, Office of the Assistant Secretary of Defense for
Health Affairs, U.S. Department of Defense
Chairman Hall, Ranking Member Lamborn, and distinguished Members of
the Subcommittee, thank you for the opportunity to discuss the
Department of Veterans Affairs (VA), Title 38, United States Code,
section 1154, and how these provisions align with the Department of
Defense's (DoD) approach to diagnosing Post-Traumatic Stress Disorder
(PTSD), defining related stressors, and the use of the servicemember's
medical record.
PTSD, Stressors, and Military Mental Health
When servicemembers' medical condition(s) requires further medical
evaluation to ensure they meet Service-specific medical retention
standards, military clinicians
will write a summary and submit it for review by a military Medical
Evaluation Board (MEB). The MEB typically consists of two to three
providers at a local installation medical treatment facility. Any MEB
review of a psychiatric diagnosis must contain a thorough psychiatric
evaluation and include the signature of at least one psychiatrist. The
MEB is required to:
1. Confirm the medical diagnosis(es).
2. Document the servicemember's current medical condition to
include treatment status and potential for medical recovery.
3. Review each case based on relevant facts.
The MEB determines whether the servicemember meets Service-specific
medical retention standards and is medically qualified to return to
duty, or whether the servicemember fails to meet Service-specific
medical retention standards, in which case the MEB recommends the case
be forwarded to a Physical Evaluation Board (PEB) that has the
authority to determine retention, separation with or without severance
pay, or retirement. Decisions related to continued military service,
separation, or retirement due to a disability are part of the DoD
personnel process.
With respect to PTSD, military providers use the same criteria as
their civilian counterparts to diagnose PTSD (a common disorder in both
settings), as defined by the American Psychiatric Association's
Diagnostic and Statistical Manual for Mental Disorders, 4th Edition-TR
(DSM-IV TR). The first criterion, ``A'', requires:
The person has been exposed to a traumatic event in which both of
the following have been present:
1. The person experienced, witnessed, or was confronted with an
event or events that involved actual or threatened death or serious
injury, or a threat to the physical integrity of self or others.
2. The person's response involved intense fear, helplessness, or
horror.
In a medical record, at least one such event should be documented
by a provider in order to show how it met both components of Criterion
A: a traumatic event and specific intense responses to it. It is not
enough to simply list ``stressors,'' which, in reality, involve
perception of a threat, one's emotional and physical responses to it,
and a perception about whether or not one can manage one's reactions.
Documentation of re-experiencing, avoidance, and hyper-arousal
symptoms should connect to corresponding traumatic events. Veterans
should be encouraged to provide copies of their military medical and
mental health records to ensure continuity of care and assist in
confirmation of their entitlements.
Thank you again for allowing me the opportunity to appear before
you to discuss Military Mental Health and for your continued support. I
look forward to working together to improve mental health care for our
beneficiaries.
Prepared Statement of Bradley G. Mayes, Director,
Compensation and Pension Service, Veterans Benefits Administration,
U.S. Department of Veterans Affairs
The evolving PTSD claims process and the application of 38 U.S.C.
Sec. 1154
Mr. Chairman and Members of the Committee:
I would like to thank the Chairman for this opportunity to testify
on the important topic of post-traumatic stress disorder (PTSD). Mr.
Richard Hipolit of the Department of Veterans Affairs (VA) Office of
General Counsel accompanies me today. The number of veterans receiving
service-connected compensation for PTSD from VA has grown dramatically.
From fiscal year 1999 through fiscal year 2008, the number increased
from 120,000 to 345,520. We all share the goals of preventing this
disability, minimizing its impact on our veterans, and providing those
who suffer from it with just compensation for their service to our
country. Consequently, VA has expanded its efforts to assist veterans
with the claims process and keep pace with the increased number of
claims. Today I will describe the PTSD claims process and explain how
VA applies the statutory requirements of 38 U.S.C. Sec. 1154 to the
processing of these claims. I will also describe the challenges met by
VA through the years as PTSD claims and warfare tactics have evolved.
38 U.S.C. Sec. 1154
Section 1154, which was enacted by Congress in 1941, requires that
VA consider the time, place, and circumstances of a veteran's service
in deciding a claim for service connection. Section 1154(b) provides
for a reliance on certain evidence as a basis for service connection of
disabilities that result from a veteran's engagement in combat with the
enemy. As a result, veterans who ``engaged in combat with the enemy''
and file claims for service-connected disability related to that combat
are not subject to the same evidentiary requirements as non-combat
veterans. Their lay statements alone may provide the basis for service
connecting a disability, without additional factual or credible
supporting evidence. In PTSD claims, a combat veteran's personal
stressor statement can serve to establish the occurrence of the
stressor.
The PTSD Claims Process
The processing of PTSD claims is governed by 38 C.F.R.
Sec. 3.304(f). This regulation states that, in order for service
connection for PTSD to be granted, there must be: (a) medical evidence
diagnosing the condition, (b) medical evidence establishing a link
between current symptoms and an in-service stressor, and (c) credible
supporting evidence that the claimed in-service stressor occurred. The
first two requirements involve medical assessments, while the third
requirement may be satisfied by non-medical evidence. PTSD is defined
as a mental disorder that results from a stressor. The third
requirement of the regulation emphasizes the importance of the stressor
and the obligation of the Veterans Benefits Administration (VBA) to
seek credible evidence supporting the occurrence of that stressor.
In PTSD claims where the stressor is not combat-related, VBA
personnel will conduct research and develop credible evidence to
support the claimed stressor. However, the statutory directives of
Sec. 1154(b) have been incorporated into PTSD regulations at
Sec. 3.304(f)(2), so that when there is evidence of combat
participation, and the stressor is related to that combat, no stressor
corroboration is required. The veteran's lay statement alone is
sufficient to establish the occurrence of the stressor. In Moran v.
Peake, 525 F.3d 1157, 1159 (Fed. Cir. 2008), the United States Court of
Appeals for the Federal Circuit held ``the term `engaged in combat with
the enemy' in Sec. 1154(b) requires that the veteran have personally
participated in events constituting an actual fight or encounter with a
military foe or hostile unit or instrumentality, as determined on a
case-by-case basis.'' The Court said that ``[a] showing of no more than
service in a general ``combat area'' or ``combat zone'' is not
sufficient to trigger the evidentiary benefit of Sec. 1154(b).'' When
no combat award has been received, VBA relies on the circumstances of
the individual case, as determined from the veteran's service records
and other sources, to evaluate whether the veteran engaged in combat.
VBA responses to the changing circumstances of PTSD and warfare tactics
Through the years VA has made changes to Sec. 3.304(f) based on the
Sec. 1154 mandate to consider the time, place, and circumstances of a
veteran's service.
The definition and diagnostic criteria for PTSD evolved to a great
extent from the psychiatric community's attempt during the seventies to
explain the psychological problems of some Vietnam War Veterans. Once
the medical community recognized this mental disorder, VA added it as a
disability to the VA rating schedule. VA then moved to incorporate PTSD
diagnostic criteria from the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders (DSM) into the
PTSD claims evaluation process. According to DSM-IV, the symptoms of
PTSD ``usually begin within the first 3 months after the trauma,
although there may be a delay of months, or even years, before symptoms
appear.'' Given the delay that may occur between the occurrence of a
stressor and the onset of PTSD and the subjective nature of a person's
response to an event, VA concluded, when it first promulgated
Sec. 3.304(f) in 1993, that it is reasonable to require corroboration
of the in-service stressor, a conclusion with which the Federal Circuit
agreed in Nat'l Org. of Veterans' Advocates, Inc. v. Sec'y of Veterans
Affairs, 330 F.3d 1345, 1351-52 (Fed. Cir. 2003). Work is currently
underway to update the disability rating schedule to compensate more
effectively for disability due to PTSD.
As the military incorporated more female members into its ranks,
VBA recognized that PTSD could result from personal assault and sexual
trauma. These types of claims were increasing in numbers and are
difficult to document. To meet this evolving situation, VA added
Sec. 3.304(f)(4), which provides for acceptance of evidence for
stressor corroboration in such cases from multiple sources other than
the veteran's service records. This evidence may include local law
enforcement records, hospital or rape crisis center records, or
testimony from family, friends, or clergy members. In addition, this
evidence may be submitted to an appropriate medical or mental health
professional for an opinion regarding the occurrence of the stressor.
This expanded concept of potential evidence to corroborate the stressor
in personal assault PTSD claims shows a positive and sensitive
responsiveness on the part of VA to the changing demographics of the
veteran population.
For the evaluation of PTSD claims where the stressor is not combat-
related or the claimed stressor is related to combat but there is no
initial evidence of combat participation, VBA has provided claims
processing personnel with special tools to research veterans' stressor
statements. A website was developed that contains a database of
thousands of declassified military unit histories and combat action
reports from all periods of military conflict. In many cases, evidence
is found in these documents to support the veteran's stressor statement
or confirm combat participation. Nationwide training was conducted to
explain the use of this database and other official Web sites that can
aid with stressor corroboration. This initiative illustrates the VBA
commitment to assisting veterans with PTSD claims.
Although the combat participation provisions of Sec. 1154 have been
in effect for many years, VA has recently provided a PTSD regulatory
change that further carries out the intent of that statute and
recognizes the changing conditions of modern warfare. Section
3.304(f)(1) now provides for service connection of PTSD when there is
an in-service diagnosis of the disability. In such cases, the veteran's
lay stressor statement and the medical examiner's association of PTSD
with that stressor is sufficient to establish service connection when
PTSD is diagnosed. This liberalization of regulatory requirements is
due to the recognition by VA of the heightened awareness of PTSD among
military medical personnel, resulting in increasing numbers and
reliability of PTSD diagnoses for personnel still on active duty. This
regulation also facilitates the timely resolution of PTSD claims and
provides expedited payment of needed benefits to veterans.
These descriptions of PTSD-related initiatives make it clear that
VA is committed to following the mandate of Sec. 1154 and adjusting the
PTSD claims process as necessary to better serve veterans. This
concludes my testimony and I would be happy to answer any questions the
Committee Members may have.
Prepared Statement of Antonette Zeiss, Ph.D., Deputy Chief Consultant,
Office of Mental Health Services, Office of Patient Care Services,
Veterans Health Administration, U.S. Department of Veterans Affairs
Good afternoon, Mr. Chairman and Members of the Subcommittee. Thank
you for the opportunity to discuss ``The Nexus between `Engaged in
Combat with the Enemy' and PTSD in an Era of Changing Warfare
Tactics.'' I am here to discuss the diagnosis of post-traumatic stress
disorder (PTSD) by Veterans Health Administration (VHA) clinicians.
VA is nationally recognized for its outstanding PTSD treatment and
research programs, and the quality of VA health care in this area is
outstanding, with continual enhancements as more is learned. For
example, VA's National Center for PTSD advances the clinical care and
social welfare of Veterans through research, education and training on
PTSD and stress-related disorders. Those advances are used to guide
clinical program development in collaboration with the Office of Mental
Health Services.
All VA clinicians, including those responsible for completing
Compensation and Pension (C&P) evaluations, adhere to the Diagnostic
and Statistical Manual of Mental Disorders, 4th edition, Text Revision
(DSM-IV-TR), recognized as the authoritative source for mental health
conditions. According to the DSM-IV-TR clinical criteria, PTSD can
follow exposure to a severely traumatic stressor that involves personal
experience of an event involving actual or threatened death or serious
injury. It can also be triggered by witnessing an event that involves
death, injury, or a threat to the physical integrity of another. The
person's response to the event must involve intense fear, helplessness
or horror. The symptoms characteristic of PTSD include persistent re-
experiencing of the traumatic event, persistent avoidance of stimuli
associated with the trauma, numbing of general responsiveness, and
persistent symptoms of increased arousal. No single individual displays
all these symptoms, and a diagnosis requires a combination of a
sufficient number of symptoms, while recognizing that individual
patterns will vary. PTSD can be experienced in many ways. Symptoms must
last for more than 1 month and the disturbance must cause clinically
significant distress or impairment in social, occupational or other
important areas of functioning. Military combat certainly creates
situations that fit the DSM-IV TR description of a severe stressor
event that can result in PTSD. The likelihood of developing PTSD is
known to increase as the proximity to, intensity of, and number of
exposures to such stressors increase.
PTSD is associated with increased rates of other mental health
conditions, including Major Depressive Disorder, Substance-Related
Disorders, Generalized Anxiety Disorder, and others. PTSD can directly
or indirectly contribute to other medical conditions. Duration and
intensity of symptoms can vary across individuals and within
individuals over time. Symptoms may be brief or persistent; the course
of PTSD may ebb and return over time, and PTSD can have delayed onset.
Clinicians use these criteria and discussions with patients to identify
cases of PTSD, sometimes in combination with additional psychological
testing. VA adheres to the guidance of the DSM-IV-TR when it states,
``Specific assessments of the traumatic experience and concomitant
symptoms are needed for such individuals.'' VA seeks to ensure we offer
the right diagnosis in all clinical settings, whether for C&P
examinations or as part of a standard mental health assessment.
Because personal experience in combat can be such a significant
source of trauma, our mental health professionals have been trained to
solicit this information from patients. Only Psychiatrists and
Psychologists may conduct initial C&P examinations in which a diagnosis
of PTSD is being considered in response to a claim by a Veteran. In
addition, any Psychiatrist or Psychologist who will conduct a PTSD C&P
examination must complete training and receive certification in the
process of conducting C&P examinations in relation to the diagnostic
criteria of PTSD. We recognize that many individuals with symptoms of
combat stress or PTSD find it difficult to discuss the details of their
experiences, although they can more easily describe their symptoms and
level of distress. However, without the patient disclosing the source
of the stress, it is impossible for a clinician to diagnose PTSD
according to the clinical criteria of the DSM-IV-TR. Clinicians must
develop a sense of safety and trust with some patients in order to make
them feel comfortable enough to share their trauma in the clinical
interview. The expertise and sensitivity required for such clinical
evaluation are two reasons why only doctoral level Psychiatry and
Psychology providers are allowed to conduct initial exams. VHA
clinicians conducting the clinical interview for the diagnosis of PTSD
in the context of a Veteran's claim do not ask for external
corroborating evidence for the described stressful event. VBA requires
this evidence to make a determination of service-connection for C&P.
Apart from issues of determining diagnoses in the C&P context,
identifying and treating patients with PTSD and other mental health
conditions are paramount for VHA. VA's efforts to facilitate treatment
while removing the stigma associated with seeking mental health care
are yielding valuable results. VA screens any patient seen in our
facilities for depression, post-traumatic stress disorder (PTSD),
problem drinking, and military sexual trauma. We have incorporated this
screening and treatment into primary care settings. We also offer a
full continuum of care, including inpatient, residential
rehabilitation, and outpatient services for Veterans with one or more
of the following conditions (this list is illustrative, not
exhaustive): PTSD, alcohol and substance abuse disorders, depression,
anxiety, and other serious mental illnesses. We further offer programs
for Veterans at risk of suicide, Veterans who are homeless, and
Veterans who have experienced military sexual trauma with resulting
development or exacerbation of mental health problems.
In Fiscal Year 2008, VA treated 442,862 unique Veterans for PTSD in
VA medical centers, clinics, inpatient settings, and residential
rehabilitation programs. Given the increasing numbers of Veterans
seeking VA care for PTSD, VA is monitoring the promptness and
efficiency of services provided them, such as ``time to first
appointment'' for Veterans of all service eras who present with new
mental health problems. Nationally, we are meeting our new standard of
care, which is to see all new patients seeking a mental health care
appointment within 14 days of their requested date, 95 percent of the
time. Almost all VISNs meet this standard, and focused efforts continue
to bring all VISNs and facilities up to this standard. We conduct an
initial evaluation of all patients with potential mental health issues
within 24 hours of contact and we provide urgent care immediately. VA
has extended hours of operation, expanded points of access, and
increased our core staff to date by 5,000 positions. We plan again this
year to continue increasing the number of mental health professionals
and support staff in the field to ensure sustained operations of this
vital service line.
We also believe it is essential that our mental health
professionals across the system be able to provide the most effective
treatment for PTSD once it has been identified. In addition to use of
effective psychoactive medications, VA is conducting national training
initiatives to educate therapists in two particular evidence-based
psychotherapies (EBPs) for PTSD. A number of studies have supported the
use of these exposure-based treatments for PTSD. The first of these
therapies is Cognitive Processing Therapy (CPT); training for CPT began
in 2006, and to date, VA has trained over 1,100 VA clinicians in the
use of CPT. The second national initiative is an education and training
module on Prolonged Exposure (PE) for treatment of PTSD; this training
began in 2008, and to date, OMHS has trained over 350 clinicians in the
use of PE. For both of these psychotherapies, following didactic
training, clinicians participate in clinical consultations to attain
full competency in the therapy. VA is also using new CPT and PE
treatment manuals, developed for VA with inclusion of material on the
treatment of issues arising from combat trauma during military service.
VA provides mental health care in several different environments,
including Vet Centers. There are strong, mutual interactions between
Vet Centers and our clinical programs. Vet Centers provide a wide range
of services that help Veterans cope with and transcend readjustment
issues related to their military experiences in war. Services include
counseling for Veterans, marital & family counseling for military
related issues, bereavement counseling, military sexual trauma
counseling and referral, demobilization outreach/services, substance
abuse assessment and referral, employment assistance, referral to VA
medical centers, VBA referral and Veterans community outreach and
education. Vet Centers provide a non-traditional therapeutic
environment where Veterans and their families can receive counseling
for readjustment needs and learn more about VA's services and benefits.
By the end of FY 2009, 271 Vet Centers with 1,526 employees will be
operational to address the needs of Veterans. Additionally, VA is
deploying a fleet of 50 new Mobile Vet Centers this year that will
provide outreach to returning Veterans at demobilization activities
across the country and in remote areas. Vet Centers facilitate
referrals to either Veterans Benefits Administration offices or VHA
facilities to ensure Veterans have multiple avenues available for
receiving the care and benefits they have earned through service to the
country.
Thank you again for this opportunity to speak about VA's diagnosis
and treatment of PTSD in Veterans and its relevance to the
determination of whether a diagnosis of PTSD is warranted when Veterans
submit claims to VBA. I am prepared to answer any questions you may
have.
Prepared Statement of Maureen Murdoch, M.D., MPH, Core Investigator,
Center for Chronic Disease Outcomes Research,
Minneapolis Veterans Affairs Medical Center,
Veterans Health Administration, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to appear before you today to present findings from my
team's research on post-traumatic stress disorder (PTSD) disability
awards. I must note the views presented today are mine and do not
necessarily represent the views of the Department of Veterans Affairs
(VA) and reflect the results of my studies and not necessarily the
findings of other research. It is also important to note that these
data were collected almost 10 years ago and may not reflect experiences
of a new cohort of Veterans from Operation Enduring Freedom or
Operation Iraqi Freedom.
Background
PTSD is the most common psychiatric condition for which Veterans
seek VA disability benefits. Between 1998 and 2000, my colleagues and I
conducted three studies looking at differences in PTSD disability
awards.
The first study was a historical, administrative database
evaluation of all 180,039 Veterans who applied for PTSD disability
benefits between 1980 and 1998. The second was a mailed survey of
almost 5,000 men and women Veterans who applied for PTSD disability
benefits between 1994 and 1998. Surveys were collected from 1998 to
2000, and responses were supplemented with VA administrative data. The
third study involved conducting a claims audit of 345 Veterans who also
participated in the survey.
Although these studies had several objectives, those most relevant
to today's proceedings include: (1) Identifying the role of combat
experience on receiving PTSD service-connection; and (2) Understanding
how claiming combat versus military sexual trauma influenced gender
differences in receiving PTSD service connection.
Results of the Studies
From the historical database study, we learned that rates of
service-connection increased over time. Across all time periods, men
and women who had been identified as being ``combat injured'' in the
database were twice as likely to receive service-connection for PTSD
compared to men and women who were not combat injured.
By 1998, the observed rate of service-connection for PTSD was 94
percent among combat-injured men and 92 percent among combat-injured
women.
For men without combat injuries, the rate of PTSD service-
connection in 1998 was 64 percent, and the rate for women without
combat injuries was 57 percent.
