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Introduction: The author of this article, Diane L. Elmore, PhD, MPH, will participate in a workshop, "How ISTSS Can Make a Difference: The Work of the Public Policy Committee" at the ISTSS Annual Meeting, November 15-17 in Baltimore.
 

Federal officials in the United States are focusing greater attention on the issue of posttraumatic stress disorder (PTSD) among service members involved in the conflicts in Afghanistan and Iraq. This attention has been demonstrated by several new studies by the Institute of Medicine, frequent congressional hearings and briefings, countless new legislative proposals, and ongoing investigations by government agencies. ISTSS members have been among those who were asked to share their expertise and participate in the national health policy debate on this critical issue. This article provides an overview of some of these new federal policy initiatives related to PTSD.  

Institute of Medicine Studies Related to PTSD
The Institute of Medicine (IOM) is a nonprofit organization that provides unbiased, evidence-based information and advice concerning health and science to policy makers, professionals, leaders in every sector of society, and the public at large. In 2006, the IOM convened two important studies related to PTSD at the request of the U.S. Department of Veterans Affairs (VA).

The first study was titled, “Post-Traumatic Stress Disorder (PTSD): Diagnosis and Assessment.” This study committee reviewed the scientific literature related to the diagnosis and assessment of PTSD and addressed a series of specific questions from VA regarding diagnosis and assessment. Committee members included:

  • Richard Mayeux, MD, MSc (chair), Columbia University;
  • Kathryn Karusaitis Basham, PhD, MSW, Smith College of Social Work;
  • Dennis Charney, MD, Mount Sinai School of Medicine;
  • Michael Davis, PhD, Emory University;
  • Dwight Evans, MD, University of Pennsylvania School of Medicine;
  • Jack Gorman, MD, Harvard Medical School/McLean Hospital;
  • Janice Krupnick, PhD, Georgetown University;
  • Bruce McEwen, PhD, Rockefeller University;
  • Jerrold Rosenbaum, MD, Massachusetts General Hospital/Harvard Medical School;
  • Carol North MD, The University of Texas Southwestern Medical Center at Dallas (consultant).

Of the committee members, Charney, Davis, Krupnick, McEwen and North are ISTSS members. The Committee released its final report in June 2006, which provided an overview of the evidence base related to the diagnosis and assessment of PTSD (including relevant assessment instruments) and laid the groundwork for a second study regarding compensation issues.

The second study was entitled “Veterans’ Compensation for Post Traumatic Stress Disorder,” an issue which has generated considerable debate on Capitol Hill and in the media. This study committee was charged with reviewing VA’s compensation practices for PTSD (including examining the criteria for establishing severity of PTSD as published in the Schedule for Rating Disabilities); the basis for assigning a specific level of compensation to specific severity levels and how changes in the frequency and intensity of symptoms affect compensation practices for PTSD; how VA’s compensation practices and reevaluation requirements for PTSD compare with those of other chronic conditions that have periods of remission and return of symptoms; and strategies used to support recovery and return to function in patients with PTSD.

Members of the Committee included several former ISTSS presidents:

  • John Fairbank, PhD, Duke University Medical Center/National Center for Child Traumatic Stress;
  • Bonnie Green, PhD, Georgetown University Medical School; and
  • Dean Kilpatrick, PhD, National Crime Victims Research and Treatment Center/Medical University of South Carolina.

Additional Committee members included:

  • Nancy Andreasen, MD, PhD (Chair), University of Iowa Carver College of Medicine;
  • Jacquelyn Campbell, PhD, RN, FAAN, The Johns Hopkins School of Nursing;
  • Judith Cook, PhD, University of Illinois, Chicago;
  • Kurt Kroenke, MD, Indiana University;
  • Richard Kulka, PhD, Abt Associates Inc./Duke University;
  • Patricia Owens, MPA, Independent Consultant,;
  • Robert Reville, PhD, RAND Institute of Civil Justice;
  • David Salkever, PhD, University of Maryland-Baltimore County/National Bureau of Economic Research; and
  • Robert Ursano, MD, Uniformed Services University of the Health Sciences.

