I am including the two Salon articles here, as well as a commentary by David Dobbs of Neuron Culture, who has written for Scientific American that PTSD is a mess of a diagnosis in that needs serious revision.
Here is some of the first article:
"I am under a lot of pressure to not diagnose PTSD"
A secret recording reveals the Army may be pushing its medical staff not to diagnose post-traumatic stress disorder. The Army and Senate have ignored the implications.
Editor's note: Last June, during a medical appointment, a patient named "Sgt. X" recorded an Army psychologist at Fort Carson, Colo., saying that he was under pressure not to diagnose combat veterans with post-traumatic stress disorder. Listen to a segment of the tape here.
By Michael de Yoanna and Mark Benjamin
Salon image / AP photo
Listen to a segment of the recording of an Army psychologist at Fort Carson, Colo., saying that he was under pressure not to diagnose combat veterans with post-traumatic stress disorder.
April 8, 2009 | FORT CARSON, Colo. -- "Sgt. X" is built like the Bradley Fighting Vehicle he rode in while in Iraq. He's as bulky, brawny and seemingly impervious as a tank.
In an interview in the high-rise offices of his Denver attorneys, however, symptoms of the damaged brain inside that tough exterior begin to appear. Sgt. X's eyes go suddenly blank, shifting to refocus oddly on a wall. He pauses mid-sentence, struggling for simple words. His hands occasionally tremble and spasm.
For more than a year he's been seeking treatment at Fort Carson for a brain injury and post-traumatic stress disorder, the signature injuries of the Iraq war. Sgt. X is also suffering through the Army's confusing disability payment system, handled by something called a medical evaluation board. The process of negotiating the system has been made harder by his war-damaged memory. Sgt. X's wife has to go with him to doctor's appointments so he'll remember what the doctor tells him.
But what Sgt. X wants to tell a reporter about is one doctor's appointment at Fort Carson that his wife did not witness. When she couldn't accompany him to an appointment with psychologist Douglas McNinch last June, Sgt. X tucked a recording device into his pocket and set it on voice-activation so it would capture what the doctor said. Sgt. X had no idea that the little machine in his pocket was about to capture recorded evidence of something wounded soldiers and their advocates have long suspected -- that the military does not want Iraq veterans to be diagnosed with PTSD, a condition that obligates the military to provide expensive, intensive long-term care, including the possibility of lifetime disability payments. And, as Salon will explore in a second article Thursday, after the Army became aware of the tape, the Senate Armed Services Committee declined to investigate its implications, despite prodding from a senator who is not on the committee. The Army then conducted its own internal investigation -- and cleared itself of any wrongdoing.
When Sgt. X went to see McNinch with a tape recorder, he was concerned that something was amiss with his diagnosis. He wanted to find out why the psychologist had told the medical evaluation board that handles disability payments that Sgt. X did not, in fact, have PTSD, but instead an "anxiety disorder," which could substantially lower the amount of benefits he would receive if the Army discharged him for a disability. The recorder in Sgt. X's pocket captured McNinch in a moment of candor. (Listen to a segment of the recording here.)
"OK," McNinch told Sgt. X. "I will tell you something confidentially that I would have to deny if it were ever public. Not only myself, but all the clinicians up here are being pressured to not diagnose PTSD and diagnose anxiety disorder NOS [instead]." McNinch told him that Army medical boards were "kick[ing] back" his diagnoses of PTSD, saying soldiers had not seen enough trauma to have "serious PTSD issues."
"Unfortunately," McNinch told Sgt. X, "yours has not been the only case ... I and other [doctors] are under a lot of pressure to not diagnose PTSD. It's not fair. I think it's a horrible way to treat soldiers, but unfortunately, you know, now the V.A. is jumping on board, saying, 'Well, these people don't have PTSD,' and stuff like that."
Contacted recently by Salon, McNinch seemed surprised that reporters had obtained the tape, but answered questions about the statements captured by the recording. McNinch told Salon that the pressure to misdiagnose came from the former head of Fort Carson's Department of Behavioral Health. That colonel, an Army psychiatrist, is now at Fort Lewis in Washington state. "This was pressure that the commander of my Department of Behavioral Health put on me at that time," he said. Since McNinch is a civilian employed by the Army, the colonel could not order him to give a specific, lesser diagnosis to soldiers. Instead, McNinch said, the colonel would "refuse to concur with me, or argue with me, or berate me" when McNinch diagnosed soldiers with PTSD. "It is just very difficult being a civilian in a military setting."
