Combat PTSD or Adjustment Disorder? Saving Money, Not Lives

Last year, a firestorm erupted when it was found that 24,000 or more OEF/OIF veterans had been booted out of the military with Personality Disorder discharges. PD (once labeled "Section 8") discharges are a quicker and more cost-efficient way of dealing with service members who are exhibiting problematic behavior.

The problem, of course, was that some of the discharged were combat-injured Purple Heart recipients who may have instead been coping with PTSD, a fact that would allow them access to VA health care benefits to treat their condition.

This week, we've moved from the military's diagnoses of Personality Disorder over PTSD to a Texas VAMC PTSD program coordinator advising that Adjustment Disorder diagnoses should be handed out over that of PTSD. The reason given? Saving money.

From the Washington Post:

"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." VA staff members "really don't . . . have time to do the extensive testing that should be done to determine PTSD," Perez wrote.

"Adjustment disorder is a less severe reaction to stress than PTSD and has a shorter duration, usually no longer than six months, said Anthony T. Ng, a psychiatrist and member of Mental Health America, a nonprofit professional association.

"Veterans diagnosed with PTSD can be eligible for disability compensation of up to $2,527 a month, depending on the severity of the condition, said Alison Aikele, a VA spokeswoman. Those found to have adjustment disorder generally are not offered such payments, though veterans can receive medical treatment for either condition. ...

"Veterans Affairs Secretary James B. Peake said in a statement that Perez's e-mail was "inappropriate" and does not reflect VA policy. It has been "repudiated at the highest level of our health care organization," he said. "VA's leadership will strongly remind all medical staff that trust, accuracy and transparency is paramount to maintaining our relationships with our veteran patients," Peake said."

Citizens for Responsibility and Ethics in Washington (CREW) and VoteVets released a copy of the email on Thursday.

In educational interest, article(s) quoted from extensively.

The fallout, from AP:

"Two congressional committee chairmen said Friday they plan to investigate whether there were broader motives behind a Veterans Affairs Department employee's e-mailed suggestion to diagnose veterans with mental disorders that have a lower disability payout.

"Sen. Daniel K. Akaka, D-Hawaii, chairman of the Senate Veterans Affairs Committee, said he has asked the VA's Inspector General to review diagnosis patterns at the facility. ...Akaka said in a statement that he asked Peake to provide renewed guidelines to all VA offices on the proper treatment of PTSD cases.

"Last week, House Veterans Affairs Committee Chairman Bob Filner, D-Calif., called Peake before his committee to answer questions about a different set of e-mails that had surfaced during a trial that seemed to suggest VA officials were hiding the number of veterans who were trying to commit suicide. Filner asked Peake to fire those involved with the e-mails, but Peake said after the hearing that he had no plans to do so.

"Filner said Friday in an interview at his office that he will likely ask Peake to appear again to answer more questions. Filner said he wants to know what motivated the Texas employee to send the e-mail about saving the VA money. "Where is she getting it from?" Filner said. "Why is she saying this? Who is giving her the order?"

"Although the employee was a team leader, VA spokeswoman Alison Aikele said Friday that the woman was not in management and her e-mail was just a suggestion. "We're not aware of any other instances where this happened," Aikele said."

Senator Barack Obama is also calling for a formal investigation. In addition, CREW has filed a Freedom of Information Act [pdf] request "asking for all records pertaining to any guidance given [the VA] regarding the diagnosis of PTSD."

To help in understanding the difference between Adjustment Disorder and PTSD, some helpful definitions from a 2006 brochure produced by the US Army Center for Health Promotion and Preventive Medicine [pdf]:

An Overview of Deployment-Related Stress

Our bodies and minds are built to deal with and handle stress. Sometimes, though, the amount of stress we face overwhelms our defenses. When this happens, we start to act, feel, and think in ways that are different from what is normal for us - we just don't feel "right," or we feel like we can't do the things we are used to doing.

Whether these problems are mild or serious and whether they last for a short time or a long time depends on the nature of the stress and the strength of our defenses at the time the stress occurs. Keep in mind, though, that the strength of everyone's defenses varies over time based on what else is going on in their lives and their overall health.

For the most part, there are four kinds of deployment-related stress problems that you should know about. These are...

* Combat/Operational Stress Reactions (COSRs)
* Adjustment Disorders
* Acute Stress Disorder (ASD)
* Posttraumatic Stress Disorder (PTSD)

You can think of COSRs as being the mildest and most common form of deployment-related stress problems and PTSD as the most severe. Another way of thinking about this is to say that Soldiers experiencing COSRs are in the Green/Amber Zone, Soldiers with Adjustment Disorders are in the Amber Zone, and Soldiers with ASD or PTSD are in the Red.

Any deployment-related stress problem can be serious, but most are resolved quickly with just a little bit of help. ...

Adjustment Disorders
Adjustment Disorders are much more common than either PTSD or ASD and, on the whole, are usually much less serious. An Adjustment Disorder occurs when an individual is exposed to stress, causing a reaction that results in significant distress or impairment. That reaction can involve depression, anxiety, disturbance of conduct, or any combination of the above.

