VA Urged to Broaden Criteria for Assessing PTSD Disability

The Department of Veterans Affairs (VA) should place less emphasis on occupational impairment alone and use more comprehensive and consistent methods to evaluate veterans filing claims for disability from posttraumatic stress disorder, according to a report from the Institute of Medicine (IOM) released last month.

Psychosocial and occupational aspects of functional impairment should be evaluated separately.

“The emphasis on occupational impairment in the current criteria penalizes veterans who may be symptomatic or impaired in other ways but who are capable of working, and that could serve as a disincentive to both work and recovery,” said Nancy Andreasen, M.D., Ph.D., who chaired the IOM Committee on Veterans' Compensation for Posttraumatic Stress Disorder. She is also the Andrew H. Woods Chair of Psychiatry and director of the Neuroimaging Research Center at the University of Iowa Carver College of Medicine.

The report also found “abundant scientific evidence” that PTSD or its symptoms could appear many years after the incident that caused the traumatic stress.

Andreasen presented the committee's report to the Veterans' Disability Benefits Commission in Washington, D.C., on May 10.

The commission, on behalf of the VA, is examining diagnostic, clinical, and compensation issues regarding PTSD among military veterans. The wide-ranging study began after the VA's inspector general reported in 2005 that beneficiaries receiving compensation for PTSD rose from 120,265 in 1999 to 215,871 in 2004—an increase of 80 percent.

Last June, another IOM committee found that DSM-IV criteria for diagnosing PTSD were well founded and should remain the standard for diagnosis (Psychiatric News, July 21, 2006). A third study, on treatment issues, should be completed by autumn, said the commission chair, retired Army Lt. Gen. James Terry Scott. The final commission report and its recommendations are due by October 1, Scott told Psychiatric News.

The new report sought to address inadequacies in how the VA evaluates and compensates veterans for service-connected PTSD. Current methods used by the VA Schedule of Rating Disabilities were “crude” at best, said the IOM committee, partly because they placed all mental disorders under a single heading and often were applied inconsistently.

The present rating system relies heavily on the General Assessment of Functioning (GAF), a scale that was developed for schizophrenia and depression, not PTSD, said Andreasen, who helped write the definition of PTSD that appeared in the DSM-III.

“The GAF has limited usefulness in assessing PTSD for compensation,” she told the commission. However, the GAF was so embedded in the VA's current operations that its use should be temporarily continued, as long as raters understand both its uses and its limitations and are trained to use it uniformly and consistently.

“In the long term, the VA will need to find a replacement for the GAF, but that will take research,” said Andreasen, the former editor in chief of the American Journal of Psychiatry. “We need new criteria specific to PTSD and based on DSM-IV.”

Such a multidimensional framework should include general functional impairment, pain and suffering, quality of life, and treatment intensity and complexity, as well as work limitations, she said.

Most persons with PTSD also have other psychiatric disorders, such as depression or anxiety. The current VA compensation system is based on a separate evaluation of each diagnosis, yet there is no way to separate these comorbid disorders, as is possible, for example, with a broken leg and ruptured spleen.

She recommended that the VA establish a certification program specifically for raters who evaluate PTSD compensation claims and take steps to keep them up to date and their judgments consistent.

PTSD evaluations are not carried out in a standardized manner now, said Andreasen. To assess a patient, some raters take 20 minutes, while others take four hours.

“The VA should allocate the time and resources for experienced professionals to thoroughly examine each patient filing for a PTSD claim,” she said. Psychological testing is often desirable as part of this process but is not a substitute for clinical evaluation, she explained to the commissioners.

Andreasen said that the committee also considered whether receiving disability compensation would discourage veterans from seeking treatment. While some drop out of treatment once they begin receiving compensation, many more often seek treatment because they are able and motivated to do so. A state-of-the art initial compensation examination would reduce inappropriate claims and malingering, she said. Greater coordination of veterans' health and benefit services might also reduce disincentives and maximize incentives for veterans to seek treatment and achieve optimal functioning.

The committee also recommended, she continued, that the VA set a certain long-term minimum level of benefits available to all veterans with service-connected PTSD to provide a safety net that would take into account the relapsing/remitting nature of PTSD. Patients might be reevaluated on a case-by-case basis, but the committee opposed regular reevaluations as stigmatizing, Andreasen said.

Finally, the VA must upgrade its systems of data collection, analysis, and publication, she advised. Some VA data were unavailable to her committee because they were not collected, retained, or retrievable, she said.

The executive summary of the IOM report is posted at<http://books.nap.edu/execsumm_pdf/11870.pdf>.▪