From the survey study, which covered the time period from 1994 to
1998, we learned that 94 percent of men and 29 percent of women
reported some type of combat experience. Twenty-four percent of men and
2 percent of women were identified as being ``combat-injured'' in VA
databases. ``Combat injury'' probably anchors the extreme end of a
broad range of combat-associated experiences for these Veterans. Four
percent of men and 71 percent of women reported sexual assault. As with
the historical study, we again saw that more than 90 percent of men and
women identified as ``combat-injured'' received PTSD service-
connection. Among those who were not identified as combat-injured, 52
percent of women and 64 percent of men received PTSD service-
connection. However, this gender difference was almost entirely
explained by men and women's different rates of combat experience.
Regardless of gender, Veterans with more combat experiences were more
likely to receive a service-connection for PTSD than Veterans with
fewer or no combat experience. Since men were more likely to report
combat experiences, they were also more likely to receive service-
connection for PTSD.
In our claims audits of 345 Veterans who participated in the mail
survey, we found that 85 percent of men received a diagnosis of PTSD
from a qualified clinician compared to 76 percent of women. No Veteran
selected for chart audit received a service-connection for PTSD unless
his or her examining clinician made a diagnosis of PTSD. About a third
of Veterans diagnosed with PTSD did not receive service-connection.
Veterans diagnosed with PTSD at the time of their clinical examination
reported an average of two more combat experiences at the time of the
survey compared to men who were not diagnosed with PTSD. Women who were
diagnosed with PTSD were as likely to report a military sexual assault
on the survey as were women not diagnosed with PTSD. The factor most
strongly associated with Veterans receiving a diagnosis of PTSD was
having a stressor documented in their claims file.
Mr. Chairman, this concludes my statement. I am pleased to respond
to any questions you or the Subcommittee Members may have. Thank you.
Statement of John R. Vaughn, Chairperson, National Council on
Disability
National Council on Disability
Washington, DC.
April 2, 2009
The Honorable John Hall
The Honorable Doug Lamborn
House Committee on Veterans' Affairs
337 Cannon House Office Building
Washington, DC 20515
Dear Chairman Hall and Ranking Member Lamborn:
I am pleased to write to you on behalf of the National Council on
Disability (NCD), an independent Federal agency, to submit for the
record the executive summary of our most recent report entitled
``Invisible Wounds: Serving Servicemembers and Veterans with PTSD and
TBI.'' We are making this submission in order for it to be considered
part of the record for the March 24, 2009 hearing of the House
Veterans' Affairs Subcommittee on Disability Assistance and Memorial
Affairs entitled ``The Nexus between Engaged in Combat with the Enemy
and PTSD in an Era of Changing Warfare Tactics.''
In light of last Tuesday's hearing on Post-Traumatic Stress
Disorder (PTSD), we have chosen to submit a summary of our most recent
report, which addresses the military health care systems which are
serving servicemembers and veterans with PTSD and Traumatic Brain
Injury (TBI). The Council addressed both PTSD and TBI together, as they
are often experienced together and because the symptoms of each are
often difficult to distinguish.
In its full report, NCD outlines a reality that many studies and
commissions have presented in greater detail--that while many evidence-
based practices exist to address PTSD and TBI, servicemembers and
veterans face numerous barriers in accessing these vital interventions
and services. The summary that follows offers ten policy
recommendations for the Committee's consideration.
NCD is composed of 15 members, appointed by the President with the
consent of the U.S. Senate. The purpose of NCD is to promote policies,
programs, practices, and procedures that guarantee equal opportunity
for all individuals with disabilities, and that empower individuals
with disabilities to achieve economic self-sufficiency, independent
living, and integration into all aspects of society. To accomplish
this, we gather stakeholder input, review Federal programs and
legislation, and provide advice to the President, Congress and
governmental agencies. Much of this advice comes in the form of timely
reports and papers NCD releases throughout each year.
If you have any questions about this submission or any matter
related to disability policy, please contact NCD Executive Director
Michael Collins by phone at (202) 272-2004, or email at
[email protected]. On behalf of NCD, thank you for your leadership in
focusing attention on this important topic. I also thank you for the
opportunity to submit this statement for the record.
Sincerely,
John R. Vaughn
Chairperson
__________
Invisible Wounds: Serving Service Members and Veterans With PTSD and TBI
National Council on Disability
March 4, 2009
National Council on Disability
1331 F Street, NW, Suite 850
Washington, DC 20004
Read the full report at: http://www.ncd.gov/newsroom/publications/2009/
veterans.doc
Executive Summary
More than 1.6 million American servicemembers have deployed to Iraq
and Afghanistan in Operation Iraqi Freedom (OIF) and Operation Enduring
Freedom (OEF). As of December 2008, more than 4,000 troops have been
killed and over 30,000 have returned from a combat zone with visible
wounds and a range of permanent disabilities. In addition, an estimated
25-40 percent have less visible wounds--psychological and neurological
injuries associated with post traumatic stress disorder (PTSD) or
traumatic brain injury (TBI), which have been dubbed ``signature
injuries'' of the Iraq War.
Although the Department of Defense (DoD) and the Veterans
Administration (VA) have dedicated unprecedented attention and
resources to address PTSD and TBI in recent years, and evidence
suggests that these policies and strategies have had a positive impact,
work still needs to be done. In 2007, the Department of Defense Task
Force on Mental Health concluded that
Despite the progressive recognition of the burden of mental
illnesses and substance abuse and the development of many new
and promising programs for their prevention and treatment,
current efforts are inadequate to ensure the psychological
health of our fighting forces. Repeated deployments of mental
health providers to support operations have revealed and
exacerbated pre-existing staffing inadequacies for providing
services to military members and their families. New strategies
to effectively provide services to members of the Reserve
Components are required. Insufficient attention has been paid
to the vital task of prevention.
PTSD and TBI can be quite debilitating, but the effects can be
mitigated by early intervention and prompt effective treatment.
Although medical and scientific research on how to prevent, screen for,
and treat these injuries is incomplete, evidence-based practices have
been identified. A number of panels and commissions have identified
gaps between evidence-based practices and the current care provided by
DoD and VA and have recommended strategies to address these gaps. The
window of opportunity to assist the servicemembers and veterans who
have sacrificed for the country is quickly closing. It is incumbent
upon the country to promptly implement the recommendations of previous
panels and commissions and fill the remaining gaps in the mental health
service systems.
In terms of prevention, emphasis must be placed on minimizing
combat stress reactions, and preventing normal stress reactions from
developing into PTSD when they do occur. When PTSD or TBI does occur,
the goal of treatment must be to help the servicemember regain the
capacity to lead a complete life, to work, to partake in leisure and
civic activities, and to form and maintain healthy relationships.
PTSD and TBI are often addressed together because they often occur
together and because the symptoms are at times difficult to
distinguish.
PTSD is an anxiety disorder arising from ``exposure to a traumatic
event that involved actual or threatened death or serious injury.'' It
is associated with a host of chemical changes in the body's hormonal
system, and autonomic nervous system. Symptoms vary considerably but
the essential features of PTSD include:
Re-experiencing: Such as flashbacks, nightmares and
intrusive memories;
Avoidance/Numbing: Including a feeling of estrangement
from others; and,
Hyperarousal/Hypervigilance: Including feelings of being
constantly in danger.
The challenge for both professionals and veterans is to recognize
the difference between ``a normal response to abnormal circumstances''
and PTSD. Some will develop symptoms of PTSD while they are deployed,
but for others it will emerge later, after several years in many cases.
According to current estimates, between 10 and 30 percent of
servicemembers will develop PTSD within a year of leaving combat. When
we consider a range of mental health issues including depression,
generalized anxiety disorder, and substance abuse, the number increases
to between 16 and 49 percent.
Traumatic brain injury (TBI), also called acquired brain injury or
simply head injury, occurs when a sudden trauma causes damage to the
brain. TBI can result when the head suddenly and violently hits an
object, or when an object pierces the skull and enters brain tissue.
Victims may have a wide range of symptoms such as difficulty thinking,
memory problems, attention deficits, mood swings, frustrations,
headaches, or fatigue. Between 11 and 20 percent of servicemembers may
have acquired a traumatic injury in Iraq and Afghanistan.
Evidence-based practices to prevent PTSD include teaching skills to
enhance cognitive fitness and psychological resilience that can reduce
the detrimental impact of trauma. In terms of screening, evidence
suggests that identifying PTSD and TBI early and quickly referring
people to treatment can shorten their suffering and lessen the severity
of their functional impairment. Several types of rehabilitative and
cognitive therapies, counseling, and medications have shown promise in
treating both injuries.
Servicemembers and veterans may access care through the Department
of Defense, the Veterans Health Administration, or the private sector.
Each health care system has a number of strengths and weaknesses in
delivering evidence-based care. For example:
Department of Defense: DoD has developed a number of evidence-based
programs designed to (1) maintain the psychological readiness of the
forces in order to reduce the incidence of stress reactions; (2) embed
psychological services in deployed settings to ensure early
intervention when stress reactions occur; and (3) deliver evidence
based rehabilitative therapies on base and through TRICARE, a managed
care system that uses a network of civilian providers. However, the
military, not unlike the civilian health care setting, has a shortage
of mental health providers who must be spread about military bases and
deployed settings.
Servicemembers who rely on the TRICARE network may have limited
access to services. Because of the low reimbursement rates, many of
TRICARE's providers are not accepting new TRICARE patients and because
of the shortage of available mental health providers in some areas,
enrollees may wait weeks or months for an available appointment.
Veterans Health Administration: VA has undergone significant
changes in the past 10-15 years that has transformed it into an
integrated system that generally provides high quality care. In
response to the increased demand for services to treat OEF/OIF veterans
with PTSD, the system has invested resources in expanding outreach
activities enhancing the availability and timeliness of specialized
PTSD services. Nevertheless, access to care is still unacceptably
variable across the VA system.
Some servicemembers continue to face barriers to seeking care.
These barriers include stigma and limited access.
Stigma: Servicemembers are affected by three types of stigma:
Public stigma: The notion that a veteran would be
perceived as weak, treated differently, or blamed for their problem if
he or she sought help.
Self Stigma: The individual may feel weak, ashamed and
embarrassed.
Structural Stigma: Many servicemembers believe their
military careers will suffer if they seek psychological services.
Although the level of fear may be out of proportion to the risk, the
military has institutional policies and practices that restrict
opportunities for servicemembers who reveal that they have a
psychological health issue by seeking mental health services.
Limited Access: Even when servicemembers or veterans decide to seek
care, they need to find the ``right'' provider at the ``right'' time.
Long waiting lists, lack of information about where to find treatment,
long distances to providers, and limited clinic hours create barriers
to getting care. When care is not readily available, the ``window of
opportunity'' may be lost.
Culturally diverse populations and women face additional barriers.
Despite high rates of PTSD, African American, Latino, Asian, and Native
American veterans are less likely to use mental health services. This
is due, in part, to increased stigma, absence of culturally competent
mental health providers, and lack of linguistically accessible
information for family members with limited English proficiency who are
providing support for the veteran. Women have an increased risk of PTSD
because of the prevalence of Military Sexual Trauma.
Family and Peer Support: Family support is a key component to the
veteran's recovery. However, because of the stress of providing care,
the veteran's PTSD puts the family at increased risk of developing
mental health issues as well. The current system provides inadequate
support for the family in its caregiving role and inadequate access to
mental health services that directly address the psychological well-
being of the spouse, children, or parents.
Support from peers who have shared a similar experience is also
important. Peers can provide information, offer support and
encouragement, provide assistance with skill building, and provide a
social network to lessen isolation. Peer support may come in the form
of naturally occurring mutual support groups; consumer-run services;
formal peer counseling services. In addition, consumers need to be
involved in the development and deployment of services for patients
with PTSD and TBI.
Recommendations and Conclusion
The wars in Iraq and Afghanistan are resulting in injuries that are
currently disabling for many, and potentially disabling for still more.
They are also putting unprecedented strain on families and
relationships, which can contribute to the severity of the
servicemember's disability over the course of time. NCD concurs with
the recommendations of previous Commissions, Task Forces and national
organizations that:
1. A comprehensive continuum of care for mental disorders, including
PTSD, and for TBI should be readily accessible by all servicemembers
and veterans. This
requires adequate staffing and adequate funding of VA and DoD health sys
tems.
2. Mechanisms for screening servicemembers for PTSD and TBI should be
continuously improved to include baseline testing for all
servicemembers pre-deployment and followup testing for individuals that
are placed in situations where head trauma may occur.
3. The current array of mental health and substance abuse services
covered by TRICARE should be expanded and brought in line with other
similar health plans.
It is particularly critical that prevention and early intervention
services be robust. Effective early intervention can limit the degree
of long term disability and is to the benefit of the servicemember or
veteran, his or her family and society. Therefore, NCD recommends that:
4. Early intervention services such as marital relationship
counseling and short term interventions for early hazardous use of
alcohol and other substances should be strengthened and universally
accessible in VA and TRICARE.
Consumers play a critical role in improving the rehabilitation
process. There are many opportunities for consumers to enhance the
services offered to servicemembers and veterans and their families. NCD
recommends that:
5. DoD and VA should maximize the use of OIF/OEF veterans in
rehabilitative roles for which they are qualified including as outreach
workers, peer counselors and as members of the professional staff.
6. Consumers should be integrally involved in the development and
dissemination of training materials for professionals working with OIF/
OEF veterans and servicemembers.
7. Current and potential users of VA, TRICARE and other DoD mental
health and TBI services should be periodically surveyed by a competent
independent body to assess their perceptions of: a) the barriers to
receiving care, including distance, cost, stigma, and availability of
information about services offered; and b) the quality, appropriateness
to their presenting problems and user-friendliness of the services
offered.
8. VA should mandate that an active mental health consumer council be
established at every VA medical center, rather than have this be a
local option as is currently the case.
9. Congress should mandate a Secretarial level VA Mental Health
Advisory Committee and a Secretarial level TBI Advisory Committee with
strong representation from consumers and veterans organizations, with a
mandate to evaluate and critique VA's efforts to upgrade mental health
and TBI services and report their findings to both the Secretary of
Veterans Affairs and Congress.
DoD and VA have initiated a number of improvements, but as noted by
earlier Commissions and Task Forces, gaps continue to exist.
It is imperative that these gaps be filled in a timely manner.
Early intervention and treatment is critical to the long-term
adjustment and recovery of servicemembers and veterans with PTSD and
TBI. NCD recommends that:
10. Congress and the agencies responsible for the care of OEF/OIF
veterans must redouble the sense of urgency to develop and deploy a
complete array of prevention, early intervention and rehabilitation
services to meet their needs now.
As this report indicates, the medical and scientific knowledge
needed to comprehensively address PTSD and TBI is incomplete. However,
many evidence-based practices do exist. Unfortunately, servicemembers
and veterans face a number of barriers in accessing these practices
including stigma; inadequate information; insufficient services to
support families; limited access to available services, and a shortage
of services in some areas. Many studies and commissions have presented
detailed recommendations to address these needs. There is an urgent
need to implement these recommendations.
Statement of Paul Sullivan, Executive Director, Veterans for Common Sense
Veterans for Common Sense (VCS) thanks Subcommittee Chairman John
Hall, Ranking Member Doug Lamborn, and Members of the Subcommittee for
allowing us to submit a written statement for the record about today's
hearing on ``The Nexus Between Engaged in Combat with the Enemy and
Post-Traumatic Stress Disorder in an Era of Changing Warfare Tactics.''
VCS applauds your attention to the issue of post traumatic stress
disorder (PTSD) among deployed veterans. Left untreated, PTSD is a
significant factor that increases the risk of broken homes,
unemployment, drug and alcohol abuse, crime, homelessness, and suicide.
According to the Institute of Medicine (IOM), deployment is associated
with increased risk of PTSD, suicide, and other significant health
problems.
In order to mitigate the long-term adverse consequences of PTSD,
VCS advocates improving the quality and timeliness of how the
Department of Veterans Affairs (VA) processes PTSD disability
compensation benefit claims.
The situation is most acute for the 1.83 million U.S.
servicemembers deployed to the Iraq and Afghanistan wars, especially
since nearly 40 percent have deployed to combat twice or more.\1\
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\1\ Department of Defense, ``Contingency Tracking System,'' through
Oct. 31, 2008.
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We are disappointed VA failed to take advantage of five
opportunities to address this issue since 2007. Less than 2 years ago,
VA ignored an important PTSD disability claim ruling, Castle v.
Mansfield. In 2008, VA ignored the IOM report linking PTSD to
deployment to a war zone. The same year, VA ignored the growing
disability backlog and the escalating surge of PTSD claims filed by
Iraq and Afghanistan war veterans. In 2009, VA ignored a request by VCS
to issue new regulations to streamline the adjudication of PTSD claims.
In light of VA's intentional inaction on this issue, VCS strongly
urges Congress to quickly pass H.R. 952, the ``COMBAT PTSD Act,''
introduced by Chairman Hall last month.
VA Ignored Three Important Cases: Daye, Suozzi, and Pentecost
VA missed an important opportunity to streamline PTSD claims after
the United States Court of Appeals for Veterans Claims (``the Court'')
issued its recent decision in the case of Daye v. Nicholson 20 Vet.
App. 512 (2006) concerning the amount of evidence needed for a veteran
to corroborate a stressor occurred. The Court held that:
When a claim for PTSD is based on a noncombat stressor, `the
noncombat veteran's testimony alone is insufficient proof of a
stressor.' Corroboration does not require, however, `that there
be corroboration of every detail including the appellant's
personal participation in the [activity].'
The Daye decision relied upon two prior decisions by the Court:
Souzzi v. Brown 10 Vet. App. 307 (1997), and Pentecost v. Principi 16
Vet. App. 124 (2002). Clearly, a veteran does not need to ``verify''
personal involvement in a stressful event. The veteran need only
provide corroborating evidence they were deployed in the war zone along
with credible evidence of an event.
Yet, even though the Court has provided clear guidance as to how VA
should assess in-service stressor-related evidence submitted in support
of PTSD claims, VA consistently fails to develop and adjudicate these
claims correctly.\2\
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\2\ VA, ``No Across-the-Board Review of PTSD Cases--Secretary
Nicholson,'' press release quoting then Secretary James Nicholson, Nov.
11, 2005. http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1042.
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These three Court decisions are equally important because the
military does not document every combat incident, especially the deaths
of civilians.
In 2004, a landmark Army study confirmed nearly universal
involvement in combat among U.S. servicemembers deployed to Iraq and
Afghanistan. In one critical finding, the study found that nearly all
Marines and soldiers deployed to Iraq reported they were ``attacked or
ambushed.'' \3\
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\3\ Hoge, Charles, et. al., ``Combat Duty in Iraq and Afghanistan,
Mental Health Problems, and Barriers to Care,'' New England Journal of
Medicine, 2004. http://content.nejm.org/cgi/content/full/351/1/13.
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This table prepared by Army Colonel Charles Hoge demonstrates the
need for the VA to make a whole-sale change in its mindset; that is,
simply because a veteran's service records do not include notations of
combat, it does not mean they were not exposed to combat-related events
or incidents, and the stresses to those incidents.
Too often, the VA is quick to assume that when a veteran's service
record is void of combat notations, their PTSD-related claim for VA
benefits is fraudulent or not valid.
