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july/august 2007

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PTSD/Substance Abuse COMMITTEE REPORT

BY TOM BERGER, CHAIR
Back in the fall of 2005, the office of Sen. Larry Craig (R-Idaho) announced that the VHA had contracted with the National Academies’ Institute of Medicine (IOM) to conduct a review of PTSD diagnoses, treatment, and compensation. The press release stated that the IOM would form two committees to conduct its review—one committee was “to review the literature of various treatment modalities (including pharmacotherapy and psychotherapy),” while the other committee was to review “the objective measures used in the diagnosis of PTSD and known risk factors for the development of PTSD,” and “the utility and objectiveness of the criteria in the DSM-IV and will comment on the validity of current screening instruments and their productive capacity for accurate diagnoses.” Upon completion, the PTSD reviews are to be forwarded to the Veterans’ Disability Benefits Commission, which is charged with the overall review of the VA’s compensation system.

After the IOM committees were constituted, this committee chair and members of the VVA national staff presented testimony for the record at every IOM committee meeting. Subsequently on May 8, the IOM review of PTSD and compensation (entitled “PTSD and Compensation for Military Service”) was released (Note: The separate National Academies’ IOM committee report addressing PTSD treatment issues will be released later in 2007), and I am pleased to note that most, if not all, of VVA’s recommendations and suggestions were incorporated into this first IOM report. Among the many findings were the following:

Standardized psychological testing of claimants may be a useful adjunct to the PTSD C&P examination, but not a substitute for a thorough clinical evaluation.

PTSD can develop at any time after exposure to a traumatic stressor.

A standardized training program should be developed for clinicians conducting C&P evaluations for PTSD.

VA should establish a specific certification program for raters who deal with PTSD claims, with the training to support it and periodic re-certification.

Research reviewed by the committee indicates that PTSD compensation does not, in general, serve as a disincentive to seeking treatment.

It is not appropriate to require across-the-board periodic re-examinations for veterans with PTSD service-connected disability.

The determination of whether and when re-evaluations of PTSD beneficiaries are carried out should be made on a case-by-case basis using information developed in a clinical setting. Specific guidance on the criteria for such decisions should be established so that these can be administered fairly and consistently.

VA should conduct more detailed data gathering on determinants of service connection and rating levels for military sexual assault-related PTSD claims and develop and disseminate reference materials for raters that more thoroughly address the management of such claims. More research is also needed on gender differences in vulnerability to PTSD.

Does this mean an end to the entire hullabaloo over PTSD disability claims? We don’t think so. Stay tuned for the next IOM report. The National Academies’ May 8 news release and report are accessible at http://national-academies.org

DOD MENTAL HEALTH ADVISORY TEAM SURVEY
On May 7, DoD’s MHAT-IV survey was released; it was the fourth in a series of studies since 2003 to assess the mental health and well-being of the deployed forces serving in Iraq. Although scheduled for release last November, reasons for the delay were not announced. The MHAT-IV, conducted in August and October of last year, assessed more than 1,300 soldiers and, for the first time, nearly 450 Marines. The commanding general of Multinational Force, Iraq, also requested a first-ever study of battlefield ethics with the participation of soldiers and Marines currently involved in combat operations.

Significant findings include:

Soldiers who deployed longer (greater than six months) or had deployed multiple times were more likely to screen positive for a mental-health issue.

Approximately 10 percent of soldiers reported mistreating noncombatants or damaging their property when it was not necessary.

Less than half of soldiers and Marines would report a team member for unethical behavior.

More than one-third of all soldiers and Marines reported that torture should be allowed to save the life of a fellow soldier or Marine.

The 2006 adjusted rate of suicides per 100,000 soldiers was 17.3, lower than the 19.9 rate reported in 2005, but higher than the Army average of 11.6 per 100,000. However, there are important demographic differences between these two populations that make direct comparisons problematic:

Soldiers experienced mental health-problems at a higher rate than Marines.

Deployment length was directly linked to morale problems in the Army.

Leadership is key to maintaining soldier and Marine mental health.

Both soldiers and Marines reported at relatively high rates—62 and 66 percent, respectively—that they knew someone seriously injured or killed, or that a member of their team had become a casualty.

PTSD AND REDEPLOYMENT
According to a November 2006 memo issued by the assistant secretary of defense, psychotic and bipolar disorders automatically disqualify someone from being redeployed to combat by the military—but PTSD does not. The memo calls the disorder treatable, although it says the potential for effective treatment is considered on a case-by-case basis that takes into account a soldier’s vulnerabilities and demands of the job.

If soldiers are diagnosed outside the military health system, such as at a VA hospital or a family doctor’s office, it’s up to them to raise the issue—although officials say they are working to share medical records more easily between the military and Veterans Affairs. Army officials have not responded to repeated requests for the number of soldiers with PTSD who are now deployed.

COALITION TROOPS AND PTSD
According to a soon-to-be-published article in The British Journal of Psychology, the number of British military reservists suffering mental-health problems after tours of duty in Iraq has doubled in the past four years. The report suggests that reservists may need more official support after returning from operations. It also suggests that part-timers experience increased stress because of family and civilian employment pressures caused by their absence from home and job.

Almost 13,000 reservists have served in Iraq and Afghanistan to plug gaps in the regular forces and perform a range of specialist roles in short supply among their full-time counterparts. Most part-timers are also deployed as individual replacements or in small groups, while regulars are sent as 500-strong battalions or 100-man “bolt-on” reinforcement rifle companies or armored squadrons used to living and working together.

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