Principle Types of Adjustment Disorders

* Adjustment Disorder with Depressed Mood
* Adjustment Disorder with Anxiety
* Adjustment Disorder with Mixed Anxiety and Depressed Mood
* Adjustment Disorder with Disturbance of Conduct
* Adjustment Disorder with Mixed Disturbance of Emotions and Conduct

In general, Adjustment Disorders do not last for extended periods of time. Symptoms may start to appear as long as three months following the stressor, but are usually resolved in no more than 6 months.

And finally, a personal account by former Army Sergeant Kristofer Shawn Goldsmith, an Iraq veteran diagnosed with Adjustment Disorder, who testified before Congress earlier this week at a hearing organized by the Congressional Progressive Caucus [view C-Span coverage; read written testimony]. He is a member of Iraq Veterans Against the War, and his story may shed light on the genesis of the severity of psychological injuries and disillusionment that some returning soldiers carry home with them from war:

While deployed in support of Operation Iraqi Freedom III, the morale of Soldiers in 3-15 Infantry was very low. This was aggravated by the unit's Command and the tactics they used to attain reenlistment numbers. In the summer of 2005 the Battalion Command Sergeants Major and the Brigade Command Sergeant Major locked Soldiers who refused to reenlist in a room for hours, demanding that we sign up for a meeting with a career councilor. This included Soldiers who were affected by the Stop-Loss policy, who if not for the deployment they were currently on, would have already separated from Active Duty. Most of the Stop-Lossed Soldiers had already been deployed in OIF-I. I personally refused to consider reenlistment, and instead of being allowed to hydrate and prepare my gear for an upcoming patrol, I was kept in this room for over three hours. This reenlistment tactic put my life, and the lives of those I worked with, in real physical danger.

During this time my Battalion Command Sergeant Major attempted to make each of us who remained in the room believe that none of us could succeed in life outside of the Army. This is common practice in attempting to gain reenlistment numbers for my former unit. Our command would prey on the Soldiers who because of the stress of deployment felt hopeless about their future. These Soldiers who may have been candidates for therapy, were instead used to meet the Army's required unit reenlistment numbers while they were obviously distressed. Another unethical tactic often used by 3-15 to increase reenlistment numbers was to give the option to Soldiers who tested positive for drug use to reenlist in order to make the test results "disappear". This tactic was well known in my Battalion. ...

The ineffectiveness of 3-15 IN's role during OIF-III led to an immediate pitfall in troop morale. Upon returning home to America in December 2005 and January 2006, there was little for we, the Soldiers, to be proud of. Although we were automatically considered as 'heroes' for having served overseas, all that we really did well in Sadr City was do our best to keep each other alive. The tremendous sacrifice of taking more than one thousand Soldiers from 3-15 IN away from their homes and families to spend eight months in Sadr City and having them accomplish nothing of real value, was forever damaging to those who made the sacrifice.

As with any group who have deployed, some came home with serious mental issues, such as Post Traumatic Stress Disorder and Severe Chronic Depression. As we were preparing to leave Iraq, we were given a mental screening test, which was supposed to identify possible mental ailments. But we were warned by the medical staff issuing the test that "should you come up positive for mental problems, you could be forced to stay in [Iraq] for three to four more months before you can go home." Most lied while completing the test because they wanted to get home as soon as possible. No one was held in Iraq any longer due to this test, but in hindsight, it is clear that verbal warning was used to prevent the inconvenience to the Army of having Soldiers that needed medical attention.

Alcoholism, drug use and violence plagued the unit upon our return home. Relationships stressed from a year long deployment resulting in dozens of divorces, while many men were arrested for Driving Under the Influence or domestic assault. The eight months in Sadr City, the total year long deployment in Baghdad, has not left the psyche of anyone who served in 3-15 IN during OIF-III. Most Soldiers whose contract was up with the Army after the OIF-III Stop-Loss policy expired, left without ever seeking council for Mental Health problems, because they feared it could possibly extend their time in the Army or make getting out more difficult.

For those who still had time to serve in the Army, getting help for alcoholism or mental issues was viewed as one of the most damaging things they could do to their careers. During weekly safety briefings as per the Army's mandate, commanders would almost jokingly say "if you're thinking about killing yourself, don't be afraid to get some help". However, it was in the back of everyones minds that if they were found to be a "broken Soldier" or diagnosed with any mental illness, as with any physical illness, it could prevent them from promotion of favorable action by the unit. Moreover, real instructions were not provided to inform Soldiers of the availability of mental health assistance on Fort Stewart either verbally or in written form by commanders, or by being posted on the information boards in the company areas.

I am one of the Soldiers who was too intimidated to get help when I first realized that I needed it. Suffering from depression and alcoholism in 2006, I came up for promotion to Sergeant (E-5) that May and had to hide my problems to protect my career. With the active duty part of my contract expiring in May 2007, I had every reason to believe I was never going to set foot in Iraq again, and would be going to college in fall of 2007.

With the troop surge of last year, Goldsmith's plans fell through.