Table 1. Combat Experiences Reported by Members of the U.S. Army and Marine Corps after Deployment to Iraq or
Afghanistan *
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Marine Groups
Army Groups
-----------------------------------------------
----------------------------------------------------------------------------------------------------------------
Afghanistan
(N=1062) Iraq (N=894) Iraq (N=815)
-------------------------------------------------
Experience number/total number (percent)
----------------------------------------------------------------------------------------------------------------
Being attacked or ambushed 1139/1961 (58) 798/883 (89) 764/805 (95)
----------------------------------------------------------------------------------------------------------------
Receiving incoming artillery, rocket, or
mortar fire 1648/1960 (84) 753/872 (86) 740/802 (92)
----------------------------------------------------------------------------------------------------------------
Being shot at or receiving small-arms fire 1302/1962 (66) 826/886 (93) 779/802 (97)
----------------------------------------------------------------------------------------------------------------
Shooting or directing fire at the enemy 534/1961 (27) 672/879 (77) 692/800 (87)
----------------------------------------------------------------------------------------------------------------
Being responsible for the death of an enemy
combatant 229/1961 (12) 414/871 (48) 511/789 (65)
----------------------------------------------------------------------------------------------------------------
Being responsible for the death of a
noncombatant 17/1961 (1) 116/861 (14) 219/794 (28)
----------------------------------------------------------------------------------------------------------------
Seeing dead bodies or human remains 771/1958 (39) 832/879 (95) 759/805 (94)
----------------------------------------------------------------------------------------------------------------
Handling or uncovering human remains 229/1961 (12) 443/881 (50) 445/800 (57)
----------------------------------------------------------------------------------------------------------------
Seeing dead or seriously injured or killed 591/1961 (30) 572/882 (65) 604/803 (83)
----------------------------------------------------------------------------------------------------------------
Knowing someone seriously injured or killed 850/1962 (43) 751/878 (86) 693/797 (87)
----------------------------------------------------------------------------------------------------------------
Participating in demining operations 314/1962 (16) 329/867 (38) 270/787 (34)
----------------------------------------------------------------------------------------------------------------
Seeing ill or injured women or children
whom you were unable to help 907/1961 (5) 604/878 (69) 665/805 (83)
----------------------------------------------------------------------------------------------------------------
Being wounded or injured 90/1961 (5) 119/870 (14) 75/803 (9)
----------------------------------------------------------------------------------------------------------------
Had a close call, was shot or hit, but
protective gear saved you -- 67/870 (8) 77/805 (10)
----------------------------------------------------------------------------------------------------------------
Had a buddy shot or hit who was near you -- 192/880 (22) 208/797 (26)
----------------------------------------------------------------------------------------------------------------
Clearing or searching homes or building 1108/1961 (57) 705/884 (80) 695/805 (86)
----------------------------------------------------------------------------------------------------------------
Engaging in hand-to-hand combat 51/1961 (3) 189/876 (22) 75/800 (9)
----------------------------------------------------------------------------------------------------------------
Saved the life of a soldier or civilian 125/1961 (6) 183/859 (21) 150/789 (19)
----------------------------------------------------------------------------------------------------------------
* Data exclude missing values, because not all respondents answered every question. Combat experiences are
worded as in the survey.
The question was not included in the survey.
VA Ignored 2008 IOM Study Linking Deployment to PTSD and Suicide
VA missed their second opportunity to issue new regulations
streamlining PTSD claims when an IOM review of peer-reviewed scientific
research concluded that PTSD and suicide are associated with deployment
to a war zone:
The epidemiologic literature on deployed vs. nondeployed
veterans yielded sufficient evidence of an association between
deployment to a war zone and psychiatric disorders, including
post traumatic stress disorder (PTSD), other anxiety disorders,
and depression; alcohol abuse; accidental death and suicide in
the first few years after return from deployment; and marital
and family conflict, including interpersonal violence (emphasis
added).\4\
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\4\ IOM, Gulf War and Health: Volume 6. Physiologic, Psychologic,
and Psychosocial Effects of Deployment-Related Stress, 2008, page 319,
http://www.nap.edu/catalog.php?record_id=11922.
Similarly, VA ignored two prior IOM reports on PTSD. In 2006, IOM
validated the diagnosis of PTSD and listed war zone exposures not
---------------------------------------------------------------------------
directly associated with combat:
A war environment is rife with opportunities for exposure to
traumatic events of many types. Types of traumatic stressors
related to war include serving in dangerous military roles,
such as driving a truck at risk for encountering roadside
bombs, patrolling the streets, and searching homes for enemy
combatants, suicide attacks, sexual assaults or severe sexual
harassment, physical assault, duties involving graves
registration, accidents causing serious injuries or death,
friendly fire, serving in medical units, killing or injuring
someone, seeing someone being killed, injured, or tortured, and
being taken hostage.\5\
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\5\ IOM, Subcommittee on Post-Traumatic Stress Disorder of the
Committee on Gulf War and Health: Physiologic, Psychologic, and
Psychosocial Effects of Deployment-Related Stress, ``Post-Traumatic
Stress Disorder: Diagnosis and Assessment'' 2006, http://www.nap.edu/
catalog/11674.html.
In 2007, a third IOM report addressed VA's concerns regarding the
steep increase in disability payments made to veterans service-
connected for PTSD. During the period from 1999 to 2004, the amount of
money VA paid rose from $1.72 billion to $4.28 billion.\6\ To explain
the rise in PTSD benefit payments, the IOM concluded that:
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\6\ IOM, ``PTSD Compensation and Military Service'' 2007, http://
www.nap.edu/catalog.php? record_id=11870.
PTSD can develop at any time after exposure to a traumatic
stressor. The scientific literature does not identify any
differences material to the consideration of compensation
between delayed-onset or delayed-identification cases and those
chronic PTSD cases where there is a shorter time interval
between the stressor and the recognition of symptoms.\7\
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\7\ Ibid.
VA leaders could and should have promptly issued regulations to
streamline PTSD claims based on the best available current scientific
literature, including three separate IOM reports.
VA Ignored Growing Disability Claims Backlog, Now Nearly 900,000
VA missed their third opportunity to issue improved PTSD
regulations when the claim backlog ballooned over the past few years.
The disability claims backlog has soared, from just over 600,000 in
January 2004 to nearly 900,000 in March 2009.\8\
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\8\ VA, ``Monday Morning Workload Report,'' Mar. 14, 2009,
indicates 697,000 claims of all types pending at VA regional offices
plus another 190,000 claims pending at VA's Board of Veterans Appeals.
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VA's current claims backlog nightmare includes more than 60,000
pending claims from Iraq and Afghanistan war veterans for any type of
medical condition. To date, more than 370,000 Iraq and Afghanistan war
veterans have filed a disability claim against VA for any type of
condition, overwhelming evidence that the two current wars are creating
a sustained and significant hardship on VA's already broken claims
system.\9\
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\9\ VA, ``VA Benefits Activity: Veterans Deployed to the Global War
on Terror,'' Mar. 2009.
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VA could and should have issued new regulations to expedite PTSD
claims in order to break the bottleneck of 900,000 claims awaiting
adjudication.
VA Ignored PTSD Claims Filed by Iraq and Afghanistan War Veterans
VA missed their fourth opportunity for new regulations when the
Department learned that only half of the Iraq and Afghanistan war
veterans diagnosed with PTSD received PTSD disability compensation
benefits from VA.
According to the most recent VA reports obtained exclusively by VCS
using the Freedom of Information Act (FOIA), more than 105,000 Iraq and
Afghanistan war veterans were diagnosed by VA with PTSD.\10\ However,
only 51,000 Iraq and Afghanistan war veterans were granted disability
benefits by VA for PTSD.\11\
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\10\ VA Facility Specific OIF/OEF Veterans Coded with Potential
PTSD, 4th Qt FY 2008, Dec. 23, 2008.
\11\ VA, ``VA Benefits Activity: Veterans Deployed to the Global
War on Terror,'' Mar. 2009.
---------------------------------------------------------------------------
More than 338,000 Iraq and Afghanistan war veterans are at risk of
developing PTSD. According to a 2008 report by RAND, 18.5 percent of
the 1.83 million servicemembers deployed to the Iraq and Afghanistan
war zones are expected to return home and develop PTSD.\12\
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\12\ RAND, ``Invisible Wounds: Mental Health and Cognitive Care
Needs of America's Returning Veterans,'' Apr. 17, 2008.
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PTSD among deployed veterans may be further exacerbated by the high
rates of military sexual trauma (MST) among Iraq and Afghanistan war
veterans.\13\
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\13\ Blumenthal, Les, ``VA Struggles to Gear Up to Care for Female
Veterans,'' McClatchy News, May 18, 2009, http://www.mcclatchydc.com/
reports/veterans/story/37409.html.
---------------------------------------------------------------------------
According to VA's National Center for PTSD, MST is a very serious
problem among both female and male Iraq and Afghanistan war veterans:
Among [Iraq and Afghanistan war] veterans, nearly one in
seven women, about 15 percent, who accessed care through VA
screened positive for MST and 0.7 percent of males also
reported having experienced MST. Both males and female [Iraq
and Afghanistan war] veterans who reported a history of MST
also were more likely to be diagnosed with a mental health
condition than patients who did not report an experience of MST
in their history.\14\
---------------------------------------------------------------------------
\14\ VA, National Center for PTSD, Fact Sheet, ``Female OIF/OEF
Veterans Report Military Sexual Trauma--Associated with Higher Rates of
Mental Health Problems--October 2008.''
Based on VA's estimate of 15 percent, more than 30,000 of our
female servicemembers experienced MST while deployed to the Iraq and
Afghanistan wars. Similarly, based on an estimate of 0.7 percent, more
than 11,000 of our male servicemembers experienced MST while deployed
to the two current wars. The grand total could be as high as 41,000 MST
cases from the Iraq and Afghanistan war zones.
VA could and should have issued new rules based on the tidal wave
of Iraq and Afghanistan war veterans diagnosed by VA with PTSD who are
filing disability claims against VA for PTSD, including those who
experienced MST while deployed to war.
VA Rejected VCS Request for Streamlined PTSD Regulations
VA missed their fifth opportunity to write new PTSD regulations
when VCS wrote a letter to VA requesting the Department use their rule-
making authority to address the growing crisis.
On January 26, 2009, VCS wrote VA Secretary Eric Shinseki asking VA
to issue streamlined PTSD regulations based on the IOM report and the
failure of VA to approve PTSD claims filed by Iraq and Afghanistan war
veterans.
The rule change VCS sought was simple and straightforward: we
clearly demonstrated how science supported the rule and how veterans
are being harmed by on-going VA failures. VCS provides a copy of our
letter to VA for the Subcommittee's records.
On February 27, 2009, VA's Chief of Staff, John Gingrich, wrote to
VCS and rejected our request for streamlined PTSD claim regulation.
Tragically and inexplicably, VA ignored the overwhelming scientific
evidence, ignored the growing claims backlog, and ignored the pressing
needs of our Iraq and Afghanistan war veterans. VCS provides a copy of
VA's incomprehensible and outrageous rejection letter for your records.
VA could and should have issued new rules based on our letter and
the new scientific evidence.
VA Confirmed PTSD Claim Fraud is Not a Problem
During 2005, as the number of PTSD claims filed by veterans
continued to increase, VA leaders tasked VA's Office of the Inspector
General to review PTSD claims that were already approved. According to
a VA statement issued in 2005:
The problems with these files appear to be administrative in
nature, such as missing documents, and not fraud. . . . In the
absence of evidence of fraud, we're not going to put our
veterans through the anxiety of a widespread review of their
[approved PTSD] disability claims. . . . Instead, we're going
to improve our training for VA personnel who handle disability
claims and toughen administrative oversight.\15\
---------------------------------------------------------------------------
\15\ VA, ``No Across-the-Board Review of PTSD Cases--Secretary
Nicholson,'' press release quoting then Secretary James Nicholson, Nov.
11, 2005. http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1042.
VA confirmed fraud is not a problem. Rather, poor documentation,
poor training, and poor administrative oversight by VA were the actual
culprits. VA could and should have instituted better documentation,
better training, and better administrative oversight.
VA Should Launch Campaign to De-Stigmatize PTSD
VA, Congress, and veterans groups should do more to end
discrimination against veterans with mental health conditions. In our
view, passage of H.R. 952 may further assist veterans by reducing the
stigma that two medical research studies found often prevents veterans
from seeking medical care.\16\
---------------------------------------------------------------------------
\16\ RAND, ``Invisible Wounds: Mental Health and Cognitive Care
Needs of America's Returning Veterans,'' Apr. 17, 2008; Hoge, Charles,
et al., ``Combat Duty in Iraq and Afghanistan, Mental Health Problems,
and Barriers to Care,'' New England Journal of Medicine, 2004.
---------------------------------------------------------------------------
VCS encourages veterans with mental health conditions to reach out
to VA for assistance. We also urge VA to be ready, willing, and able to
assist veterans by providing both prompt mental health care and
disability benefits when veterans seek help--especially for PTSD.
Urgent Unmet Need: Congress Should Act Now to Assist Veterans
The scientific evidence is overwhelming: engaging in combat with
the enemy can and does cause PTSD among some veterans. In addition, the
scientific evidence concludes that deployment itself, without combat,
is also linked to PTSD and suicide. Due to VA's cumbersome, complex,
and adversarial rules for veterans diagnosed with PTSD to prove the
existence of a combat stressor incident, VA takes longer than 6 months
to process PTSD claims. As a result, VA's claim system becomes further
mired in a growing backlog of benefit requests.
VCS believes a fair and reasonable way to resolve this situation,
keeping with VA's stated objective of putting veterans first, would be
to define combat under the law (38 USC Sec. 1154) as deployment to any
nation or body of water declared a war zone by the Department of
Defense. Deployment itself, not combat with the enemy, should be
considered the stressor for PTSD claims, as the IOM study concluded.
In an effort to resolve VA's claim crisis, VCS urges Congress to
pass H.R. 952 as soon as possible because of VA's continued adversarial
policies against veterans and because VA has utterly failed to address
the PTSD claim disaster. VA's crisis is expected to worsen
significantly as the two current wars continue and multiple deployments
increase.\17\ Based on VA's health care use reports indicating 10,000
new, first-time Iraq and Afghanistan war veterans flooding into VA each
month, VCS estimates VA may diagnose and treat total of 450,000 mental
health patients by the end of 2013, including as many as 250,000
diagnosed with PTSD.
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\17\ Tyson, Ann Scott, ``Repeat Tours Raise Risk of PTSD, Army
Finds,'' Washington Post, Dec. 20, 2006, http://www.washingtonpost.com/
wp-dyn/content/article/2006/12/19/AR2006121901659. html.
---------------------------------------------------------------------------
Now is the time to fix the problem of unreasonable claim delays for
veterans with PTSD so they can receive the disability benefits needed
and earned in a timely manner. With a new law, VA should be able to
quickly approve tens of thousands of PTSD claims filed by Iraq and
Afghanistan war veterans that remain mired in VA red tape. Veterans of
other conflicts may also find justice with the passage of H.R. 952.
VA should and could be putting disability benefits into the hands
of deserving veterans during the current economic crisis when their
need is most acute. A timely and proper adjudication of claims may make
the difference between staying in a home or living on the streets for
veterans, especially veterans deployed to a war zone with PTSD.
Although enactment of H.R. 952 may cost billions of dollars in the
short-term, these are entitlement payments VA will eventually pay to
veterans and survivors. This is true because VA confirms fraudulent
claims are nearly non-existent. VA may actually realize a cost savings
and improved efficiency when VA employees now working on complex and
time-consuming PTSD claims are freed up to process other disability
compensation claims of equally deserving veterans.
MATERIAL SUBMITTED FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
April 7, 2009
Ian De Planque
Assistant Director, Veterans Affairs and Rehabilitation Commission
The American Legion
1608 K Street, NW
Washington, DC 20006
Dear Mr. De Planque:
Thank you for testifying at the House Committee on Veterans'
Affairs' Subcom-
mittee on Disability Assistance and Memorial Affairs hearing on
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly
appreciate if you would provide answers to the enclosed followup
hearing questions by Monday, May 4, 2009.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for material for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your responses
to Ms. Megan Williams by fax at (202) 225-2034. If you have any
questions, please call (202) 225-3608.
Sincerely,
John J. Hall
Chairman
__________
The American Legion
Washington, DC.
May 4, 2009
Honorable John J. Hall, Chairman
Subcommittee on Disability Assistance and Memorial Affairs
Committee on Veterans' Affairs
U.S. House of Representatives
337 Cannon House Office Building
Washington, DC 20515
Dear Chairman Hall:
Thank you for allowing The American Legion to participate in the
Subcommittee hearing on March 24, 2009, entitled ``The Nexus between
Engaged in Combat with the Enemy and PTSD in an Era of Changing Warfare
Tactics.'' I respectfully submit the following response to your Post-
Hearing Question:
Question 1: What is the American Legion's position on the VA rule-
making process that promulgated regulations for defining combat?
Response:
a.
During the process of the implementation of the Congressional
action which resulted in the creation of 38 USC Sec. 1154 VA conducted
an examination to determine whether the phrasing used by Congress in
passage of the Bill was significant. What VA determined was that
Congress had, in other legislation, distinguished Combat Zone, but
here, in this legislation, specifically described ``combat with the
enemy,'' therefore indicating that the intent was there to
differentiate.
b.
The American Legion disagrees with this interpretation for a
number of reasons, not least of which is the profound recognition that
the conditions and expectations of warfare in 1941 were very different
than what soldiers in later conflicts would face.
c.
In 1941, with Europe and mainland Asia erupting into combat, but
no direct experience of U.S. servicemembers involved, the primary
experience of warfare to consider was World War I and the emerging
details of World War II. World War I, as any student of basic history
will be cognizant of, was marked by uniformed combatants, defined
trenches of battle lines, clearly drawn across the fields of Europe in
mud and barbed wire. Even in the emerging battlefields of World War II,
it would become clear that the distinction between lines of battle and
the rear echelons was widely apparent. Artillery fire did indeed bring
the fighting to some in the rear, but the vast majority of action seen
was by combat arms soldiers on the pointy front end of combat.
d.
Flash forward several years and we began to see changes. Vietnam
was marked by stealthy guerilla warfare ``behind the lines'' as well as
what would be considered today terrorist bombings on the streets of
Saigon. Remote forward operating bases sometimes required
servicemembers to take up arms in activities not normally considered
part of their military specialty. When the numbers of Infantrymen grow
short, you must still defend your perimeter utilizing clerks, cooks,
whoever can hold a rifle and remember their Basic Training.
e.
As we watch the events of the modern warfare conducted by the
United States and its allies in the Global War on Terror, nobody can
doubt that the expectations and face of the battlefield have
substantially changed over the last 70 years. Regularly stories are
shown of supply clerks, of mechanics, or communications specialists and
other servicemembers not traditionally thought of as combat soldiers
engaging in activity against the enemies. We see IEDs detonated in the
streets as a commonplace event. We see journalists cringe from incoming
rocket fire, and Members of Congress and the USO wearing protective
vests and helmets as they visit troops even in locations in the heart
of the so called ``Green Zone'' of safety in Iraq or at Bagram Air Base
in Afghanistan. We know that the danger is all around the brave men and
women who fight for this country.
f.
The American Legion believes strongly that the legislative intent
of section 1154 (b) is to recognize the difficulties inherent in record
keeping in combat, and to provide a means to assist the men and women
of this country in proving the occurrence of events under these
difficult conditions. What we have seen time and time again in the
advocacy for veterans is that the very same conditions which make the
proving of individual events difficult further make the proving of an
individual's participation in the combat a great difficulty. Yet we
know these servicemembers face these conditions day in and day out.
Therefore it is the belief of The American Legion that the legislative
intent, which must be recognized, or amended to specifically state
such, is to recognize the word of these servicemembers under combat
conditions to be true and honorable as long as they are consistent with
the conditions and hardships of battle in the combat zone.
Question 2: What would you suggest be the standard for combat related
stressors and who should make that determination?
Response:
a.
This could potentially be seen as two questions. Decisions
revolving around the adequacy of stressors to trigger PTSD are
specifically stated in the Diagnostic and Statistical Manual of Mental
Disorders (4th Edition, 1994. The 5th Edition is current under revision
for estimated distribution in 2012). A medical opinion is necessary to
determine the adequacy of a stressor event in triggering PTSD.
Therefore, the determination as to whether a combat event ``meets the
standard'' for PTSD in terms of severity of experience should be made
by a medical expert.
b.
If however, this question is interpreted to mean-what is the
standard for determining if an incident is combat related and should
fall under the criteria of 38 USC Sec. 1154 with regard to confirmation
of the occurrence of the event through lay testimony alone, then one
must examine the standard already existing to measure if claimed events
described by a servicemember are acceptable under 1154 where combat has
been confirmed.
i.
Such actions as are consistent with the circumstances,
conditions or hardships of combat.
c.
