Army's new PTSD guidelines fault Madigan's screening tests
By Hal Bernton | The Seattle Times | Published: April 22, 2012
The Army Surgeon General's Office has issued new guidelines for diagnosing PTSD that criticize an approach once routinely used at Madigan Army Medical Center.
The policy, obtained by The Seattle Times, specifically discounts tests used to determine whether soldiers are faking symptoms of post-traumatic stress disorder. It says that poor test results do not constitute malingering.
The written tests often were part of the Madigan screening process that overturned the PTSD diagnoses of more than 300 patients during the past five years.
Madigan medical-team members cited studies that said fabricated PTSD symptoms were a significant — and often undetected — phenomenon. They offered the tests as an objective way to help identity "PTSD simulators" among the patients under consideration for a medical retirement that offers a pension and other benefits.
The team's approach once was called a "best practice" by Madigan leaders, including Lt. Gen. Patricia Horoho, a former commander who now serves as the Army's surgeon general. But earlier this year, amid patient protests about overturned diagnoses, the team was shut down as the Army launched several investigations.
Though none of the Army findings have been publicly released, the April 10 "policy guidance" from the surgeon general charts new directions for PTSD screening at Madigan and elsewhere in the Army medical system.
PTSD is a condition that results from experiencing a traumatic event, such as a battlefield casualty. Symptoms can include recurrent nightmares, flashbacks, irritability and feeling distant from other people.
Some people recover from PTSD. For others, it may be a lifelong struggle.
The new policy downplays the frequency of soldiers faking symptoms to gain benefits, citing studies indicating it is rare. It also rejects the view a patient's response to the hundreds of written test questions can determine if a soldier is faking symptoms for financial gain, and it declares that a poor test result "does not equate to malingering, which requires proof of intent... "
Broad approach to issue
The new policy offers broad guidance on how the Army medical staff should evaluate and treat patients for PTSD, a condition affecting 5 to 25 percent of soldiers returning from combat zones. The 17-page document was distributed to commanders throughout the Army medical system.
During more than a decade of war, the Army's handling of PTSD often has been contested.
Some soldiers at Madigan and elsewhere have alleged their symptoms were improperly discounted and they were unfairly denied medical retirements.
Within the Army and Department of Veterans Affairs, others have argued PTSD has been over-diagnosed, and they pushed for improved ways to ferret out malingerers.
The surgeon general's policy document says PTSD is being under — not over — diagnosed. It states that most combat veterans with PTSD do not seek help, and as a result their conditions are not recognized and identified.
The policy also questions the use of a class of drugs in treating anxiety in troops with PTSD and other mental conditions.
The document found "no benefit" from the use of Xanax, Librium, Valium and other drugs known as benzodiazepines in the treatment of PTSD among combat veterans. Moreover, use of those drugs can cause harm, the Surgeon General's Office said. The drugs may increase fear and anxiety responses in these patients. And, once prescribed, they "can be very difficult, if not impossible, to discontinue," due to significant withdrawal symptoms compounded by PTSD, the document states.
The policy also said the harm outweighs the benefits from the use of some antipsychotics, such as Risperidone, which have shown "disappointing results" in clinical trials involving PTSD.
PTSD patients may frequently have other physical and mental-health problems. The new memorandum encourages a range of treatment options, including yoga, biofeedback, massage, acupuncture and hypnosis.
"Very welcome step"
Sen. Patty Murray, who earlier this year pressed for investigations of the Madigan screening team, calls the new policy guidance "an overdue but very welcome step."
"It shows that the Army has been responsive to many of the concerns that have been raised, and I'm hopeful similar directives will be given to all branches of the military," said Murray, a Washington Democrat and chair of the Senate Veterans' Affairs Committee.
Andrew Pagony, a veteran who assists other soldiers in the medical-retirement process, says the big question is whether the policy will be followed by the Army medical establishment.
"On the surface, this absolutely is moving in the right direction," he said. "There have been plenty of policies published in the past that weren't followed."
More than five years ago, Pagony helped document the struggles of Fort Carson, Colo., soldiers as they returned home from combat duty. Then, PTSD was seldom rated as a condition debilitating enough to render soldiers unfit for duty and eligible for a medical retirement with pension.
In 2008, Congress approved an overhaul of the disability system, saying a soldier rendered unfit for duty by PTSD qualified for a medical retirement.
Since then, the number of Army personnel with PTSD receiving a temporary disability (the first step in the retirement process) has escalated sharply. More than 2,790 soldiers were given a PTSD-related temporary disability in 2011, more than a fivefold increase since passage of the congressional overhaul.
The pensions, health insurance and other retirement benefits are financed through the Defense Department, which is facing significant budget cuts as Congress struggles to trim federal spending.
In a controversial presentation to colleagues last fall, Dr. William Keppler, then the leader of the Madigan screening team, said a PTSD diagnosis could cost as much as $1.5 million over the lifetime of a soldier, and he urged staff to be good stewards of taxpayer dollars.
Keppler is a forensic psychiatrist whose work had helped Madigan gain a national reputation for innovative screening for PTSD before questions were raised about the accuracy of his team's diagnoses.
Soldiers evaluated by the screening team often took the Minnesota Multiphasic Personality Test, which consists of more than 500 true-or-false questions. Some are relatively straightforward, such as questions about sleep and anxiety. Others are designed to detect patterns of exaggeration, such as answers that reflect what people think mental illness is like rather than what it is actually like.
Most of the screenings also included patient interviews. But some of the soldiers who went through the process told The Seattle Times the interviews often felt confrontational, at times hostile.
More than 300 patients screened by Keppler's team are now being offered re-evaluations by new screening teams established at Madigan. The results of the new examinations have not been announced.
All this has spurred plenty of debate at Madigan and in the broader Army medical community.
One forensic team member, Dr. Juliana Ellis-Billingsley, quit in February, and in a letter of resignation blasted the Madigan investigations as a charade.
The surgeon general's policy memorandum notes that many soldiers have become wary of the Army's mental-heath care providers. It calls for a "culture of trust" that will give more soldiers confidence to seek help.