Both Kulka and Ursano are ISTSS members. In May 2007, the Committee released its final report, “PTSD Compensation and Military Service,” which provided several important recommendations for improving the veterans’ compensation system.

Congressional Hearing - Mental Health Problems Confronting Soldiers Returning from Iraq, Afghanistan
On May 24, John Fairbank, PhD, former ISTSS president and member of the IOM Committee on Veterans’ Compensation for PTSD, testified at a hearing held by the House of Representatives Committee on Oversight and Government Reform related to the mental health needs of returning service members. In his congressional testimony, Dr. Fairbank presented an overview of the key conclusions of the IOM Committee report and shared some observations drawn from his experience as a VA psychologist and as a researcher on PTSD and veterans’ health.

Additional hearing witnesses included Army Specialist Thomas Smith; Richard and Carol Coons, parents of Army Master Sergeant James Coons; Tammie LeCompte, wife of Army Specialist Ryan LeCompte; Army Specialist Michael Bloodworth; Thomas Insel, MD, director, National Institute of Mental Health; Michael Kilpatrick, MD, deputy director, Force Health Protection and Readiness Programs, Department of Defense; Antonette Zeiss, deputy chief consultant, Office of Mental Health Services, Department of Veterans Affairs; Major General Gale Pollock, Army Surgeon General. For more information on this hearing and to view the testimony of the witnesses, please visit http://oversight.house.gov/story.asp?ID=1330.

PTSD and Personality Disorders
Earlier in 2007, allegations that military service members were being inappropriately diagnosed with personality disorders and improperly discharged were the subject of much media attention. Members of Congress expressed concern that some service members may have been misdiagnosed and that legitimate claims of PTSD (and other disorders) might have been overlooked. In recent months, federal policy makers have taken several important actions in response to these concerns regarding PTSD and personality disorders.

Congressional Hearing - PTSD and Personality Disorders: Challenges for the VA
On July 25, the House of Representatives Committee on Veterans’ Affairs held a hearing related to PTSD and personality disorders which highlighted some of the high profile discharge cases recently reported in the media, discussed the way in which the VA addresses personality disorders, and reviewed the recent IOM report on PTSD Compensation and Military Service. Among those invited to testify at this important congressional hearing included Dean Kilpatrick, PhD, former ISTSS president and member of the IOM Committee on Veterans’ Compensation for PTSD. In his testimony, Dr. Kilpatrick provided a brief background regarding PTSD, an overview of the VA compensation process, and some of the key recommendations of the IOM Committee on Veterans’ Compensation for PTSD.

Specifically, Dr. Kilpatrick highlighted three IOM Committee recommendations to improve the compensation evaluation process for veterans with PTSD, including: the need for compensation and pension exams to be done by mental health professionals who are adequately trained in PTSD and who are allotted adequate time to conduct the exams; the current VA disability rating system should be substantially changed to focus on a more comprehensive measure of the degree of impairment, disability, and clinically significant distress caused by PTSD; and the VA should establish a certification program for raters who deal with PTSD claims.

Other hearing witnesses included:

  • Jason Forrester, director of policy, Veterans for America;
  • Jonathan Town, veteran;
  • Joshua Kors, reporter, The Nation, and contributor, ABC News;
  • Paul Sullivan, executive director, Veterans for Common Sense;
  • Tracie Shea, PhD, psychologist, Veterans Affairs Medical Center, Providence, RI;
  • Sally Satel, MD, resident scholar, American Enterprise Institute;
  • Ira Katz, MD, PhD, deputy chief, Patient Care Services for Mental Health, Veterans Health Administration;
  • Colonel Bruce Crow, PhD, chief, Department of Behavioral Medicine, Brooke Army Medical Center and clinical psychology consultant to the Army Surgeon General.


Government Accountability Office Study and Legislative Proposals
Congress recently instructed the Government Accountability Office (GAO), the federal agency responsible for providing oversight of the federal government, to conduct a review of the Department of Defense (DoD) screenings, diagnoses, referrals and treatment of service members who may have PTSD and other mental heath conditions related to their service in Iraq and Afghanistan. In addition, federal policy makers in both the House of Representatives and the Senate have introduced legislation that would temporarily suspend service member discharges due to personality disorders.