It is the position of The American Legion that the interpretation
of 1154(b) should be recognized for all soldiers serving in a combat
zone (to be adequately determined by conference with the Secretaries of
Defense and of the Department of Veterans Affairs) when describing the
occurrence of events ``consistent with the conditions and hardships of
combat.'' This provision was meant to reduce the heavy burden of proof
required in recognition of the exigencies of record keeping on the
battlefield. It is the position of The American Legion that the
dispersed nature of the modern non-linear battlefield has rendered the
battlefield less clear, and thus a more broad net must be cast to
capture the conditions the provision was intended to remedy.
Question 3: In your testimony, you stated that VA overdevelops claims.
Can you explain this contention further and give examples of how this
occurs?
Response:
a.
VA is often presented with evidence, anecdotal or non-traditional
in the sense of concrete military records, which would tend to confirm
the veteran's statements and allow them to move on with their
adjudication. However, they continue to ignore this information and
continually send out for records which may or may not even exist,
further lengthening the process through exhaustive record searches.
b.
Furthermore, VA tends to get locked in on proving ``combat'' and
overlook that they may have already proved the existence of an event
specific to the veteran. Once they determine that a veteran was in a
convoy they then have to go back to the beginning of the process and
start tracking the events of the convoy. They continue to find more and
more questions that need to be answered as each new piece of evidence
is uncovered.
c.
When VA discovers each new piece of evidence, they must then
contact the veteran, let the veteran know they are in receipt of such
evidence, and then seek to confirm the next piece in the puzzle rather
than taking a holistic approach which could drastically simplify
things.
d.
A veteran could be sent for an exam in which the doctor confirms
the veteran has PTSD and links it to the experiences described by the
veteran. VA denies this claim because they don't find evidence of the
stressor. Later, through Herculean efforts the veteran manages to prove
that not only were they stationed at a firebase in the middle of the
heart of the Tet Offensive. However, VA determines that they must still
confirm that this firebase . . . in the heart of the fighting of the
Tet Offensive, actually took fire. Eventually this is proven. Now VA
decides to send the veteran BACK for another examination because ``now
they can confirm the incident.'' This is obviously a needlessly lengthy
and convoluted process for something that should be conducted more
smoothly.
e.
Something further to consider, which could greatly reduce the
number of bounce back examinations described above, would be to either
wait to conduct the examinations until the events are proven, or to
direct the examining physicians to assume for the purposes of the
examination, that all statements regarding stressors or incidents
described by the veteran are true when considering their diagnosis.
i.
In the second part of the above example, if VA finds clear and
convincing evidence later that the events did not occur, then that
knowledge could be applied to assess the validity of the diagnosis.
However, should VA determine that the events described occurred, they
would be in possession of enough evidence to grant the claim and reduce
the backlog by not keeping claims around needlessly in endless
development.
Question 4: When The American Legion conducts its quality reviews with
NVLSP, does it evaluate the accuracy and completeness of PTSD C&P
examinations being used by the adjudicators? What issues, if any, has
the organization been able to identify during these site visits
regarding PTSD claims?
Response:
a.
In conducting the quality reviews, The American Legion and NVLSP
review all aspects of accuracy in the claims processed through the
Regional Offices (RO's). A common theme throughout many RO's is the
inadequacy of the exams being conducted. One of the most consistent
problems noted in PTSD exams is that examiners are being asked to
examine the veterans without evidence of a stressor event--leading them
to state they cannot confirm a diagnosis without a confirmed stressor.
Also, very often medical examiners will review the medical aspects of a
claims file, but not the personnel portions of the file from the
military record. In some cases, subsequent exams when an advocate has
directed the examiner to note the patterns of behavior before and after
the claimed stressors (for a servicemember with exemplary service
before a stressor event and extremely derelict service afterwards) the
examiner will note that the changes in behavior are consistent with the
behavioral changes associated with PTSD type disorders.
b.
However, it is also important to point out that many types of
examinations are inadequately performed at the RO level, and end up
being remanded by the Board of Veterans' Appeals (BVA) for the
performance of an adequate examination. Although it is beyond the PTSD
oriented purview of this question, an overall effort to get the
examinations right the first time would go a long way to reducing the
backlog by removing a lot of the cases clogging the system that could
be removed from consideration if they were adjudicated properly the
first time.
Question 5: In PTSD cases where the veteran does not have the required
medals or awards, what does a service officer do to develop the claim?
Response:
a.
To assist a veteran in developing claims of this nature, service
officers will try to seek some additional types of information which
may confirm the claimed stressor or incident in service.
i.
By combing the veteran's military files, hopefully the
personnel records can confirm which units the veteran was assigned to
for which dates. Then, sometimes, unit records can be obtained which
would help establish events for non-combat servicemembers such as
mechanics or other non-Infantry soldiers who may not have decorations
indicating combat.
ii.
In the above examples, advocates often will try to track down
information from independent research regarding which units were
stationed where (which firebases in Vietnam for example) and then see
if they can establish any incidents which affected the LOCATION. If a
unit can be placed at a location when an incident occurred, the veteran
is assumed, in the absence of clear evidence to the contrary, to have
been present with their unit.
iii.
Also, sometimes a search of back issues of hometown or
national newspapers document the occurrence of some of these issues.
These newspaper articles would require a good deal of research to track
down.
iv.
By asking the veterans to try to dig up old photos and old
letters home which could confirm any of the claimed events. Sometimes,
such as in the case of communications soldiers who are seconded out to
other units to provide support in the field, a diligent service officer
can associate the veteran with a unit they were temporarily assigned to
by identifying the unit patches on soldiers in a photograph. Keep in
mind such activities are very time consuming and difficult.
v.
As a last resort, the veteran can submit their own lay
testimony, which VA is usually reluctant to accept, and/or the
testimony of other witnesses who were present for the events described.
This is a lesser course of action because 1) it can be difficult to
find old members of the unit, especially after many, many years; and 2)
VA must ``weigh'' the lay testimony against the balance of the case and
generally does not accept it if there is no independent military
records confirming the lay testimony.
Question 6: In the experiences of The American Legion Service Officers,
does VA accept the lay statement of a veteran when he/she has not
already met the criteria in 38 USC Sec. 1154(b) by establishing that
they had engaged in combat with the enemy? Or, does the veteran have to
first prove combat before VA uses the lay statement to identify the
specific stressor?
Response:
a.
Although this is largely anecdotal and we have no exact figures
on this, the overwhelmingly prevalent situation is that without proving
combat, the VA is very reluctant to accept lay evidence to confirm a
stressor. This occurs even in situations when a veteran has presented
stressor descriptions in detail relating stressor events which mirror
those expressed by the veteran as a part of an examination by a
psychiatrist. Even in cases where the psychiatrist clearly diagnoses
PTSD and relates it to a described stressor by the veteran, unless the
veteran can provide military records to document a combat event, VA is
reluctant to acknowledge the stressor and grant the service connection
for PTSD.
b.
Sometimes a veteran will also supply supporting statements from
other veterans who served with them in their unit. Again, the VA
frequently does not accept these statements without independent
confirmation in military records, citing to their requirements to weigh
the validity of lay testimony.
c.
The one area where there has been some success is in situations
where the veteran may have a postmarked letter from the dates
described, say a 1968 letter to their parents from Vietnam, which
describes the circumstances claimed, and/or if the veteran can provide
verifying photographs as detailed above. There have been more successes
in establishing the credibility of this lay evidence, although even
this is not always foolproof.
d.
Ultimately, one of the largest difficulties in this area is that
recognition of these types of evidence is widely inconsistent between
not only Regional Office to Regional Office, but even Rater to Rater
within certain RP's.
Thank you for your continued commitment to America's veterans and
their families.
Sincerely,
Ian De Planque, Assistant Director
National Veterans Affairs and Rehabilitation
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
April 7, 2009
Thomas Berger, Ph.D.
Senior Analyst for Veterans' Benefits and Mental Health Issues
Vietnam Veterans of America
8605 Cameron Street, Suite 400
Silver Spring, MD 20910
Dear Mr. Berger:
Thank you for testifying at the House Committee on Veterans'
Affairs' Subcom-
mittee on Disability Assistance and Memorial Affairs hearing on
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly
appreciate if you would provide answers to the enclosed followup
hearing questions by Monday, May 4, 2009.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for material for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your responses
to Ms. Megan Williams by fax at (202) 225-2034. If you have any
questions, please call (202) 225-3608.
Sincerely,
John J. Hall
Chairman
__________
Questions from the House Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Hearing on ``The Nexus Between Engaged in Combat With the Enemy
and PTSD in an Era of Changing Warfare Tactics''
March 24, 2009
Question 1: In your testimony you cited the findings of the
National Vietnam Veterans Readjustment Study regarding PTSD in Vietnam
veterans. How can this study further inform Congress to better help
future generations of veterans while still meeting the needs of Vietnam
veterans who enter the VA disability claims processing system?
Response: The National Vietnam Veterans Readjustment Study (NVVRS)
is the largest nationwide psychiatric study of veterans ever conducted
to date. Results of the NVVRS demonstrated that some 15.2 percent of
all male and 8.5 percent of all female Vietnam theater veterans were
current PTSD cases (i.e., at some time during 6 months prior to
interview). Rates for those exposed to high levels of war zone stress
were dramatically higher (i.e., a fourfold difference for men and
sevenfold difference for women) than rates for those with low-moderate
stress exposure. Rates of lifetime prevalence of PTSD (i.e., at any
time in the past, including the previous 6 months) were 30.9 percent
among male and 26.9 among female Vietnam theater veterans. Comparisons
of current and lifetime prevalence rates indicate that 49.2 percent of
male and 31.6 percent of female theater veterans, who ever had PTSD,
still had it at the time of their interview. The NVVRS also found that
African American veterans and Latino veterans not only had a higher
rate of PTSD, but also were much less likely to seek assistance. Thus
the NVVRS was a landmark investigation in which a national random
sample of all Vietnam Theater and era veterans, who served between
August 1964 and May 1975, provided definitive information about the
prevalence and etiology of PTSD and other mental health readjustment
problems in comparison with a random sample of those who had never
served in the military. The study over-sampled African-Americans,
Latinos, as well as women, enabling conclusions to be drawn about each
subset of the veterans' population.
Subsequently in August 2006, the preeminent research journal,
Science, published a study by Dr. Bruce Dohrenwend and colleagues that
included a re-analysis of the NVVRS data. After application of a
particularly rigorous method for validating combat exposure was applied
to the data, their re-analysis concluded that nearly one out of every
five (18.7 percent) Vietnam veterans had experienced post-traumatic
stress disorder (PTSD) and that nearly one out every ten (9.1 percent)
Vietnam veterans was still suffering from chronic and disabling PTSD,
more than 10 years after the war had ended. In VVA's opinion, this
study only underscores our belief that the Congressionally mandated
NVVRS followup study be conducted so that there can truly be a
longitudinal study of Vietnam veterans that will be useful both for us
and for the veterans who follow us.
COMPARISONS WITH OTHER STUDIES
There are two other studies under consideration by the VA for
establishing prevalence rates, course, and physical health outcomes
associated with PTSD. The ``Vietnam Veteran Twin Registry'' was
assembled some 15 years ago to conduct behavioral genetics studies. The
goal was to determine if a wide range of psychological, neurological,
and behavioral conditions could be related to a common genetic pattern.
The Twin Registry was established by recruiting male-male twin pairs
using a wide variety of approaches to identifying the pairs. However,
VVA's concerns about this registry for establishing prevalence of PTSD
and related problems are:
The study is too simple to be substituted for the NVVRS.
Twins are inherently not representative of the population
who served in the war.
Recruitment strategies didn't focus on random selection
nor representativeness.
The registry doesn't include women; only male twins are
included.
The registry doesn't reflect the racial and ethnic
diversity of those who served in Vietnam. It is a registry that is
largely and disproportionately Caucasian.
The vast majority of the early work on the sample was
conducted through the mail with only recent studies employing state of
the art measurement of PTSD.
A second ongoing study that is supported by the VA is a risk and
resiliency study of Persian Gulf War 2 active duty military soldiers.
This ``Deployment Health Study'' by J. Vasterling and S. Proctor is
examining risk factors for health, mental health and cognitive
functioning prior to and at intervals following deployment. The samples
included in this study are also not representative of all military
serving in OIF-OEF as they were selected based upon the willingness of
commanders of several military bases to participate. The sample, thus,
isn't able to answer or address questions about prevalence of PTSD or
any condition among individuals in service in Afghanistan or Iraq. The
sampling again is very selective and may possess significant biases
from which erroneous conclusions could be drawn about the prevalence of
PTSD, its nature and its course. Obviously, this study tells us nothing
about the long-term course of PTSD in Vietnam veterans, nor the long-
term physical health implications of being afflicted with PTSD for
decades.
Through the initial NVVRS the American public and medical community
has become aware of the high rates of current and lifetime PTSD, and of
the long-term consequences of high stress war zone combat exposure,
enabling better policies and services available to military personnel
returning from deployments today. Because of its unique scope, the
NVVRS has had a large effect on VA and Department of Defense (DoD)
policies, and direct health care delivery and services planning.
Question 1(a): Does VVA have additional recommendations for
research to improve the disability claims process for veterans with
PTSD?
Response: Another noteworthy NVVRS finding was the unusually high
number of health problems reported by veterans who served in the
Vietnam theater of operations. This finding is consistent with a
steadily growing body of research evidence suggesting a link between
PTSD and physical health conditions, such as cardiovascular disorders,
for example, as well as related mental health problems such as chronic
depression. Therefore, in VVA's opinion, only completion of the NVVRS
followup could best establish the bases for any additional research
needed to improve the disability claims process for veterans suffering
with PTSD.
Question 2: What has been the impact to Vietnam veterans suffering
from PTSD who have been denied compensation?
Response: Generally the impact has been devastating, including for
some the risk of homelessness, substance abuse, unemployment, and
suicide. However, the most obvious impact is the loss of hope in
achieving any meaningful quality of life, followed closely by an ever-
increasing sense of abandonment by the nation they so proudly served.
Lastly, language for the NVVRS follow up has been included in the
past two Congressional budget proposals, but not acted upon. More
importantly, however, despite the law requiring it and the
recommendation of the Institute of Medicine of the National Academies
of Science in July 2007 that the VA move forward to complete the NVVRS
follow up study, the VA remains obdurate in its refusal to adhere to
the law and good sense, and complete the study as directed by the
Congress. Therefore, the need is for Congress to obtain accountability
from the VA in this matter, as VVA's presumption is that the current VA
Secretary will follow the letter of the law.
Thank you for the opportunity to provide this information, and
please let me know if there are any additional questions.
Thomas J. Berger, Ph.D.
Senior Analyst for Veterans' Benefits and Mental Health Issues
Vietnam Veterans of America
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
April 7, 2009
Carolyn Schapper
Member
Iraq and Afghanistan Veterans of America
308 Massachusetts Ave., NW
Washington, DC 20002
Dear Ms. Schapper:
Thank you for testifying at the House Committee on Veterans'
Affairs' Subcom-
mittee on Disability Assistance and Memorial Affairs hearing on
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly
appreciate if you would provide answers to the enclosed followup
hearing questions by Monday, May 4, 2009.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for material for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your responses
to Ms. Megan Williams by fax at (202) 225-2034. If you have any
questions, please call (202) 225-3608.
Sincerely,
John J. Hall
Chairman
__________
Answers to Additional Questions From the March 23rd Hearing on
``The Nexus Between Engaged in Combat With the Enemy and
PTSD in an Era of Changing Warfare Tactics''
Carolyn Schapper, IAVA Veteran Spokeswoman
Question 1: In your statement you noted that life in Iraq and
Afghanistan is combat. Can you describe other types of stressful events
besides rocket attacks, IED, or weapons fire that might also cause a
servicemember to develop PTSD?
Question 1(a): In the experiences of Iraq or Afghanistan veterans
would you say that a stressor might be one event or could it be
multiple events or hardships?
Response: In my statement I stated that some of my fellow female
servicemembers consider life in Iraq and Afghanistan as combat, and
this statement was to imply that life on a base, for even those who do
not leave, can be considered combat because of the constant threat of
mortars and rocket fire, which is a very real threat. I, personally,
did leave base and had exposure to IEDs and sniper-fire in addition to
mortars and rockets while on base. So, there is no way that I can
quantify what is real for people who did not have my experience.
Regarding whether it takes one incident or several incidents to
create a stressor significant enough to lead to PTSD it is
unfortunately not an easy answer. I have no doubt that a person that
was involved in one significant event that caused injury or death can
have PTSD. Again, I cannot answer for others and how they process their
experiences. Personally, I experienced seven significant events
involving vehicle damage and/or enemy contact within 100 yards, which
all factor into my PTSD. There is no way for me to remove myself from
six of these events to determine if one of them would have led to
adjustment issues.
Question 2: At the hearing on March 24, 2009, you urged a stronger
presence of women veterans' centers. How could these centers better
assist female veterans
file claims for PTSD when they have been in combat or experienced a sexu
al trauma?
Response: Women Veterans' Centers can assist female veterans
primarily through addressing comfort levels. It is not an
understatement that women who have been traumatized by combat or MST
can feel intimidated in relaying their experiences to males. We feel
like we will be judged in a more skeptical manner than our male
counterparts would be. Therefore, these centers would assist females
just through their very existence. If women knew they had the
opportunity to go to a VA center that routinely deals with females I
believe more women would be likely to seek help and counseling. This
would include having all-female PTSD groups.
Personally I feel very uncomfortable going to the VA because of the
predominance of males at the VA. I am the obvious ``other'' which leads
to uncomfortable looks and questions. If I knew there would be more
women seeking services at the VA I would not feel as uncomfortable
going there as I do now.
However, all this being said, I would like to point out that the VA
does have some very significant women's services, such as a state of
the art breast cancer research center. The VA has reached out to women
and the issues that affect them, but there is certainly more that can
be done to make women more willing to get the help they deserve.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
April 7, 2009
Dean G. Kilpatrick, Ph.D.
Member, Committee on Veterans' Compensation for
Posttraumatic Stress Disorder
Institute of Medicine
500 Fifth Street, NW
Washington, DC 20001
Dear Mr. Kilpatrick:
Thank you for testifying at the House Committee on Veterans'
Affairs' Subcom-
mittee on Disability Assistance and Memorial Affairs hearing on
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly
appreciate if you would provide answers to the enclosed follow-up
hearing questions by Monday, May 4, 2009.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for material for all full
committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your responses
to Ms. Megan Williams by fax at (202) 225-2034. If you have any
questions, please call (202) 225-3608.
Sincerely,
John J. Hall
Chairman
__________
Dr. Dean Kilpatrick's Response to Questions Posed by
The Honorable John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, House Committee on Veterans' Affairs
Pursuant to the Hearing on ``The Nexus Between Engaged in Combat With
the Enemy and PTSD in an Era of Changing Warfare Tactics''
March 24, 2009
Question 1: What does the IOM mean by a comprehensive, consistent
and rigorous PTSD evaluation process? Does VA have such a process?
Response: Our IOM committee (the Committee on Veterans'
Compensation for Post-Traumatic Stress Disorder) concluded the
following in its report PTSD Compensation and Military Service (IOM,
2006):
The most effective strategy for dealing with problems with
self-reports of traumatic exposure is to ensure that a
comprehensive, consistent, and rigorous process is used
throughout the VA to verify veteran-reported evidence. (p. 194)
The committee's report did not detail the elements of such a
process but did cite examples:
One approach to achieving this objective is routine and
consistent use of the full range and battery of methods
implemented and tested by Dohrenwend and colleagues (2006). The
best-practice manual for C&P examinations, written by VA
clinicians, already recognizes the value of careful and in-
depth review of records (Watson et al., 2002). (p. 174)
Although our committee did not recommend mandating use of the Best
Practice Manual, this manual offers guidelines for assessing traumatic
exposure that represent the type of comprehensive, consistent, and
rigorous evaluation process that the committee recommended.
Question 1(a): How well does VA use its own Best Practice Manual
for PTSD C&P Exams?
Response: Our committee did not conduct a systematic assessment of
the content of, nor of the average length of time taken to complete, VA
PTSD compensation and pension (C&P) examinations; and it did not
collect data on the frequency with which the procedures contained in
the Best Practice Manual (Watson et al., 2002) were used. However, it
did obtain anecdotal information on the process. Testimony presented to
the committee indicated that clinicians often feel pressured to
severely constrain the time that they devote to conducting a PTSD C&P
examination--to as little as 20 minutes (Arbisi, 2006)--even though the
examination protocol suggested in the Best Practice Manual requires up
to 3 hours to complete, with additional time needed for complex cases.
