Quashing PTSD

The ~~government~~ VA is trying to cut costs by influencing diagnosis:

A psychologist who helps lead the post-traumatic stress disorder program at a medical facility for veterans in Texas told staff members to refrain from diagnosing PTSD because so many veterans were seeking government disability payments for the condition.
“Given that we are having more and more compensation seeking veterans, I’d like to suggest that you refrain from giving a diagnosis of PTSD straight out,” Norma Perez wrote in a March 20 e-mail to mental-health specialists and social workers at the Department of Veterans Affairs’ Olin E. Teague Veterans’ Center in Temple, Tex. Instead, she recommended that they “consider a diagnosis of Adjustment Disorder.”

Comments

Anonymous
1. I have spoken to two psychiatrists who were former civilian employees of the defense department who left over the issue of undue pressure regarding diagnoses. That is of course inappropriate and it is unethical to buckle to such pressure. If one is unable to defy them, then it is unethical to work there. It is wrong.
2. On the other hand, data suggest that PTSD rates after intense combat, are quite high. Nearly 80% of Guadacanal vets had substantial symptoms still 40 years later. The rates of full occupational disability in that group were quite low however. Just because one is miserable, never gets a peaceful nights sleep, and wakes up every night with nightmares not only does not mean that one can’t work the next day, but it doesn’t even mean that one isn’t better off working. Suffering is not lessoned by having endless free time to contemplate it.
The problem with VA disability being easily abused to the detriment of not only the public purse but in reality to the Veteran himself is real–both due to the potential for malingering and exageration as well as real PTSD symptoms that neither lesson with idleness nor require it.
The notion that PTSD = disability is not one the nation can sustain as it creates a ridiculous and financially non-viable situation where a huge portion, maybe the majority, of men who serve in combat are on the dole the rest of their natural lives.
The answer is not dishonesty, but improving the system of assigning disability. At least since the gunpowder age, the fact that a great many men come home from war different has been well known, and never before was considered a basis for a life of living without working.
David Hager, M.D.
I’m very disturbed by the wildly absurd political spin given to an email by Dr. Perez containing appropriate clinical thinking. I don’t know anything about Dr. Perez. Maybe she’s a good doc … maybe she’s not. However, I see nothing wrong at all with what she wrote. I merely heard her to be endorsing mindful diagnosis.
Since when do we castigate a clinician for being careful? Would this same discussion be occurring if she were talking about cancer? “Given that cancer has serious implications, I’d like to suggest that you refrain from giving a diagnosis of cancer straight out …”
Further, one of the responsibilities inherent to the medical/psychological professions is stewardship, a responsibility not well taught during education and training. Society’s resources are not unlimited and must be carefully distributed to those who need them most. Failure on our part to do this forces others to manage us, instead.
Finally, psychiatric diagnosis is not precise. A lifetime disability determination MUST be grounded in a careful evaluation over time, with reliance upon multiple sources of information. Doing less is fundamentally insulting to the mental health profession and to those who are truly disabled.
Anonymous
I agree with Dr. Hagar regarding the need to be careful etc. This email is not the only evidence that I have heard of undue pressure. Care in making the diagnosis is called for. But diagnositic accuracy and the potential harm to the patient of an inaccurate diagnosis are the proper reasons for caution–not Stewardship. If the reason for the leash being jerked is concerns of about excess disability payments, then the method of awarding those payments must be reassessed. Psychiatric disability is not, to my knowledge dependent on diagnosis and should never be awarded on that basis.
Does the VA allow it’s clinicians to see enough of the patients for a “careful evaluation over time” by psychiatrists? Or does it relegate most patient contact to inadequatlely trained “mental health professionals”?
Bernie
I am a disabled Vietnam Veteran rated 50% for PTSD, 30% for other, and Individual unemployability for the full 100% disabled rating. I am also in the Central Texas Veterans Health Care System where this email originated. I do not know Dr. Perez personally but would like to comment on the VA system (specifically Central Texas). The primary problem is systemic going from upper management downward. The focus is on making management and the VA look good and not what is best for the patients. I can back this statement up, if needed. I would say that my PTSD hit full stride during the first Gulf War, but it wasn’t until I went into a major depression in 1996 that I sought help. The VA social worker I saw told me the first visit I had PTSD and sent me to a psychiatrist for further help and medications. I would love to work and be able to. Again, part of the problem is the VA system does not allow that freedom without serious penalty to benefits.

Quashing PTSD

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