McNinch added that he also received pressure not to properly diagnose traumatic brain injury, Sgt. X's other medical problem. "When I got there I was told I was overdiagnosing brain injuries and now everybody is finding out that, yes, there are brain injuries," he recalled. McNinch said he argued, "'What are we going to do about treatment?' And they said, 'Oh, we are just counting people. We don't plan on treating them.'" McNinch replied, "'You are bringing a generation of brain-damaged individuals back here. You have got to get a game plan together for this public health crisis.'"
When McNinch learned he would be quoted in a Salon article, he cut off further questions. He also said he would deny the interview took place. Salon, however, had recorded the conversation.
On the tape and in his interview with Salon, McNinch seemed to admit what countless soldiers not just at Fort Carson but across the Army have long suspected: At least in some cases, the Army tries to avoid diagnoses of PTSD. But McNinch did not directly address why the Army discourages these diagnoses, in either the interview with Salon or the tape-recorded encounter with Sgt. X.
The answer probably has to do with money.
Here is some of the follow-up article, published this morning. The Army and the Senate dismiss the story as false, despite the admissions of the doctor involved and other evidence uncovered by the Salon investigation.
Read the rest of this article.Tale of the secret Army tape
After a soldier taped a psychologist saying he'd been pressured not to diagnose PTSD, the Army launched an investigation. Read the details of how the Army declared itself innocent.
Editor's note: Read about Sgt. X's tape -- and listen to a segment of it -- in the first story in this series, "I Am Under a Lot of Pressure to Not Diagnose PTSD." Read a summary of the Army's internal investigation, in which it determined that it was not exerting such pressure, here.
By Mark Benjamin and Michael de Yoanna
April 9, 2009 | In a story published yesterday, Salon reported on a surreptitious tape recording of an Army psychologist telling a patient last June that he had been pressured not to diagnose soldiers as having post-traumatic stress disorder. The soldier, whom Salon dubbed Sgt. X to protect his identity, recorded the Fort Carson, Colo., psychologist, Douglas McNinch, twice describing pressure to label soldiers with "anxiety disorder" instead of PTSD. The diagnosis of anxiety disorder could result in improper treatment and lower disability payments if the Army discharges a soldier from the military. "It's not fair," McNinch said on the tape. "I think it's a horrible way to treat soldiers."
But neither the U.S. Senate nor the Army apparently agrees with McNinch's assessment of the treatment that returning soldiers are receiving. By early July, news of the tape recording had made its way to both the Senate Armed Services Committee and the upper reaches of the Pentagon. Despite prodding from Sen. Kit Bond, the Senate Armed Services Committee declined to investigate the tape's implications. A veterans' advocacy group then had a combative July 14 meeting at the Pentagon with the Army's vice chief of staff, at which the vice chief was reportedly dismissive. Two weeks later, the Army issued the results of an internal investigation and absolved itself of any wrongdoing.
Today's article describes the contentious meeting at the Pentagon, how the tape got to the Senate and the secretary of the Army in the first place, and which Senate aide determined it was not worth investigating. It also details how the individuals assigned by the Army to investigate the tape were connected both to the individual who had allegedly pressured McNinch not to diagnose soldiers as having PTSD and to earlier questionable in-house investigations of Army medical care.
Salon dubbed the soldier who made the tape "Sgt. X" because he is still in the process of being put out of the Army and he fears that if he is identified, it might affect the process meant to gauge his disability. He made the tape during a visit to McNinch's office in June so he could remember what the psychologist told him -- a traumatic brain injury suffered in Iraq has affected his short-term memory. When she heard what McNinch said about PTSD diagnoses on the tape, Sgt. X's wife handed the tape over to Georg-Andreas Pogany, an investigator with a group called the National Veterans Legal Services Program. The NVLSP is a group of lawyers who take on difficult medical entitlement cases for soldiers, free of charge.
Pogany told Salon that he found the tape shocking. On July 2, he handed it over to the Fort Carson's post commander, Maj. Gen. Mark Graham.
In a telephone interview, Graham refused to name Pogany as the man who gave him the tape, but confirmed that he had received it and that it set off alarms. "Anytime anyone brings me information regarding the health and welfare of our soldiers, I take it very seriously, as I did this," Graham said, adding that he has not yet seen the results of Army's internal investigation.
After receiving the tape, Graham forwarded it up the Army chain of command, where it ultimately wound up in the hands of Gen. Richard Cody, then the Army's vice chief of staff.
At about this same time, Sen. Kit Bond, R-Mo., a longtime champion of veterans' issues, also became aware of the tape. Bond's staff attempted to prod the Senate Armed Services Committee into an independent investigation of the implications of the tape, but were ignored.