In my opinion, this information suggests that use of the Best
Practices Manual was not universal when the Committee conducted its
review. In fairness to the VA, it is possible that the agency may have
subsequently implemented some of the Committee's recommendations
concerning C&P exams, so the best way to answer this question would be
to ask the VA to provide current data.
Question 2: Is the VA's regulation requiring certain awards and
medals to document a stressor for PTSD consistent with the DSM-IV
criteria for the diagnosis?
Response: According to the DSM-IV criteria for the PTSD diagnosis,
a characteristic set of symptoms must develop following exposure to an
extreme traumatic stressor (APA, 2000). The text describing the types
of traumatic stressors that qualify includes events that are directly
experienced, witnessed, or learned about (IOM, 2006; p. 72). Many of
these traumatic stressors are relevant to and can occur during military
service (e.g., military combat; sexual assault; being kidnapped or
taken hostage; torture; incarceration as a prisoner of war or in a
concentration camp; severe motor vehicle accidents; observing serious
injuries or deaths of others due to assaults, accidents or war;
learning about serious injury or deaths of friends). Veterans who have
experienced some of these types of traumatic stressors might receive
awards or medals documenting their exposure, but it is unlikely that
exposure to many of these traumatic stressors would result in awards or
medals. In any case, the DSM-IV diagnostic criteria for PTSD do not
require having received an award, medal, or other independent
recognition of exposure to a traumatic stressor for that stressor to
count as a traumatic stressor.
The committee was not aware of an explicit VA regulation requiring
certain awards or medals to document a stressor. It was aware that VA
values such devices and other documentation found in military personnel
records--duty stations and assignments, military occupational
specialties (MOS), and related administrative information--because they
are perceived as unbiased evidence that can corroborate or refute
claimants' accounts. The committee noted and commented--on page 193 of
its report--on a student guide produced by the Veterans Benefits
Administration (VBA) for use in the training of examiners (VBA, 2005),
stating:
. . . a great deal of guidance is given on various service
medals and devices that can be used to support PTSD claims and
on how to use DoD resources to corroborate possible combat-
related traumatic exposures.
The Student Guide delineates a number of decorations that ``may
serve as evidence that the veteran engaged in combat'' but indicates
that the evaluation needed to support an assertion that a claimant
served in the area in which the incident stressful event is reported to
have occurred is to be ``made on an individual case basis following
analysis of all the evidence of record, particularly the veteran's
description of the events'' (p. 8).
As my testimony indicated, much of the research that the committee
examined calls into question whether the information available in the
military personnel files is always adequate to evaluate trauma exposure
and notes circumstances--notably, cases of military sexual assault--
where veterans are less likely to receive service connection for PTSD
as a consequence of the relative difficulty of substantiating exposure
to noncombat traumatic stressors.
The VA's disability examination workshop for an initial evaluation
of PTSD states that:
[s]ervice connection for post-traumatic stress disorder
(PTSD) requires medical evidence establishing a diagnosis of
the condition that conforms to the diagnostic criteria of DSM-
IV, credible supporting evidence that the claimed in-service
stressor actually occurred, and a link, established by medical
evidence, between current symptomatology and the claimed in-
service stressor (IOM, 2006; p. 224; quoting the workshop
contained at the following Web address: http://www.vba.va.gov/
bln/21/Benefits/exams/disexm 43.htm).
The committee's report indicates that C&P examinations ``. . .
differ in both scope and purpose from standard clinical examinations,
as their core function is to provide VBA staff with the evidentiary
foundation with which a claim for a service-connected disability can be
rated or denied'' (IOM, 2006; p. 89). It goes on to discuss the ways in
which C&P exams deviate from examinations that clinicians administer in
diagnostic and treatment settings. Quoting Greenberg and Shuman (1997),
the report notes on page 89:
In most instances, it is not realistic, nor is it typically
the standard of care, to expect a therapist to be an
investigator to validate the historical truth of what a patient
discusses in therapy. . . . In contrast, the role of a forensic
examiner is, among other things, to offer opinions regarding
historical truth and the validity of the psychological aspects
of . . . claims. The accuracy of this assessment is almost
always more critical in a forensic context than it is in
psychotherapy (Greenberg and Shuman, p. 53).
The requirements for documentation of a stressor for service
connection of PTSD thus go beyond the diagnostic criteria set out in
the DSM-IV (APA, 2000), but it must be remembered that the C&P exam has
a different intent than the diagnostic evaluation set forth in the DSM.
Question 3: If Congress were to redefine the criteria for
determining combat engagement to include a theater of combat operations
do you think it would improve the claims process or harm it?
Response: Our IOM Committee did not address this question directly
and did not make recommendations regarding it. Therefore, this response
reflects my own opinion and not necessarily that of the Committee.
In my opinion, there are two advantages to clarifying the meaning
of ``combat with the enemy'' to include service in a theater of combat
operations. First, this change would highlight the fact that exposure
to the types of traumatic stressors that can cause PTSD is no longer
limited to those with particular Military Occupational Specialties or
who are serving at the ``front lines.'' The distinction between serving
at the front line in a combat role and at the rear in a supporting role
is certainly less pronounced than it was in World War II, and anyone
serving anywhere in a theater of combat operations is at risk of
experiencing a wide variety of stressor events capable of producing
PTSD. Second, establishing service connection for PTSD would still
require an examiner to gather information about the actual traumatic
events that the veteran reported they experienced within the theater of
combat operations and to determine if these events were causally
related to their PTSD symptoms. It would therefore be impossible for an
examiner to diagnose PTSD and to establish that it is service-connected
without obtaining information about specific traumatic events that
happened to the veteran and determining that exposure to these events
were causally related to the PTSD and/or had aggravated preexisting
PTSD.
For these reasons, it is my opinion that this change would improve
the claims process--not harm it.
References
APA (American Psychiatric Association). 2000. Diagnostic and
Statistical Manual of Mental Disorders DSM-IV-TR, Fourth Edition (Text
Revisions). Washington, DC: APA.
Arbisi PA. 2006 (July 6). Issues and Barriers to Implementation of
Best Practice Guidelines in Compensation and Pension Examinations.
Presentation to the Committee on Veterans' Compensation for Post
Traumatic Stress Disorder. Washington, DC.
Dohrenwend BP, Turner JB, Turse NA, Adams BG, Koenen KC, Marshall
R. 2006. The psychological risks of Vietnam for U.S. veterans: a
revisit with new data and methods. Science 313:979-982.
Greenberg SA, Shuman DW. 1997. Irreconcilable conflict between
therapeutic and forensic roles. Professional Psychology: Research and
Practice 28(1):50-57.
IOM (Institute of Medicine). 2006. PTSD Compensation and Military
Service. Washington, DC: The National Academies Press. [Online]
Available: http://books. nap.edu/catalog.php?record_id=11870 [accessed
April 20, 2009].
VBA (Veterans Benefits Administration). 2005. Post-Traumatic Stress
Disorder--Student Guide. Washington, DC:Department of Veterans Affairs.
Watson P, McFall M, McBrine C, Schnurr PP, Friedman MJ, Keane T,
Hamblen JL. 2002. Best Practice Manual for Posttraumatic Stress
Disorder (PTSD) Compensation and Pension Examinations. [Online].
Available: http://www.avapl.org/pub/PTSD%20Manual%20final%206.pdf
[accessed April 20, 2009].
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
April 7, 2009
Terri Tanielian
Study Co-Director, Invisible Wounds of War
RAND Center for Military Health Policy Research
1776 Main Street P.O. Box 2138
Santa Monica, CA 90407-2138
Dear Ms. Tanielian:
Thank you for testifying at the House Committee on Veterans'
Affairs' Subcom-
mittee on Disability Assistance and Memorial Affairs hearing on
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly
appreciate if you would provide answers to the enclosed follow-up
hearing questions by Monday, May 4, 2009.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for material for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your responses
to Ms. Megan Williams by fax at (202) 225-2034. If you have any
questions, please call (202) 225-3608.
Sincerely,
John J. Hall
Chairman
__________
Responses of Terri Tanielian and Christine Eibner,\1\ Study Co-Director
Invisible Wounds of War Study Team, The RAND Corporation
In Response to Questions From the House Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Hearing on ``The Nexus Between Engaged in Combat With the Enemy and
PTSD in an Era of Changing Warfare Tactics''
March 24, 2009
Chairman Hall, thank you for requesting answers to your followup
hearing questions. My responses appear below, following each of your
questions which are repeated here.
---------------------------------------------------------------------------
\1\ The opinions and conclusions expressed in this testimony are
the authors' alone and should not be interpreted as representing RAND
or any of the sponsors of its research. This product is part of the
RAND Corporation testimony series. RAND testimonies record testimony
presented by RAND associates to Federal, State, or local legislative
Committees; Government-appointed commissions and panels; and private
review and oversight bodies. The RAND Corporation is a nonprofit
research organization providing objective analysis and effective
solutions that address the challenges facing the public and private
sectors around the world. RAND's publications do not necessarily
reflect the opinions of its research clients and sponsors.
Question 1: The information contained in the Invisible Wounds of
War Report is very impressive; however it seems there are still some
unanswered questions. If you were going to recommend further study,
what would you suggest that the VA or DoD study in order to better
assist veterans with PTSD? What other data would we need to further
---------------------------------------------------------------------------
develop the cost estimate model used by RAND?
Response: We will answer each of these sub-questions in turn.
First, our recommendations for further study:
In many respects, the Invisible Wounds of War study raises more
research questions than it provides answers. Better understanding is
needed of the full range of problems (emotional, economic, social,
health, and other quality-of-life deficits) that confront individuals
with post-combat post traumatic stress disorder (PTSD). This knowledge
is required both to enable the health care system to respond
effectively and to calibrate how disability benefits are ultimately
determined. Greater knowledge is needed to understand who is at risk
for developing mental health problems and who is most vulnerable to
relapse, and how to target treatments for these individuals. We also
need to be able to accurately measure the costs and benefits of
different treatment options so that fiscally responsible investments in
care can be made. We need sustained research into the effectiveness of
treatments, particularly treatments that can improve the functioning of
individuals who do not improve from the current evidence-based
therapies. Finally, we need research that evaluates the effects of
policy changes implemented to address the injuries of veterans who
served in Operations Enduring and Iraqi Freedom (OEF/OIF), including
how such changes affect the health and well-being of the veterans, the
costs to society, and the state of military readiness and
effectiveness.
Addressing these vital questions will require a substantial,
coordinated, and strategic research effort. We see the need for several
types of studies to address these information gaps. A coordinated
Federal research agenda on these issues within the veterans' population
is needed. Further, to adequately address knowledge gaps will require
funding mechanisms that encourage longer term research that examines a
broader set of issues than can be financed within the mandated
priorities of an existing funder or agency. Such a research program
would likely require funding in excess of that currently devoted to
PTSD research through DoD and the VA, and would extend to the National
Institutes of Health, the Substance Abuse and Mental Health Services
Administration, the Centers for Disease Control and Prevention, and the
Agency for Health Care Research and Quality. These agencies have
limited research activities relevant to military and veteran
populations, but these populations have not always been prioritized
within their programs. Initial strategies for implementing this
national research agenda include the following:
A large, longitudinal study on the natural course of
these mental health and cognitive conditions among OEF/OIF veterans,
including predictors of relapse and recovery. Ideally, such a study
would gather data pre-deployment, during deployment, and at multiple
time points post-deployment. The study should be designed so that its
findings can be generalized to all deployed servicemembers while still
facilitating identification of those at highest risk, and it should
focus on the causal associations between deployment and mental health
conditions. A longitudinal approach would also make it possible to
evaluate how use of health care services affects symptoms, functioning,
and outcomes over time; how TBI and mental health conditions affect
physical health, economic productivity, and social functioning; and how
these problems affect the spouses and children of servicemembers and
veterans. These data would greatly inform how services are arrayed to
meet evolving needs within this population of veterans. They would also
afford a better understanding of the costs of these conditions and the
benefits of treatment so that the nation can make fiscally responsible
investments in treatment and prevention programs. Some ongoing studies
are examining these issues (Smith et al., 2008; Vasterling et al.,
2006); however, they are primarily designed for different purposes and
thus can provide only partial answers.
Aggressive support for research to identify the most
effective treatments and approaches, especially for TBI care and
rehabilitation. Although many studies are already under way or under
review (as a result of the recent congressional mandate for more
research on Post traumatic stress disorder (PTSD) and traumatic brain
injury (TBI), an analysis that identifies priority-research needs
within each area could add value to the current programs by informing
the overall research agenda and creating new program opportunities in
areas in which research may be lacking or needed. More research is also
needed to evaluate innovative treatment methods, since not all
individuals benefit from the currently available treatments.
Evaluations of new initiatives, policies, and programs.
Many new initiatives and programs designed to address psychological and
cognitive injuries have been put into place, ranging from screening
programs and resiliency training, to use of care managers and recovery
coordinators, to implementation of new therapies. Each of these
initiatives and programs should be carefully evaluated to ensure that
it is effective and is improving over time. Only programs that
demonstrate effectiveness should be maintained and disseminated.
Second, with respect to the data that would be needed to further
develop our cost estimates. As we highlighted in our earlier testimony,
based on limitations in the existing literature, our model only
considers costs incurred within the first 1 to 2 years following
deployment. We know the consequences of PTSD, depression, and TBI can
extend beyond 2 years; however, estimating long-term costs is difficult
because we have limited information on the long term course of illness
for these conditions under different treatment regimes. Longitudinal
data on servicemembers that tracked treatment use, remission, and
relapse would be necessary to fully understand costs.
Another limitation of our current model is that, because we did not
have data from either DoD or the VA, we had to estimate costs based on
TRICARE reimbursement rates, Medicare reimbursement rates, published
literature, and civilian sources. More detailed cost and workload data
from DoD and VA would allow us to estimate more accurate costs figures
overall, and for these systems in particular.
Finally, there are many potential consequences of PTSD, TBI, and
depression that require further study before they can be definitively
linked to the illnesses. For example, we know that veterans with PTSD
and depression are more likely to be homeless than other veterans.
However, it is unclear whether PTSD and depression caused this
homelessness. It's possible that homelessness causes depression. A
better understanding of the causal relationship between homelessness
and mental illness would be needed in order to confidently ascertain
costs. A similar argument could be made for other potential
consequences of PTSD, TBI, and depression, including family strain,
drug and alcohol abuse, and violent behavior. A longitudinal study of
service personnel could be used to better understand the causal
relationship between mental health and cognitive conditions and
downstream consequences.
Question 2: Based on your microsimulation model, could you estimate
the cost to Congress, if veterans who have been deployed to a theater
of combat operations were able to enter the disability compensation
system within months of filing a claim rather than if they are denied?
Response: Currently, our model is not designed to answer this type
of question. In order to understand costs to Congress, we'd need better
information on costs to DoD and the VA, as well as any costs incurred
by SSA (e.g. through disability payments) as well as through CMS
(Medicaid). We'd also need a better understanding of how disability
payments and access to VA health systems improve outcomes. Access to
cost information from DoD and VA would enable us to partially answer
this question. However, longitudinal data would be required to fully
understand how veteran's benefits mitigate against the negative
consequences of PTSD, TBI, and depression.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
April 7, 2009
Rear Admiral David Smith, M.D., SHCE, USN
Joint Staff Surgeon, Office of the Chairman of the Joint Chiefs of
Staff
Wounded and Survivor Care Task Force
U.S. Department of Defense
1400 Defense Pentagon
Washington, DC 20301
Dear Rear Admiral Smith:
Thank you for testifying at the House Committee on Veterans'
Affairs' Subcom-
mittee on Disability Assistance and Memorial Affairs hearing on
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly
appreciate if you would provide answers to the enclosed followup
hearing questions by Monday, May 4, 2009.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for material for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your responses
to Ms. Megan Williams by fax at (202) 225-2034. If you have any
questions, please call (202) 225-3608.
Sincerely,
John J. Hall
Chairman
__________
Response From Rear Admiral David Smith, M.D., SHCE, USN
U.S. Department of Defense
To the House Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Hearing on ``The Nexus Between Engaged in Combat With the Enemy and
PTSD in an Era of Changing Warfare Tactics''
March 24, 2009
Question 1: I understand that the Defense Department has a process
for agreeing on terms, which it publishes in a Dictionary of Military
and Associated Terms. Can you describe how DoD develops an agreed upon
understanding for the terms that are entered into the Dictionary, and
are they applied consistently throughout the branches?
Response: Joint Publication (JP) 1-02, The Department of Defense
Dictionary of Military and Associated Terms, (aka ``the DoD
Dictionary'') contains terms and definitions that are commonly used
throughout the DoD, but not adequately defined for DoD purposes in
standard English-language dictionaries. These terms broadly underpin
joint operations, education and training; as such, JP 1-02 definitions
are best defined and introduced in a descriptive context that
facilitates understanding.
Terms in JP 1-02 come from four sources, as follows:
a.
Joint Doctrine. The 77-volume Joint Doctrine \1\ hierarchy
issued under CJCS Title 10 authority consists of the principles that
guide the employment of U.S. military forces in coordinated action
toward a common objective. It represents what is taught, believed and
advocated as what is right (i.e., what works best). Its purpose is to
enhance the operational effectiveness of U.S. forces. Joint Doctrine is
neither policy nor strategy; it is authoritative guidance that is
implemented by a commander exercising judgment regarding a specific
circumstance. Terminology routinely emanates from recording these
principals; certain terms are therefore both defined and described in
context. This is the preferred method as the narrative text of the
doctrine provides contextual meaning.
---------------------------------------------------------------------------
\1\ The current Joint Doctrine library can be found at: http://
www.dtic.mil/doctrine/nipr_ index.html.
b.
Policy Issuances. Policy issuances from the Secretary of
Defense and the CJCS (specifically DoD Directives, DoD Instructions,
and CJCS Instructions) have the authority of orders (vice the
authoritative advice of Joint Doctrine). Certain terms are defined and
then briefly described in context of these issuances. (Policy issuances
do not normally have the space to provide full contextual meaning.)
c.
NATO Agreed. The North Atlantic Treaty Organization issues
Allied joint doctrine and policy. Terms that emanate from those
issuances, when agreed to by the U.S., may be entered in JP 1-02 to
delineate their usage in a NATO context. (This is germane when a NATO
definition may be different than a U.S. definition. Inclusion in JP 1-
02 cues U.S. users to the differences.)
d.
Specifically Directed. Certain terms will be incorporated in JP
1-02 when specifically directed by either the Secretary of Defense or
the CJCS. This normally occurs when development efforts regarding the
other paths to inclusion requires a specific decision in order to
progress.
It should be noted that not all terms defined in Joint Doctrine, in
DoD or CJCS policy issuances, or agreed to in NATO are entered into JP
1-02. In the staffing relative to producing these items, terms proposed
for inclusion in JP 1-02 are specifically so marked so that they may be
considered in a DoD-wide context. Terms having specific, vice general
application (e.g. limited applicability), such as those used in medical
diagnosis or administrative determinations, are not considered
appropriate for inclusion in the DoD dictionary.
The administrative process regarding the inclusion of terms in JP
1-02 involves DoD-wide \2\ staffing. During the staffing process, any
DoD component may comment on a proposal recommending approval,
disapproval, or modification. The CJCS, through the Joint Staff J-7, is
responsible for resolving any contentious issues that arise during
staffing.
---------------------------------------------------------------------------
\2\ DoD components which review Terminology proposals are the
Office of the Secretary of Defense, the Military Departments, the CJCS
and the Joint Staff, the Office of the Inspector General of the DoD,
the combatant commands, the DoD agencies, field activities, and all
other organizational entities in the DoD.
Question 2: Thank you for your observations on the problems with
the DoD Disability Evaluation System. How would you suggest that DoD
and VA work to streamline the process and correct deficits? a. What
---------------------------------------------------------------------------
legislative fixes are you anticipating from Congress?