The Stop-Loss and Stop-Movement Orders came to my unit soon after the plan for the Surge was announced. Those orders meant that no Soldier, for any reason other than administrative separation, could leave the unit until three months after the unit returned home from its deployment. The Troop Surge meant that my Brigade, 2nd Brigade, 3rd Infantry Division, was going to deploy three months earlier- in may 2007. In reaction the the early deployment, my unit immediately scheduled two months of field training exercises from the end of January 2007 until mid March 2007. Faced with so much isolation from family and loved ones and an impending fifteen to eighteen month deployment, over a dozen Soldiers from 1-30 IN went Absent With-Out Leave (AWOL). Many Soldier affected by Stop-Loss began to stop caring about training and acted out while on duty, while drug tests increasingly had higher levels of positive testing results. I personally found myself extremely frustrated during field exercises and was verbally reprimanded on a few occasions for not having greater control of myself.

On multiple occasions between January and March 2007, I attempted to seek mental counseling but initially had no success in finding help. As recommended by my unit, I asked the Medical Platoon of 1-30 IN and received guidance to find a building close to my company which held the Mental Health team of the Third Infantry Division. I found this building to be abandoned, and received no further instruction on how to find the Mental Health team.

On March 27 2007, I admitted myself to the emergency room at Winn Army Community Hospital on Fort Stewart complaining of what I believed to be a heart attack. After various cardiac screenings, I tested negative for any physical problem and after confiding in the doctor that I had been feeling depressed and under extreme stress, I was finally given accurate instructions on how to find the Mental Health Division at Winn Army Community Hospital. I was told to sign in as an emergency patient as a possible suicide risk at the front desk. After anxiously waiting nearly six hours in a waiting room I was finally seen by a therapist, who diagnosed me with Adjustment Disorder with Disturbance of Emotions and Conduct. Although I showed the obvious symptoms of PTSD, I was not diagnosed with it at this time. Months later, after separating from Active Duty, I was finally diagnosed with PTSD by the Veterans' Affairs Hospital at Northport, New York.

I was then recommended by the therapist to attend group therapy sessions run by Colonel Ana Parodi twice weekly because one-on-one counseling was mostly unavailable due to the Third Infantry Division Mental Health team having been overwhelmed by Soldiers and the families of Soldiers who needed assistance. I attended as many sessions as I could, but found few positive results. Each session held for approximately 90 minutes contained only one Psychologist, Colonel Ana Parodi, and up to two dozen patients. Unlike typical group therapy, the patients attending varied in age, social status, rank in the military, and civilian relation to members of the military. No two patients seemed to have the same problem, so the therapeutic experience was minimal for all attending. I frequently witnessed people leaving in frustration because the sessions seemed more harmful to them than helpful. There were many times when patients were asked to leave due to overcrowding in the room. Most everyone seemed disappointed with the care that we were receiving, however, this was the best treatment available to the Soldiers of Fort Stewart, so we kept coming just hoping for things to get better.

Things did not improve. Goldsmith attempted suicide and was later threatened with an Article 15 violation. His closing words:

In my testimony, I have specifically mentioned just three of the victims of the Troop Surge and the Stop-Loss Policy. Thirty thousand American Soldiers were directly affected by George Bush's Troop Surge. Thousands of those Soldiers were like me, Stop-Lossed, forced to serve on active duty beyond the date they signed on their contract. Most are still currently overseas. Those who are not overseas have either been administratively separated from the Army and lost their benefits as I have, or have been injured and possibly lost a limb or an eye and medically evacuated from combat, or have lost their lives.

Most Soldiers are eligible for upwards of forty thousand dollar, tax-free reenlistment bonuses while overseas; but many are choosing instead not to reenlist, and to simply wait until the Army releases them from their involuntarily extended contracts. This is happening while suicide rates among Veterans are at the highest rate since they began keeping such records in 1980. Last year, about 2,100 soldiers injured themselves or attempted suicide, compared with about 350 in 2002, according to the U.S. Army Medical Command Suicide Prevention Action Plan. Reports from the Veterans Affairs (VA) state that approximately 20% of Veterans are returning from Iraq with symptoms of PTSD and Depression, 70% of which do not seek help through the Army Medical system or VA. Each deployment reportedly makes a Soldier 60% more likely to have contract a mental illness.

Some of the best, most qualified, and patriotic Americans of my generation have grown tired of repeat deployments in support of a mission with unclear or impossible objectives, and refuse to fight any longer. Stop-Lossed Soldiers should be seen as not as part of "an all volunteer force" but as silent protesters, who refuse large sums of money and have chosen to just wait out their time rather than continue serving Our Nation. In reality, Stop-Lossed Soldiers, a huge part of the Troop Surge, are simply prisoners of the contracts which bind them into a war they no longer wish to fight.

Harsh words that make many uncomfortable -- or even angry -- to be sure, but they are reflections that we must consider with as much weight as those that more easily fulfill our need of doing right and good by each other. Both views are correct. Both views are valid. Both views are required for us to explore and understand if we are to wrap our head around the events and situations that lead some of our veterans to become disillusioned, to return home with injuries that many of us would prefer not to see.