Salon has learned that Gerald Leeling, a majority counsel to the Senate Armed Services Committee, was informed of the tape and its contents. Leeling reports to Sen. Carl Levin, D-Mich., the chairman of the committee. However, there is no evidence that Levin's committee ever launched an investigation or did anything to check whether the Army's investigation was thorough and unbiased.
Leeling did not respond to a request for an interview. A committee spokeswoman released a statement, essentially deferring to the official Army line: "The Army conducted an investigation into whether mental health providers at Fort Carson were being pressured by the Command to change diagnoses from PTSD to Anxiety Disorder. The investigation found that that there was no command pressure to influence diagnoses."
While the Senate was declining to act last July, there was building pressure within the Army to do something about the tape. (Heat would come from the outside as well -- though the timing of the contact is unclear, a spokeswoman for Sen. Bond confirms that the senator personally contacted Army Secretary Pete Geren to express alarm about the implications of the recording.)
On July 10, the Army initiated an investigation. In addition, Gen. Cody, the Army's second-most-powerful officer, contacted the NVLSP to arrange a meeting at the Pentagon.
The Pentagon's sprawling parking lot shimmered with heat as Bart Stichman, a co-executive director for the NVLSP, arrived for a face-to-face meeting with Cody last July 14, flanked by fellow co-executive director Ron Abrams and investigator Andreas Pogany.
It was already halfway through a year that would mark the highest suicide rate in Army history.
Finally, here is an article from David Dobbs at Neuron Culture on the issue of PTSD and whether or not it under- or over-diagnosed. He has written an article in the past for Scientific American that I posted and commented on here. Here are his thoughts on the Salon article.
Read the whole article.Can PTSD be both over- and underdiagnosed?
Posted on: April 8, 2009 11:26 PM, by David Dobbs
When you propose that we are overdiagnosing PTSD in vets, you run into not only a lot of flak but many offerings of evidence suggesting that we're missing a lot of cases. Since publishing my article on PTSD, I've received those arguments directly in comments, and on Wednesday, April 8, Salon published an article, "I am under a lot of pressure to not diagnose PTSD," by Michael de Yoanna and Mark Benjamin, that offers unsettling evidence that at least some doctors working for the VA are being pressed to not diagnose PTSD in combat vets.
So which is it? Are we under- or overdiagnosing PTSD in vets?
As I suggested in the article, and as the blogger Neuroskeptic suggested in a comment on another of my posts, the answer is almost certainly both. I won't repeat the evidence in the article and its supporting materials that we're overdiagnosing PTSD. But what about the evidence we're missing cases?
Two answers. First, as I noted in the article,
The idea that PTSD is overdiagnosed seems to contradict reports of resistance in the military and the VA to recognizing PTSD denials of PTSD diagnoses and disability benefits, military clinicians discharging soldiers instead of treating them, and a disturbing increase in suicides among veterans of the Middle East wars. Yet the two trends are consistent. The VA's PTSD caseload has more than doubled since 2000, mostly because of newly diagnosed Vietnam veterans. The poor and erratic response to current soldiers and recent vets, with some being pulled quickly into PTSD treatments and others discouraged or denied, may be the panicked stumbling of an overloaded system.Keep in mind that the VA is a huge, sprawling organization -- the biggest single part of the government -- and that different VA facilities can behave quite differently from one another, with some tending to overdiagnose and perhaps others not so much.
The military, meanwhile -- meaning the Army, Navy, Marines, and Air Force -- is driven by different criteria, policies, concerns, and cultures. Overall -- though this varies a lot by base, region, and even unit -- the military appears less friendly to giving PTSD diagnoses. The soldier on active duty has more to lose from a PTSD diagnosis than does a vet, and so is less likely to seek it (or other mental health help), and there are many reports of both the general culture and specific policies (de facto or official) discouraging recognition of PTSD or other forms of mental distress. And the military is under great strain from its overextension in Iraq and Afghanistan. So you have many soldiers under tremendous mental and psychological pressure even as the military is desperately trying to retain them.
That would account for the sort of resistance to PTSD diagnoses documented in the Salon article.
It's a deeply troubling article. But it doesn't prove we aren't overdiagnosing PTSD. It is perfectly possible that we can overdiagnose a condition -- that is, mistakenly give diagnoses of Condition A to a lot of people who have something else -- while also missing and failing to treat people who actually have Condition A.
This is a highly challenging topic, especially because it concerns the military and an apparent effort to deny benefits to those who have served our country bravely and honorably.
Perhaps PTSD is diagnosed in general, but I suspect that is not the case among veterans of war. More than anyone else, these people have long-term psychological damage from what they have seen and experienced - and they need our help to regain a measure of balance in their lives. We owe them that much and more.
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