Response: Since the passing of the Career Compensation Act of 1949,
DoD and VA have operated parallel systems to examine, rate and
compensate disabled veterans. DoD's responsibility is to make fit
versus unfit determinations; our disability ratings and compensation
are based solely on the unfitting conditions. In contrast, VA examines,
rates and compensates veterans based upon all service-related disabling
conditions. There are different ground-rules and evidentiary standards
for each, and as a result, the parallel processes produce different
results. This duplicative system is confusing and frustrating to
servicemembers and veterans alike. Disability compensation rules
further compound the problem, frequently resulting in DoD benefits paid
to servicemembers which must then be repaid before VA benefits may
begin.
Prior to and since the aftermath of the Walter Reed articles in
early 2007, multiple commissions and review groups have been chartered
to evaluate and make recommendations on the treatment, rehabilitation
and compensation of our wounded warriors and veterans. The Dole-
Shalala, Scott and Nicholson reports, in particular, recommended
significant reform of the Disability Evaluation and Compensation
Systems. The DoD, VA and Military Departments established a DES pilot
program that has streamlined within the constraints of existing
statutes, moving to a single physical exam (done by VA for both DoD and
VA rating purposes) and reducing the timeline for some portions of the
process.
However, even with the DES pilot, the DoD and VA Disability and
Compensation Systems are still frustrating and complex, and two
separate ratings are still required by statute. It is our belief that
the time has come for a more revolutionary, systematic overhaul of DoD
and VA disability evaluation and compensation policy and procedures.
Our vision is a disability and compensation system that simultaneously
promotes ability--with the goal of returning all servicemembers or
veterans to either continued service in the military or transition to
productive lives in their community while the system appropriately
compensates service-related disability. The path to this vision is not
yet fully mapped, but we feel it is a journey worth taking, and we ask
for your support.
Some of the possible elements of the transformed system were
outlined by the Dole-Shalala and Scott commissions to include: (a)
elimination of parallel activities, e.g., DoD to only determine fitness
and provide annuity benefits based on longevity and rank if found unfit
and VA to provide all disability ratings and associated benefits; (b)
restructuring disability payments in to three components: transition,
earning loss, and quality of life payments (transition payments to
provide a solid base for the return of injured veterans to productive
lives and to improve vocational, rehabilitation, and education
completion rates. The proposed system must be transparent, relatively
simple and understandable by the patients and beneficiaries it affects.
This issue has been identified by the Secretary of Defense (Sec.
Gates) and Chairman of the Joint Chiefs of Staff as an important focus
area for DoD and VA. To achieve this vision, continuing emphasis at the
highest levels in both departments will be key components to successful
analysis, determination of the specific components and enabling actions
required for implementation, and ultimate achievement of the vision.
In addition, the VA and DoD need to continue to evaluate and
implement ``best practices'' from the civilian medical community for
incorporation into DES as well. Electronic records and system
interfaces which support sharing of medical and personnel information
between DoD, the Military Health System and VA will go a long way
toward correcting inefficiencies and expediting processes. President
Obama \3\ has identified this as a key focus area for his
administration. DoD and VA are moving toward solving this part of the
problem, although we are in the very early stages of resolution.
---------------------------------------------------------------------------
\3\ 09 April 2009, The White House Briefing Room Press Release,
``President Obama announces the Creation of a Joint Virtual Lifetime
Electronic Record.''
---------------------------------------------------------------------------
We do not have specific legislative fixes identified for the DES or
Joint Virtual Lifetime Electronic Record issues to support the outlined
vision at this point.
Question 3: In reviewing the single VA/DoD exam pilot program, what
issues still need to be addressed in order to fully institute the
program?
Response: The DES pilot program was established as a test-bed for
streamlined DES processes within present statutory constructs and
includes, but is not limited to, the single physical exam done by VA
for both DoD and VA rating purposes. Significant, positive steps have
occurred as a result of this test program, but frustration persists
with a complex system which still produces ratings which are used for
two separate purposes (DoD--unfitting condition only and VA--total
disability rating) and often results in DoD benefits which must be
repaid before VA benefits may begin.
The DES pilot program is being continually refined, and expansion
to sites outside the National Capital Regions' resource-rich
environment is moving forward. Differing levels of resources at
outlying locations may necessitate significant modification of
procedures or changes altogether.
The 2007 Dole-Shalala report made the recommendation to
``completely restructure the disability and compensation systems'' to
``update and simplify the disability determination and compensation
system, eliminate parallel activities, reduce inequities, and provide a
solid base for the return of injured veterans to productive lives.''
\4\ The report also recommended that DoD and VA create individualized
recovery plans for wounded servicemembers, help them navigate the
complex systems through improved IT infrastructure and simplified
underlying constructs, and improve the transfer of patient information
across systems.\5\ The DoD and VA Recovery Coordination Programs
provide Recovery Coordinators for seriously and severely injured
servicemembers. Standard, uniform Comprehensive Recovery Plans are
created for each recovering servicemember by their Recovery Coordinator
and the Recovery Team. DoD and the Services are in the process of
improving current IT systems to incorporate these plans. We would
contend that all of these issues require more work to institute an
improved program.
---------------------------------------------------------------------------
\4\ July 2007 ``Serve, Support, Simplify''; Report of the
President's Commission on Care for America's Returning Wounded
Warriors, pg 6.
\5\ July 2007 ``Serve, Support, Simplify''; Report of the
President's Commission on Care for America's Returning Wounded
Warriors, pg 6, 25-28.
Question 4: Does the DoD Disability Advisory Committee that VA
---------------------------------------------------------------------------
participates on provide any guidance on how to adjudicate PTSD claims?
Response: The DoD Disability Advisory Council (DAC) operates under
the policy coordinating guidance of the Office of the Under Secretary
of Defense (Transition Policy and Care Coordination) (TPCC). Its
permanent membership includes Office of the Assistant Secretary of
Defense (Health Affairs), Office of the Assistant Secretary of Defense
(Reserve Affairs), Office of the Deputy General Counsel (Personnel and
Health Policy), and Office of the Deputy Under Secretary of Defense
(Military Community and Family Policy) (Casualty Affairs). Each
Military Department appoints knowledgeable representatives and the
Secretary of the Department of Veterans Affairs is also asked to
provide representatives from the Office of the Under Secretary of
Benefits and the Under Secretary for Health Affairs.
The primary objectives of the DAC are to ensure fair and equitable
determination of servicemember fitness for continued duty; ensure the
disability determinations are uniform across the Services; ensure
servicemembers move through the DES process expeditiously and are
knowledgeable about the process and kept informed of the status of
their respective cases, and that due process rules are strictly
followed; provide oversight and advice to the Director, TPCC and USD
(P&R) regarding the efficient and effective management of the DES, and
provide information for accession policy review.
The DoD is required to rate disabilities using the Veterans Affairs
Schedule of Rating Disabilities (VASRD). The DoD Disability Advisory
Council is the chartered venue to discuss recommendations for changes
in the VASRD with the VA. In January 2009, the VBA reported that they
were convening a panel of subject matter experts to evaluate the degree
to which the VASRD adequately provides appropriate considerations for
rating those impaired by PTSD. The VBA has stated DoD experts will be
invited to participate with their experts to update this section of the
VASRD; with the next meeting scheduled for May 2009.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
April 7, 2009
Colonel Robert Ireland
Program Director, Mental Health Policy
Office of the Assistant Secretary of Defense for Health Affairs
U.S. Department of Defense
1400 Defense Pentagon
Washington, DC 20301
Dear Colonel Ireland:
Thank you for testifying at the House Committee on Veterans'
Affairs' Subcom-
mittee on Disability Assistance and Memorial Affairs hearing on
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly
appreciate if you would provide answers to the enclosed followup
hearing questions by Monday, May 4, 2009.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for material for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your responses
to Ms. Megan Williams by fax at (202) 225-2034. If you have any
questions, please call (202) 225-3608.
Sincerely,
John J. Hall
Chairman
__________
Response from Colonel Robert Ireland, U.S. Department of Defense,
To the House Committee on Veterans' Affairs,
Subcommittee on Disability Assistance and Memorial Affairs,
Hearing on ``The Nexus Between Engaged in Combat With the Enemy and
PTSD in an Era of Changing Warfare Tactics''
March 24, 2009
Question 1: In your testimony you described the diagnostic process
using the DSM-IV criteria for PTSD. Does DoD require further stressor
documentation for diagnosis and a disability award? What if the
servicemember's record does not indicate a specific event?
Question 1(a): Does DoD determine if a servicemember has been
engaged in combat with an enemy?
Response: Our Military Health System clinicians focus on the
clinical aspects of diagnosis and treatment of post-traumatic stress
disorder (PTSD), including therapeutic management of those who
experience traumatic stress. Those who suffer psychological stress from
a motor vehicle accident who have no significant physical injuries are
not required to produce a police report of the mishap. In the same
fashion, treating clinicians do not initiate investigations to confirm
traumatic combat or deployment related exposures. Rather, if a mental
disorder is diagnosed, medical records should document how the patient
meets the criteria for that disorder. If specific criteria required to
make a particular diagnosis are not documented, then it cannot be
established by such medical records that an individual has the
disorder.
When PTSD is diagnosed and treated by clinicians in the military
(to include any identified stressors), it is for treatment and clinical
management and not for consideration of disability award. When a
member's medical condition(s) calls into question his/her ability to
perform military duties, a medical evaluation board reviews the
member's case. The member's case is referred to the Service's Physical
Evaluation Boards (PEB) if the member fails to meet Service medical
retention standards. While the member is being evaluated in the
Disability Evaluation System for continued military service, his/her
treatment and clinical management of medical condition(s) continue.
The Service's PEB determine the member's fitness for continued
service and, if found unfit, determine the rating percentage for
compensation and pension, according to applicable code and regulations.
Question 2: Does DoD have Combat Stress Teams that evaluate all
servicemembers who have been on a deployment?
Response: It is DoD policy that all servicemembers receive
assessments through Post-Deployment Health Assessments (PDHA) and Post-
Deployment Health Reassessments (PDHRA). Questions on these assessments
do evaluate servicemembers' stress-related issues. Referrals for
further evaluations or treatment are made for the servicemember, if
indicated.
In addition, DoD has taken a proactive stance in addressing combat
and other military life stressors of servicemembers. Combat and
Operational Stress teams take on essential and integral roles in the
continuous monitoring, prevention, and mitigation of stress injuries in
servicemembers and units throughout the deployment cycle. Based on DoD
Instruction 6490.5, ``Combat and Operational Stress Control (COSC)
Programs,'' policies and programs are ``implemented throughout the
Department of Defense to enhance readiness, contribute to combat
effectiveness, enhance the physical and behavioral health of military
personnel, and to prevent or minimize adverse effects that may be
associated with Combat and Operational Stress Reactions and Injuries
(COSR/Is).''
The Services develop and coordinate their programs and teams,
engage line leadership throughout the development and implementation of
programs, and maintain common principles of combat and operational
stress management of COSRs. Examples of these ongoing efforts include
the Army's ``Battlemind Warrior Resiliency'' COSC Detachments and
embedded behavioral health assets within Brigade Combat Teams; the Air
Force's ``Landing Gear'' program; and the Marine Corps Operational
Stress Control and Readiness (OSCAR) programs. The Services COSC
programs share common objectives for their members and include:
1. Preparing servicemembers for military operations;
2. Providing support during transitions;
3. Building resiliency through education and awareness;
4. Promoting family participation;
5. Reducing stigma associated with behavioral health and to
promote psychological health; and
6. Assuring peer and line responsibility to ensure psychological
health and readiness and to assure programs are socialized.
Question 3: Does the Post Deployment Health Reassessment Program
specifically screen for PTSD? If a servicemember is exhibiting symptoms
of PTSD, what is the referral process?
Response: The Post-Deployment Health Reassessment Program (PDHRA)
is a clinical process designed to enhance the deployment-related
continuum of care. Targeted at 3 to 6 months after returning from a
contingency operation, the PDHRA provides education and a global health
assessment to identify and facilitate access to care for deployment-
related physical health, mental health, and re-adjustment concerns.
This is just one part of the DoD Health Assessment Cycle that includes
Baseline Assessment (soon after accession), Periodic Health Assessment
(annually), Pre-deployment Health assessment (no earlier than 60 days
before deploying), Post-Deployment Health Assessment (within 30 days of
return from deployment), and Separation-Retirement.
Standardized questions covering symptoms of post-traumatic stress
disorder (PTSD) are on the PDHRA. A primary care provider reviews the
questions with each individual, interviews the servicemember and
recommends additional specialty evaluation or treatment if clinically
indicated. Quality assurance and program evaluation to assess program
success is ongoing.
Treatment and followup are arranged on a continuum of care model,
building on DoD and Department of Veterans Affairs partnerships. The
continuum ranges from the community-based support and preclinical
counseling to referral for treatment in primary care, specialty care,
or community-based education or counseling services, as warranted. In
addition, the military health system added behavioral health providers
to the staff of many primary care settings to facilitate access to low-
stigma care and support, specifically to provide referral care related
to deployments.
Question 4: In your testimony, you stated that DoD providers who
administer the PDHRA will refer servicemembers to the VA Web site
www.afterdeployment.org if they feel they would benefit from additional
information on PTSD. Can they contact a clinician through the site or
find peer support through blogging?
Response: This is actually a DoD Web site that the Defense Centers
of Excellence (DCoE) for Psychological Health and Traumatic Brain
Injury has been collaborating on with subject matter experts from the
Department of Veterans Affairs (VA). Beginning later this year,
afterdeployment.org's Phase 3 development will be to provide users and
senior leadership with interactive forums and features. Site
enhancements will focus on incorporating innovative Web-based
technologies, such as collaborative networking, podcasting, and
blogging. Site design also will aim to provide users with up-to-date
and user-friendly content-search and navigational systems. These
features will be coordinated with the DCoE Outreach Center (866-966-
1020) to provide the user a coordinated experience in receiving
information and resources. The DCoE Outreach Center affords 24/7
availability of health resource consultants, although not in a direct
clinical care role. Customers can engage one of our consultants via
phone, email, and private chat (which will be accessible via the soon-
to-be-launched dcoeoutreach.org and realwarriors.net Web sites). Peer
support will be available at both of these Web sites, but clinician
care will not.
Question 5: How does DoD identify Potentially Traumatic Events? Is
combat stress debriefing attendance mandatory for all servicemembers
after deployments and is participation documented in their service
medical records?
Response: Every servicemember can report a potentially traumatic
event at any point of contact with the medical system. The report will
become part of the permanent medical record. They also are prompted to
report combat-related exposures and head injuries during the Post-
Deployment Health Assessment (PDHA) and Post-Deployment Health
Reassessment (PDHRA) processes.
Critical incident stress debriefing is not endorsed by DoD policy.
Research has proven this type of intervention ineffective and
potentially harmful. Commanders and small group leaders do conduct
operational debriefings after combat operations, which has been found
helpful for members to process the experience as well as to learn
valuable operational lessons. Following deployments, all Services are
required to provide education and a medical threat debriefing to
returning servicemembers. These educational products are tailored to
the specific culture and experiences of the different Services to
improve their effectiveness. The Army uses BATTLEMIND, the Marines use
Marine Operational Stress Training and Marine Corps Operational Stress
Control and Readiness team training, and the Air Force uses Landing
Gear. These programs provide information that will assist in processing
possible trauma experienced during operational deployments, identify
potential signs and symptoms to watch for during the reintegration
period and beyond, and provide information about the many resources
available for assistance. Medical threat debriefing is mandatory during
the PDHA and education is mandated as part of the PDHRA process.
Question 6: Has there been any concern that servicemembers
returning from Iraq or Afghanistan are over or under reporting PTSD
symptoms?
Response: Two sources of data are used to estimate the prevalence
of Post-Traumatic Stress Disorder (PTSD) among U.S. military deployers.
These include clinically diagnosed cases of PTSD and self-reported
symptoms of PTSD on a survey.
Diagnosed Cases of PTSD
Between October 1, 2001, and December 31, 2008, there were 42,600
servicemembers who were diagnosed with PTSD at some point following the
start of a deployment in support of Operations Enduring Freedom or
Iraqi Freedom (OEF or OIF). A case of PTSD is defined as having at
least two outpatient visits or one or more hospitalizations at which
PTSD was diagnosed. The threshold of two or more outpatient visits is
used to increase the likelihood that the individual actually had PTSD.
A single visit on record commonly reflects someone who was evaluated
for possible PTSD, but did not meet the established criteria for the
diagnosis.
This number (42,600) represents 2.4 percent of the total number
(1,769,116) of Active Duty, National Guard, and Reserve servicemembers
who deployed for at least 30 days to OEF/OIF prior to January 1, 2009,
according to the Defense Manpower Data Center deployment rosters.
The number of diagnosed cases of PTSD reported above comes from the
DoD electronic medical record system and only reflects conditions that
are coded by the provider as PTSD. This does not include the treatment
of PTSD symptoms that are coded as something other than PTSD.
There are other important caveats to consider when interpreting
these numbers. The analysis did not exclude servicemembers that had
mental health encounters (including PTSD) prior to the first
deployment. The analysis includes PTSD cases that occurred after a
qualifying deployment regardless of how long after return the
servicemember was first diagnosed--cases are not necessarily a result
of an in-theater event. Results do not consider followup time for
servicemembers (e.g., a servicemember who separates immediately after
return from deployment carries the same weight as one who remained in
service years after deployment). Identified cases only represent
individuals who were diagnosed in a military medical treatment facility
or where DoD was billed for medical care (e.g., TRICARE). Thus, OEF/OIF
servicemembers who are not seeking treatment are not represented in the
2.4 percent figure. Finally, information from Military OneSource, VA
facilities, non-DoD insurance, and non-medical providers (clergy, etc)
was not available. This analysis therefore likely underestimates the
actual total number of PTSD cases.
Self-Reported Symptoms of PTSD on a Survey
1. The Millennium Cohort study is a longitudinal stratified random
sample of the military population followed for 20 years. Results from a
recent study using these data indicated that 7.6 percent of cohort
members who deployed and reported some sort of exposure to combat
developed new onset of PTSD symptoms, compared with 1.4 percent of
cohort members who were deployed and did not report combat exposures.
These numbers exclude anyone with self-reported prior cases of PTSD,
which means that servicemembers who had prior PTSD symptoms exacerbated
by deployment would not be counted in these numbers. Furthermore, the
cohort includes Air Force and Navy personnel, as well as Army personnel
in a variety of support roles, many of whom would have had limited
exposure to sustained ground combat experiences.
2. Studies of Brigade and Regimental Combat Teams (BCTs and RCTs),
which represent about 40 percent of the total deployed force and are
known have greater exposure to sustained ground combat, have been
surveyed using the same measures and scoring criteria as was used in
the Millennium Cohort study. Investigators at the Walter Reed Army
Institute of Research in a series of studies focused on BCTs and RCTs
have shown that self-reported prevalence of PTSD symptoms during
deployment and 3-12 months post-deployment ranges from 10-15 percent.
Summary
The prevalence of clinically diagnosed cases of PTSD following a
deployment to OEF/OIF is 2.4 percent, subject to the limitations noted
above. Prevalence of PTSD symptoms based on self-reported surveys
ranges from 1.4 percent (not exposed to combat) to 15 percent
(populations exposed to sustained ground combat). As a comparison from
previous conflicts, Dohrenwend et al.'s (2006) reanalysis of the
National Vietnam Veteran's Readjustment Study found between 9.1 percent
and 12.2 percent of combat-veterans met criteria for PTSD at the time
of the evaluation, which is similar to the findings of BCTs and RCTs.
The true prevalence of PTSD among OEF/OIF deployers is unknown but
likely underestimated, primarily as a result of the well-documented
presence of stigma surrounding the reporting of mental health symptoms.
Efforts are underway to reduce the stigma of seeking mental health care
in the military, including the launching of the Defense Centers of
Excellence for Psychological Health and Traumatic Brain Injury's ``Real
Warriors. Real Battles. Real Strength'' public awareness campaign in
May of 2009. Until our efforts to change the culture related to seeking
mental health care are more successful, our reported total cases of
PTSD will likely continue to be somewhat of an underestimate.
Question 7: DoD is using the VA Schedule for Rating Disabilities
(VASRD) when determining fitness for duty and retirement for PTSD. Does
the VASRD effectively reflect PTSD symptoms and level of impairment?
What changes, if any, would you suggest be made to the VASRD so that it
could be a more consistent, precise and standardized instrument for
evaluating and rating PTSD?
Response: The DoD is required to rate disabilities using the
Veterans Administration Schedule for Rating Disabilities (VASRD). The
DoD Disability Advisory Council (DAC) now includes members from the
Department of Veterans Affairs (VA) and is the chartered venue to
discuss recommendations for changes in the VASRD with the VA. The DAC
recommended to the Veterans Benefits Administration (VBA) a formal
review of the adequacy of the VASRD to effectively reflect PTSD
symptoms and impairment. The VBA reported that they are convening a
panel of subject matter experts for this purpose and has confirmed that
DoD experts will be invited to participate with VA experts in updating
this section of the VASRD; with the next meeting scheduled for May
2009.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
April 7, 2009
Bradley Mayes
Director, Compensation and Pension Service
Veterans Benefits Administration
U.S. Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420
Dear Mr. Mayes:
Thank you for testifying at the House Committee on Veterans'
Affairs' Subcom-
mittee on Disability Assistance and Memorial Affairs hearing on
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly
appreciate if you would provide answers to the enclosed followup
hearing questions by Monday, May 4, 2009.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for material for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your responses
to Ms. Megan Williams by fax at (202) 225-2034. If you have any
questions, please call (202) 225-3608.
Sincerely,
John J. Hall
Chairman
__________
Questions for the Record
The Honorable John J. Hall, Chairman,
Subcommittee on Disability Assistance and Memorial Affairs,
House Committee on Veterans' Affairs,
Nexus Between Engaged in Combat With the Enemy and PTSD in an Era of
Changing Warfare Tactics
March 24, 2009
Questions for Bradley G. Mayes
Question 1: As you acknowledged in your testimony, the language in
section 1154 was enacted by Congress in 1941, and VA has had to base
its rule making on it. Would you agree that 1941 language and the
paradigm it represents is outdated and should be addressed by Congress
to reflect a more modern era of warfare?
Response: The purpose of section 1154 is to recognize that
recordkeeping during combat activity is not first priority and
particular combat events, as well as the resulting harm to the
individuals involved, may not be documented. Therefore, Veterans who
engaged in combat have a lowered evidentiary standard for service-
connecting disabilities incurred or aggravated during combat. We do not
believe that this concept is outdated.
Although the technology, tactics, circumstances, and nature of
warfare have evolved since section 1154 was enacted, much remains the
same. Combat military personnel continue to experience events that are
not recorded and receive injuries that may not be treated in Theater.
Even if a combat injury is treated in Theater, some documentation
consists of single paper reports and servicemembers may be treated by
more than one medical support unit. In such circumstances, there is
significant potential for missing or late-flowing documentation that
would support a Veteran's claim.
Question 2: How is VA applying the benefit of the doubt rule in
relation to section 1154(b) where it specifically states that VA shall
accept lay evidence when there is no official record? Why does VA
continue to develop those claims beyond the statement from the veteran?
What constitutes sufficient evidence of combat participation?
Response: The Department of Veterans Affairs (VA) provides Veterans
with the benefit of the doubt in any claim-related decision where the
evidence for and against an issue is evenly distributed. In such
circumstances, VA regulations require that the decision be made in
favor of the Veteran.
With respect to section 1154(b), the Veteran's lay statement will
establish the in-service incurrence or aggravation of a disease or
injury if the available evidence shows engagement in combat; the
Veteran alleges that the disease or injury was incurred in or
aggravated in such service; and the allegations are consistent with the
place, type, and circumstances of service. If the evidence for and
against engagement in combat is in approximate equipoise, the Veteran
will be given the benefit of doubt regarding any issue material to that
determination. Awards or medals indicating combat participation, such
as a Combat Infantryman Badge, Combat Action Ribbon, or Purple Heart
Medal, will automatically establish combat status. When the Veteran
claims combat participation, but there is no apparent evidence for this
in the military records, VA will develop for evidence of combat
participation. This involves researching the activities of the
Veteran's unit at the time of reported combat participation. VA will
request assistance from the Department of Defense (DoD) and the Joint
Services Records Research Center if it is unable to find evidence of
combat participation. When combat status is established, the lowered
evidentiary standard established by section 1154(b) applies.
Question 3: In a hearing last April, the Disabled American Veterans
testified that VA has circumvented the law by conducting improper
rulemaking through its Office of General Counsel and the adjudication
procedures in the M21-1MR by requiring proof of combat in official
military records. On what grounds does VA purport that it had the
authority to redefine the intent of section 1154, which specifically
states that no official records need be available?
Response: VA has not circumvented the law, conducted improper
rulemaking, or redefined the intent of section 1154(b). The statute
provides a lowered evidentiary standard permitting use of satisfactory
lay evidence as proof of service connection for a disease or injury
alleged to have been incurred or aggravated if a Veteran ``engaged in
combat with the enemy.'' This lowered evidentiary standard establishes
sufficient ``proof'' that a claimed disease or injury was incurred or
aggravated in active service; it is not a way for a Veteran to
establish ``proof'' of combat participation when there is no other
evidence of record showing combat participation. It is clear from the
language of section 1154(b) that the phrase ``notwithstanding the fact
that there is no official record'' is linked to the ``incurrence or
aggravation in such service'' of a disability. It is the incurrence or
aggravation of a disability during active service that does not require
an official record. This is distinctly different from stating that
there is no need for an official record or other credible evidence
showing combat participation. With respect to M21-1MR, the procedural
manual does not state that proof of combat must come from official
military records. To the contrary, it is much more expansive. It
states: ``There are no limitations as to the type of evidence that may
be accepted to confirm engagement in combat. Any evidence that is
probative of (serves to establish the fact at issue) combat
participation may be used to support a determination that a veteran
engaged in combat.''
Question 4: Can you provide the Committee a breakdown of how many
Veterans' claims were denied for PTSD by period of service, gender, and
race for the last 5 years? How many are on appeal?
Response: We are unable to provide the number of claims denied for
post traumatic stress disorder (PTSD) for the last 5 years. The
Veterans Benefit Administration (VBA) is converting all disability
claims records from our legacy system benefit delivery network (BDN) to
VETSNET. In cases where the rating is not currently in VBA's corporate
database, the conversion creates a new ``rating'' with data from BDN.
The ``rating'' date shows as the date of conversion, not the date the
condition was granted or denied. Therefore, we cannot say with
certainty when VA determined a condition to be service-connected or
not. We also are unable to provide data concerning claims denied by
period of service, race, or gender. Our corporate database shows that
233,265 Veterans who filed claims for PTSD at anytime in the past were
denied service connection for PTSD. As of September 30, 2008, there
were 344,533 Veterans service-connected for PTSD. There are currently
over 25,000 appeals involving PTSD.
Question 5: What are the CPEP results on the overall quality of C&P
exams when comparing exams conducted using templates to those conducted
without using templates, and, specifically the results for veterans
claiming PTSD? Please provide information on the use and frequency of
the templates nationwide and by VISN and VAMC. What are VA's intentions
regarding mandating the use of templates?
Response: The compensation and pension examination program (CPEP)
does not routinely identify the examination protocol used to prepare a
report selected for quality review. Consequently, there is no current
comparison data of the relative quality of template and dictated exam
reports. However, a special study was conducted by CPEP during calendar
2005 comparing the quality of reports prepared under the two protocols
for PTSD examinations. The table below provides the results.
Examination Protocol (CY 2005 data)
Average Scores
------------------------------------------------------------------------
Examination Type Template Dictated p-value
------------------------------------------------------------------------
Initial PTSD 95% 87% 0.0628
------------------------------------------------------------------------
Review PTSD 96% 85% 0.0154
------------------------------------------------------------------------
The p-value represents the probability that an equal or greater
difference in average scores would be found in a repeated test if the
difference observed in this test could be ascribed to chance alone. The
low p-values signify that it is unlikely the differences seen in this
test are attributable to chance alone.
Since CPEP does not routinely track template use, the latest
available data is from October 2007. At that time, approximately 28,000
templates were used per month. For context, the total number of
examinations the Veterans Health Administration (VHA) conducts per
month ranges from about 40,000 to about 70,000.
VA recognizes the value of exam reports that are reliably thorough
and that use language designed to directly support consistent
application of the rating schedule. VA is also aware, however, that the
template application, while useful in its current form, is not yet a
fully mature application. Certain practical matters must be resolved
before any systemwide mandate can be considered. Ideally, the template
application and output will soon be sufficiently superior to the
traditional exam worksheet/dictation approach that no mandate of
template use would be necessary. Clinicians would simply choose
templates because they are more efficient and assure all exam issues
are addressed. Rating Veterans service representatives (RVSR) and other
users would prefer template-generated reports because they are more
thorough, uniformly constructed, and easier to navigate than
worksheets. Mandating the use of templates is still under discussion in
VA, with careful consideration being accorded to issues of user
acceptance.
Question 6: What are the requirements for using templates for C&P
exams by the VBA contractor? What are the results of analysis of the
quality of exams in general and specifically for PTSD claims conducted
by contract in comparison with exams conducted by VHA?
Response: Two companies, QTC Management, Inc. (QTC), and MES
Solutions (MES), conduct compensation and pension (C&P) exams. QTC uses
a proprietary exam-reporting format that corresponds to the C&P exam
worksheet protocol. MES also uses a proprietary exam-reporting format
that corresponds very closely with the C&P exam worksheet protocol. VA
does not currently anticipate any change in this arrangement. Both
contractors post completed reports to a secure Web site for retrieval
by the requesting regional office.
C&P Service reviews the quality of contracted exam reports by
quarter while CPEP reviews VHA quality. The following is the latest
data on PTSD exam quality:
CPEP (VHA) FY08 sample size 1,764 Initial PTSD; 1,764 Review PTSD
------------------------------------------------------------------------
VHA Performance FY2008 FY2009 (Sep-Dec)
------------------------------------------------------------------------
Initial PTSD 94% 95%
------------------------------------------------------------------------
Review PTSD 91% 86%
------------------------------------------------------------------------
QTC and MES fiscal years run from May through April. C&P Service
review yielded the following results. [QTC results shown cover May
2008-January 2009; MES results cover August 2008-January 2009].
QTC sample size:
79 Initial PTSD; 15 Review PTSD
MES sample size:
14 Initial PTSD; 7 Review PTSD
------------------------------------------------------------------------
Contractor Performance QTC MES
------------------------------------------------------------------------
Initial PTSD 98.9% 100%
------------------------------------------------------------------------
Review PTSD 100% 100%
------------------------------------------------------------------------
Question 7: Can you tell the Committee more about the work that is
underway to update the Rating Schedule criteria for PTSD? How is that
work going to impact section 1154?
Response: VBA and VHA are working together to conduct a mental
health summit to be held sometime during the fourth quarter of fiscal
year (FY) 2009 or first quarter of FY 2010. The summit will include a
diverse representation of medical professionals from the Government and
civilian sectors. The summit will focus on determining the most up-to-
date rating criteria for all mental disorders, including PTSD. This
work will not impact section 1154.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
April 7, 2009
Antonette Zeiss, Ph.D.
Deputy Chief Consultant, Office of Mental Health Services
Office of Patient Care Services
Veterans Health Administration
U.S. Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420
Dear Ms. Zeiss:
Thank you for testifying at the House Committee on Veterans'
Affairs' Subcom-
mittee on Disability Assistance and Memorial Affairs hearing on
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly
appreciate if you would provide answers to the enclosed followup
hearing questions by Monday, May 4, 2009.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for material for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your responses
to Ms. Megan Williams by fax at (202) 225-2034. If you have any
questions, please call (202) 225-3608.
Sincerely,
John J. Hall
Chairman
__________
Questions for the Record
The Honorable John J. Hall, Chairman,
Subcommittee on Disability Assistance and Memorial Affairs,
House Committee on Veterans' Affairs,
Nexus Between Engaged in Combat With the Enemy and PTSD in an Era of
Changing Warfare Tactics
March 24, 2009
Questions for Antonette Zeiss, Ph.D.
Question 1: What is different about how the VHA conducts C&P exams
and how it conducts standard mental health assessments as referenced in
your testimony? What is the process for each?
Response: A standard mental health exam is performed for treatment
purposes, and is comprised of a clinical interview with a progress note
and a treatment plan. Both types of exams would use the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV) to reach a medical
conclusion. A C&P exam, however, is a disability exam performed for
medical-legal purposes, not for treatment, and is governed by relevant
statutes and regulations. The exam report is used as evidence by the
Ratings Board to make service-connection determinations and to
determine the average loss of earning capacity due to service-connected
conditions. The C&P exam is documented by following the approved C&P
worksheets or by using the compensation and pension records interchange
(CAPRI) templates. A treatment plan is not provided as part of a C&P
exam report.
Question 2: In your testimony, you noted that the VHA has
implemented the IOM recommendation that approximately 2 hours be
allocated for PTSD C&P exams. What is the current VHA average time to
complete these exams?
Response: CPEP does not currently collect this data, and we do not
have a database with this information. Anecdotally, 2 hours is the
average time in which most providers can complete a mental health C&P
exam, allowing 1 hour for the interview and 1 hour for documentation.
More complex cases could take longer, up to 3 or 4 hours, but rarely
would one be completed in less than 2 hours.
Question 3: In your testimony you mentioned that VHA is addressing
quality and accuracy of C&P exams for PTSD through training and
certification. Please provide the Committee the syllabus for this
training and the process by which certification takes place. Who is the
certifying agency and is competency being certified?
Response: The certifying agency is the employee education system
(EES) in cooperation with CPEP. Courses are completed and recorded in
the learning management system (LMS). There are six C&P certification
modules with an online test associated with each one. The courses are:
(1) general C&P certification, (2) musculoskeletal, (3) initial PTSD,
(4) review PTSD, (5) initial mental diseases, and (6) review mental
Diseases. The certification process ensures that the examiner has
completed the training module and has passed a test certifying their
knowledge and competency in understanding the requirements of a C&P
exam. CPEP also maintains a separate list of certified C&P providers. A
copy of the syllabus is attached. [The copies of the syllabus are being
retained in the Committee files.]
Question 4: What is the status of the Best Practices Manual for
PTSD C&P Exams? Is it mandated for all PTSD C&P exams? Are there any
plans to continuously update the manual?
Response: The Best Practices Manual for PTSD C&P Exams is not
currently mandated for all PTSD C&P exams. The manual is dated June 5,
2002, and VA does not currently plan to revise it. VA does however plan
to update the Mental Disorders section of the VA Schedule for Rating
Disabilities (VASRD). VA exam protocols and guidance will be modified
consistently with any future VASRD revisions as appropriate.
Question 5: Are the electronic templates for PTSD C&P exams
mandated? Are they available and used consistently throughout the
VISNs?
Response: CAPRI templates are not mandated. VA is aware that the
current template application is not yet a fully mature application and
is known to present some problems in data input for providers.
Question 6: Does VHA have designated C&P examiners for mental
health or is it a collateral duty?
Response: Both methods are used. This is a local decision; it is
made on a facility basis and varies from one examining site to another.
Some exams are completed by contract providers.
Question 7: Do you have access to Vet Center files when reviewing
the patient treatment record before a C&P exam?
Response: Vet Center counseling files are completely confidential
and are not electronic. If the Veteran chooses to share this
information, they can request that it be sent to the regional office
and incorporated into their claims file (C-File), thus giving the
examiner access to the information in those cases only.
Question 8: What feedback, if any, does VHA get from the CPEP
office?
Response: CPEP provides monthly and quarterly quality scores,
assessed by using quality indicator specific findings (which allows
facilities to target improvement efforts). In addition, CPEP provides
narrative explanations of our decisions in cases where the facility
disagrees with a CPEP ``unmet'' score. CPEP provides detailed
explanations on an individual basis to providers' questions regarding
quality indicators in order to improve exam quality.
Question 8(a): What does VHA do with those results?
Response: Quality scores are a performance measure for Veterans
Integrated Service Network (VISN) directors. Practices vary, but many
C&P facilities use the feedback for instructional purposes for their
examiners.
Question 8(b): Are examiners held accountable for inaccurate or
incomplete exams?
Response: CPEP does not hold individual examiners accountable for
inaccurate or incomplete exams. We review and score the exam reports
for quality indicators and for timeliness. We do not track the accuracy
of C&P exam reports. Incomplete exams would likely be identified as
they would score poorly on our quality review. Given the sampling
strategy (statistically significant at the VISN level based on a full
fiscal quarter of data), CPEP review findings are not statistically
significant for individual examiners.
Question 9: Are primary care providers taking a complete military
history when a Veteran first enrolls at a VA Medical Center?
Response:
Primary care providers perform a complete history and physical (H&P)
when a Veteran is first assigned to the provider. A portion of the H&P
is seeking information about military service to ensure proper
screening for identified Veteran-specific concerns such as traumatic
brain injury (TBI), Agent Orange, and PTSD.
Question 10: In an era of changing warfare and tactics, is it safe
to say that a stressor can be the result of individual perception? For
instance, can the hardships of war, such as witnessing extreme poverty
and destruction also be traumatic?
Response: The definition of a stressor as it occurs in the
Diagnostic and Statistical Manual of the American Psychiatric
Association, DSM-IV-TR, includes the concept that events are stressors
because of the perception of the individual who experiences them. No
explicit list of stressors is given. Rather, the stressor must meet two
criteria:
1. ``The person experienced, witnessed, or was confronted with an
event or events that involved actual or threatened death or serious
injury, or a threat to the physical integrity of self or others;
2. The person's response involved intense fear, helplessness, or
horror.''
The two examples in this question, extreme poverty and destruction,
could meet this definition, if they involve ``threatened death or
serious injury, or a threat to the physical integrity of self or
others,'' if the individual who perceives such situations responds with
``intense fear, helplessness, or horror.'' For example, seeing
destruction in which there was clear loss of life or that created new
threats to physical safety, for example after an earthquake while
aftershocks continue, might be considered such a stressor. Extreme
poverty that resulted in the death or potential death of others also
could create such an experience. The question suggests that these might
be considered stressors because of ``changing warfare and tactics'';
again, the identification of such events as potential stressors has
always been a component of the DSM-IV-TR definition of PTSD. Poverty
and destruction are characteristics of many wars, throughout human
history, not just a consequence of ``changing warfare and tactics.''
The crucial issue is whether the experiences fit the parameters
thoughtfully laid out in DSM-IV-TR in defining stressors that meet
Diagnostic Criterion A in the overall diagnostic criteria for PTSD.
Question 11: In its testimony, the Vietnam Veterans of America
noted the significant contributions of the National Vietnam Veterans
Readjustment Study to inform our understanding of disabilities related
to service in Vietnam. Public Law 106-419 required VA to conduct the
National Vietnam Veterans Longitudinal Study and report by October 1,
2004, which it has not done. Please provide VA's plan and timeline for
implementing this study to bring the Department into compliance with
the law.
Response: When initially completed back in 1988, the National
Vietnam Veterans Readjustment Study (NVVRS) did make a contribution to
better understanding disabilities, including PTSD, in Vietnam Veterans.
Many other research studies conducted since that time have even further
improved our knowledge of the health care needs of Vietnam Veterans.
VA is committed to answering the questions in Public Law (P.L.)
106-419; however, there are serious scientific concerns about using the
National Vietnam Veterans Longitudinal Study (NVVLS) approach to
adequately answer the questions. The concerns include:
The NVVLS has not undergone independent scientific peer
review to evaluate methodology, assess merit or ascertain feasibility.
The NVVRS used a complex and unconventional method to
diagnose PTSD that has not been used in other studies. Since the NVVRS
serves as the basis for the NVVLS according to P.L. 106-419, this is a
serious constraint.
The NVVRS was not designed as a longitudinal cohort
study, causing possible bias in followup. The feasibility of re-
connecting with the original participants of the NVVRS is unknown, but
likely to be low as longitudinal studies plan ways to keep cohorts
intact through continuous contacts over time to ensure high
participation rates.
Because of these concerns, VA has alternatively supported a broad
portfolio of rigorous scientific studies dedicated to addressing the
needs of the Vietnam Veteran population. Notably, the Department has
funded major research efforts, including the Vietnam Era Twins Registry
(VET-R) longitudinal followup study entitled, A Twin Study of the
Course and Consequences of Post-Traumatic Stress Disorder (PTSD) in
Vietnam Era Veterans and is planning a study entitled, Determining the
Physical and Mental Health Status of Women Vietnam Veterans. In
addition to ongoing research, these two studies will provide answers to
the questions posed in P.L. 106-419, for both male and female Vietnam
Veterans. Detailed study overviews and timelines are attached.
On January 16, 2009, the Secretary of Veterans Affairs, wrote to
the House and Senate Committees on Veterans' Affairs and Subcommittees
on Military Construction, Veterans Affairs and Related Agencies,
Committees on Appropriations, requesting that the studies proposed as
alternatives to a followup on NVVLS be accepted in lieu of the proposed
followup in P. L. 106-419.
Attached are overviews and timelines for the Vietnam Era Twins
Registry and the Long-term Health Outcomes of Women Veterans' Service
in Vietnam:
Attachments to Question 11
VA Cooperative Studies Program 569
A Twin Study of the Course and Consequences of
PTSD in Vietnam Era Veterans
Study Overview and Timeline
Study Overview
The purpose of this study is to describe and characterize the long-
term course and consequences of Post-Traumatic Stress Disorder (PTSD)
in Vietnam era Veterans. CSP #569 will estimate the impact of the
longitudinal course of PTSD on medical and psychiatric conditions and
on functioning and disability. CSP #569 is a followup of a national
sample of 7,172 male Vietnam era Veteran twins who were enrolled in the
Vietnam Era Twin (VET) Registry in 1987. These Veterans were
diagnostically assessed for PTSD in 1992 and are known to be alive in
2007. The study will collect new data using a structured psychiatric
assessment to assess current PTSD and, when combined with PTSD data
from 1992, will be used to describe the long-term course of PTSD. A
questionnaire will be used to collect information on physical health
such as cardiovascular disease (validated by medical record review) and
diabetes. Assessments of mental health outcomes, including depression,
generalized anxiety disorder and substance use disorders, will also be
conducted. Factors that may be related to the course and consequences
of PTSD, such as physical health, health habits, psycho-social
measures, and health services utilization will be collected. New data
will be combined with extensive archival data (spanning over 20 years
of studies from the VET Registry), and analyzed using epidemiologic and
biometrical genetic methods. It is expected that results from this 4.5-
year study will have broad implications for the health and health care
delivered to Vietnam era Veterans as well as Veterans of recent wars.
In addition to this specific study, many efforts have been directed
toward updating the entire VET Registry, including seeking IRB approval
to re-consent the entire cohort.
Study Timeline
April 2006 Planning request approved.
May 2006 Planning Committee membership approved.
October 2006 Planning Committee meeting #1.
October 2006 Co-principal proponents appointed; VAMC approval.
January 2007 Planning Committee meeting #2.
February 2007 Planning Committee meeting #3.
April 2007 Proposal submitted for peer review.
June 2007 Peer review; funding approval.
October 2007 Human rights committee approval.
February 2008 Revision to VET Registry recommended by ORO.
March 2008 Contractor selected.
May 2008 Protocol submitted to IRB.
July 2008 Executive committee meeting.
August 2008 Registry newsletter mailing with study information.
August 2008 Protocol submitted for Seattle R&D Committee approval.
Sept 2008 Final submission of VET Registry protocol to IRB.
October 2008 Study protocol submitted to VA Central IRB.
January 2009 Central IRB approval (with minor modification).
March 2009 VET-Registry consent begins.
May 2009 Recruitment/enrollment begins (tentative).
Mar 2009-Jun 2011 Data collection via mail survey & telephone interview.
Through 2011 Data and safety monitoring continues.
December 2011 Study closeout; publish findings.
VA Cooperative Studies Program 579
Long-term Health Outcomes of Women Veterans' Service in Vietnam
Study Overview and Timeline
Background
The VA Office of Research and Development (ORD) has aggressively
pursued an understanding of the causes and consequences of PTSD in
women Veterans. For example, the recently completed ``Clinical Trial of
Cognitive Behavioral Treatment for Post-Traumatic Stress Disorder in
Women Veterans'' was a large, multi-site randomized clinical trial
focusing exclusively on female Veterans and active duty personnel. It
is important because of its focus on treatment exclusively for women
Veterans as well as the evaluation of a psychotherapy. Results were
published JAMA February 2007 and directly impact VA PTSD treatment. In
addition, CSP566, ``Neuropsychological and Mental Health Outcomes of
OIF: A Longitudinal Cohort Study'' was approved for funding in 2007.
CSP566 will use scientifically validated methods to assess the risk
factors, prevalence, course, and consequences of PTSD, anxiety and
depression, and traumatic brain injury (TBI) following deployment to
Iraq, and is the first study ever that captured baseline performance
data prior to military service for long-term follow up. VA Central IRB
approval was obtained on February 19, 2009. In Spring 2008, VA senior
leadership determined that these activities were not sufficient to meet
the demands of fully understanding the course and consequences of PTSD
in Vietnam era women, thus, CSP579 was approved for planning and is
described below.
CSP579 Overview
ORD is planning a large-scale, cross-sectional study to assess
general and mental health status and health service utilization in the
population of women Vietnam Veterans. Many studies have examined the
effects of combat or military service in male Veterans; less is known
however about the consequences of military service for women,
especially those who served during the Vietnam era. CSP579 will focus
on determining prevalence of physical and mental disorders, including
PTSD, and the possible relationship with Vietnam war-time and war-zone
experience in women Veterans. The prevalence of medical conditions,
including cardiovascular disease, diabetes, neurologic disease, and
gender specific cancers, will be determined, and the relationship
between PTSD and functional status. This information will be valuable
in understanding the current mental and physical health care status of
women who served in the military during the Vietnam era and determining
their health care needs. The study planning Committee is comprised of
scientific experts in epidemiology, women's health, health services,
and psychological health, and is informed by women Vietnam Veterans
including representatives on the planning Committee. Prior to the
formal planning process, multiple discussions and meetings have taken
place: to solicit stakeholder input and potential interest, to meet
with Women in Military Service to America Foundation, to identify
questions of interest, and to define the population parameters.
In addition to the women's study described here, ORD recommends
pursuit of multiple scientific approaches to meet the intent of the
legislation to ``help the VA to better understand the long-term mental
health and social needs of Vietnam Veterans'' and to ``prepare the VA
for the long-term needs of Iraq and Afghanistan Veterans who are
returning in record numbers with PTSD.'' Meeting these comprehensive
goals require multiple, peer-reviewed studies. ORD has long been
studying the Vietnam Veteran population and their needs, and more
recently has aggressively supported studies to evaluate the newest
generation of Veterans. All told, these studies will help VA clearly
understand the needs of the Veteran population, and also provide the
best treatment our health care system can provide. The following
provides the timelines for CSP566 and CSP579:
CSP566 Study Timeline
Prior to 2006 Initial baseline, cohort development and data collection managed
under DoD administration.
2005 Letter of intent approved for planning longitudinal data
collection
under VA administration.
2006 Planning Committee meetings and protocol development.
Study publication JAMA, pre and post deployment Time 1 findings.
2007 Approved for funding.
2008 Kick-off meeting.
Executive committee approved and EC meetings convened.
Submission to VA Central IRB (approved on 2/19/2009).
2009 Subject enrollment begins.
2009-2011 Data collection continues; data and safety monitoring.
2012 Study closeout; results published.
CSP579, Long-term Health Outcomes of Women Veterans' Service in Vietnam
Study Timeline (Draft)
May and June 2008 VA conducted individual phone calls with senior
representatives of stakeholder groups.
July 2008 VA convened conference call with stakeholders.
August 2008 VA CSP coordinating center (CSPCC) began planning.
October 2008 Co-principal proponents appointed.
October 2008 Planning committee membership developed.
October 2008 Weekly telephone conference calls begin with study team.
November 2008 Plan to develop cohort, including validation and recruitment
strategy.
December 2008 First planning committee meeting to define specific aims,
sampling strategy, and methodology.
Dec 2008-Apr 2009 Planning committee develops study proposal.
February 2009 Second planning committee meeting to finalize protocol and
proposed budget.
April 2009 Proposal submission for scientific peer review.
June 2009 Scientific panel to review proposal and consider
recommendation for funding.
After proposal is approved for funding:
Summer 2009 Administrative startup; solicit bids for survey contract.
September 2009 Finalize protocol and survey contract. Submit protocol to
human rights committee.
October 2009 Protocol submission to VA Central IRB. Protocol submission
to R&D committee.
November 2009 Appoint executive committee. Incorporate IRB suggestions
(plan for resubmission if needed).
December 2009 Hold Kick-off meeting.
January 2010-2011 Recruitment/enrollment data collection/Data and safety
monitoring.
2012 Study closeout; publish findings.
Question 12: At the hearing, you testified that primary care
providers have been instructed to screen all generations of Veterans
for a Traumatic Brain Injury (TBI), PTSD, and Substance Abuse. Please
provide a breakdown of those screened who have TBI, PTSD, or Substance
Abuse by period of service, gender, and race.
Response: Data are available to address some, but not all of the
information requested. The standard is that all Veterans should receive
initial screening for TBI, PTSD and substance use disorder (SUD).
PTSD and SUD. The following tables provide information on the
percent of all Veterans screened by gender and race for PTSD and SUD in
FY 2008. Empty cells denote no users of VA services who needed a screen
completed in the timeframe covered. Overall, VA screened 86 percent of
all Veteran patients due for PTSD screening and 91 percent of all
Veteran patients due for SUD screening. Since Veterans have the right
to refuse to participate in screening, this represents a likely upper
limit on the level of screening that can be obtained:
--------------------------------------------------------------------------------------------------------------------------------------------------------
Percent of Veterans Screened for PTSD, by Age group, Gender, and Race/Ethnicity, in FY 2008
---------------------------------------------------------------------------------------------------------------------------------------------------------
Amer. Hispanic Hispanic
Indian Asian Black Black White White Unknown TOTAL
--------------------------------------------------------------------------------------------------------------------------------------------------------
under 30 female * * * * * 100% 77% 78.3%
--------------------------------------------------------------------------------------------------------------------------------------------------------
under 30 male * * 100% * * 100% 82% 83.1%
--------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55 female 100% 100% 82% * 50% 68% 84% 81.4%
--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55 male 100% 75% 84% 62% 56% 81% 84% 82.9%
--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55 Unknown * * * * * * 94% 94.4%
--------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55 female * * 80% * 75% 85% 81% 82.7%
--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55 male 88% 83% 86% 61% 52% 86% 87% 86.7%
--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55 Unknown * * * * * * 94% 94.3%
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total--PTSD 85.6%
--------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------
Percent of Veterans Screened for SUD, by Age group, Gender, and Race/Ethnicity, in FY 2008
---------------------------------------------------------------------------------------------------------------------------------------------------------
Amer. Hispanic Hispanic
Indian Asian Black Black White Unknown White TOTAL
--------------------------------------------------------------------------------------------------------------------------------------------------------
under 30 female * * 100% * 89% 100% 90.0%
--------------------------------------------------------------------------------------------------------------------------------------------------------
under 30 male * * 100% * 100% 87% 88% 86.9%
--------------------------------------------------------------------------------------------------------------------------------------------------------
under 30 Unknown * * * * * 66% * 66.7%
--------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55 female 100% 100% 86% 100% 93% 88% 83% 87.2%
--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55 male 90% 86% 84% 92% 82% 89% 86% 88.0%
--------------------------------------------------------------------------------------------------------------------------------------------------------
31-55 Unknown * * * * * 96% * 95.5%
--------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55 female 100% 100% 83% 100% 90% 91% 92% 91.4%
--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55 male 93% 89% 88% 86% 86% 91% 91% 91.4%
--------------------------------------------------------------------------------------------------------------------------------------------------------
over 55 Unknown * * 100% * * 91% * 91.1%
--------------------------------------------------------------------------------------------------------------------------------------------------------
Grand Total--SUD 90.6%
--------------------------------------------------------------------------------------------------------------------------------------------------------
The second part of the question involves how many of those screened
received a diagnosis of PTSD or SUD. By use of a randomized sample of
all patients seen in primary care, the Office of Quality and
Performance is currently tracking the results of the screen of Veterans
for PTSD. To be ``eligible'' for the screen, the Veteran must not have
a diagnosis of PTSD as a focus for care in the past 12 months; plus for
those who separate from service, the screen is performed annually for
the first 5 years after separation and then every 5 years thereafter.
The sample does not distinguish between ``new'' to VHA or Veterans in
ongoing care. The sample also does not record gender, race/ethnicity,
or era of service.
A FY 2008 sample included chart reviews of approximately 116,000
Veterans who met the above criteria. Of those, 97 percent were screened
for PTSD and 6.5 percent screened positive. Of those with a positive
screen, results indicate that 39 percent received a complete evaluation
by the time of the chart review (i.e., the others were in the process
of a full evaluation but were not yet completed). Of those with a
completed evaluation, 11.7 percent had a new diagnosis of PTSD, 12.5
percent were found to have had a diagnosis of PTSD greater than 1 year
ago and had apparently recurred, and 75.7 percent were not found to
have PTSD and were false positives. There must be caution in the
interpretation of this data. It cannot be used to estimate the
prevalence of PTSD in the full population, as the full population of
Veterans is not seen within VHA. In addition, the screen process does
not account for those patients in whom the clinician determines a
diagnosis based on presentation of symptoms by the patient outside the
screening process. These data do provide information that the screen is
a worthwhile process to assist in the identification of patients with
PTSD.
A comparable chart review process is underway in the Office of
Quality and Performance for Substance Use Disorder, but data are not
available at this time.
TBI. Reported diagnostic data are only applicable to the VA
patients--a population actively seeking health care--and do not
represent Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)
or other Veterans not enrolled for VHA health care. Further, VA does
not screen all generations of Veterans for TBI, but does screen all
Veterans from OEF/OIF. Compliance with TBI screening for OEF/OIF
Veterans is a VA measure of performance. From April 2007-January 31,
2009, VA has screened 270,022 OEF/OIF Veterans for possible TBI, of
which 17,179 have been confirmed with a diagnosis of mild TBI.
Demographic information is as follows:
----------------------------------------------------------------------------------------------------------------
Screened for TBI Definitive TBI Diagnosis*
----------------------------------------------------------------------------------------------------------------
Total 270,022 17,179
----------------------------------------------------------------------------------------------------------------
American Indian or Alaska Native 2,389 218
---------------------------------------------
0.9% 1.3%
----------------------------------------------------------------------------------------------------------------
Asian 5,106 238
---------------------------------------------
1.9% 1.4%
----------------------------------------------------------------------------------------------------------------
Black or African American 38,196 1,907
---------------------------------------------
14.1% 11.1%
----------------------------------------------------------------------------------------------------------------
Native Hawaiian or Other Pacific Islander 2,851 198
---------------------------------------------
1.1% 1.2%
----------------------------------------------------------------------------------------------------------------
White 155,492 10,999
---------------------------------------------
57.6% 64.0%
----------------------------------------------------------------------------------------------------------------
Declined to Answer 3,945 318
---------------------------------------------
1.5% 1.9%
----------------------------------------------------------------------------------------------------------------
Unknown 2,372 195
---------------------------------------------
0.9% 1.1%
----------------------------------------------------------------------------------------------------------------
Missing 59,671 3,106
---------------------------------------------
22.1% 18.1%
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
Total 270,022 17,179
----------------------------------------------------------------------------------------------------------------
Female 33,560 912
---------------------------------------------
12.4% 5.3%
----------------------------------------------------------------------------------------------------------------
Male 236,345 16,260
---------------------------------------------
87.5% 94.7%
----------------------------------------------------------------------------------------------------------------
Unknown 117 7
----------------------------------------------------------------------------------------------------------------
* Attachment to Question #11.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
April 7, 2009
Maureen Murdoch, M.D., MPH
Core Investigator, Center for Chronic Disease Outcomes Research
Minneapolis Veterans Affairs Medical Center
Veterans Health Administration
U.S. Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420
Dear Ms. Murdoch:
Thank you for testifying at the House Committee on Veterans'
Affairs' Subcom-
mittee on Disability Assistance and Memorial Affairs hearing on
``The Nexus between Engaged in Combat with the Enemy and PTSD in an Era
of Changing Warfare Tactics,'' held on March 24, 2009. I would greatly
appreciate if you would provide answers to the enclosed followup
hearing questions by Monday, May 4, 2009.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for material for all full
committee and subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your responses
to Ms. Megan Williams by fax at (202) 225-2034. If you have any
questions, please call (202) 225-3608.
Sincerely,
John J. Hall
Chairman
__________
Questions for the Record
The Honorable John J. Hall, Chairman
Subcommittee on Disability Assistance and Memorial Affairs
House Committee on Veterans' Affairs
Nexus Between Engaged in Combat With the Enemy and PTSD in an Era of
Changing Warfare Tactics
March 24, 2009
Questions for Maureen Murdoch, M.D., MPH
Question 1: The studies you have conducted raised great concern
over how fairly VA evaluates and compensates Veterans for PTSD. Other
studies since yours seem to replicate your findings. So, in regard to
women Veterans, how can VA do a better job of meeting their needs in
the compensation process?
Response: Since my data were collected almost 10 years ago, it is
unclear whether those findings still pertain. In addition, the
discrepancy in rates of service connection between men and women that I
described seemed to be less an issue of gender and more one of combat
exposure versus sexual assault. For example, men who reported sexual
assault were as unlikely as sexually assaulted women to be service
connected for PTSD. Rates of service connection for combat-exposed men
and women were roughly the same. Near the time of my research, VBA
liberalized the evidentiary standard for service connecting PTSD
related to sexual assault, and it launched several training initiatives
to train claims processors on how to process claims related to personal
assault. VBA also has a women's advisory group whose job is to alert
leadership about emerging issues related to women Veterans, and women
Veterans coordinators at all regional offices to assist women Veterans
in developing their claims. Before making additional recommendations
for changing the way VBA processes sexual assault claims, I would
suggest that my research be updated and replicated. Of course,
eradicating military sexual assault would be the very best strategy for
dealing with these issues.
Question 2: Does VA need to do additional research and track female
Veterans during the claims process, especially in cases of military
sexual trauma?
Response: VA tracks granted claims for post-traumatic stress
disorder (PTSD) due to personal trauma, but does not capture
information about the nature of the verified in-service stressor(s)
when a Veteran is awarded service-connected disability compensation for
PTSD. VA defines personal trauma as events of human design that
threaten or inflict harm that have lingering physical, emotional, or
psychological symptoms. Military sexual trauma (MST) is one of the
potential causes for PTSD. However, MST may also be a factor in the
development of other service-related conditions, such as physical
injury or depression.
Question 2(a): What else might you suggest for research?
Response: The VA disability system is second only to Social
Security Disability Insurance in terms of scope and size, and I believe
there are a great number of fruitful questions related to VA's
disability system that researchers could explore. Replicating my
earlier study to see if gender and race disparities in rates of PTSD
service connection still exist might be one obvious avenue of research.
I believe the most innovative, vibrant, and helpful research tends to
come through specific calls to the field, e.g., in the form of requests
for proposals (RFP). RFPs tend to attract very bright and creative
researchers while emphasizing the importance of the topic. Any
submitted proposals also benefit by being subjected to scientific peer-
review, thus ensuring rigor.
Question 3: You also noted a finding of racial disparities among
Veterans and PTSD awards, but did not draw a conclusion as to what was
causing those disparities. Can you provide any further insights in
these areas? Has there been any follow-up to that finding or are there
plans to study these rating imbalances by race?
Response: Again, keep in mind that the data is 10 years old and I
was unable to draw a conclusion as to what caused the racial disparity.
The difference did not seem to be related to racial differences in PTSD
symptoms, levels of self-reporting functioning, or combat exposures. I
am currently examining the long-term impact of receiving or not
receiving PTSD service connection on outcomes such as PTSD symptom
severity and work, role, and social functioning. I plan to see if race
interacts with PTSD service connection to affect outcomes. However, I
am not aware of any follow-up findings or plans by others to examine
race imbalances.