VA should revise its methods for evaluating post-traumatic stress disorder

May 9 2007

To ensure more consistent and appropriate disability compensation for veterans, the U.S. Department of Veterans Affairs (VA) needs to revise how it evaluates former military personnel for service-connected post-traumatic stress disorder (PTSD) and determines the payment amounts they merit, says a new report from the Institute of Medicine and National Research Council.

A surge in the number of disability claims for PTSD has revealed inconsistencies in compensation levels awarded across the country, raising questions about the effectiveness of the VA's current ways of assessing and rating this condition, and whether some veterans are getting payments that are too low, too high, or unmerited.

The agency should develop new evaluation methods and rating criteria specific to PTSD to replace current standards that yield a crude and overly general assessment of PTSD disability, said the committee that wrote the report. It urged the VA to base compensation decisions on how greatly PTSD affects all aspects of a veteran's daily life, not just his or her ability to be gainfully employed.

The agency also should ensure that all veterans applying for PTSD compensation receive a thorough, initial evaluation by an experienced clinical professional. These exams should be of sufficient duration to provide a detailed picture of each veteran's condition so that disability raters -- non-clinical personnel who determine whether a disability is connected to military service and the level of impairment it entails -- can make more consistent and better informed decisions about the level of compensation each veteran merits. More thorough evaluations also would enhance VA's ability to detect inappropriate claims, though the committee confirmed that PTSD symptoms can manifest many years after a traumatic event or may interfere with a veteran's ability to function only later in life.

"As the increasing number of claims to the VA shows, PTSD has become very significant public health problem, particularly for veterans of current and past conflicts," said committee chair Nancy Andreasen, Andrew H. Woods Chair of Psychiatry and director, Psychiatric Neuroimaging Research Center, Carver College of Medicine, University of Iowa, Iowa City. "Our review of the current methods for evaluating PTSD disability claims and determining compensation indicates that a comprehensive revision is needed."

Recent years have seen a spike in PTSD claims and a significant increase in disability payments for the condition. The number of cases jumped almost 80 percent between fiscal years 1999 and 2004, growing from 120,265 cases to 215,871. Payments for PTSD increased almost 150 percent over the same period, rising from $1.72 billion to $4.28 billion. The bulk of claims for PTSD compensation currently are coming from Vietnam War veterans who comprise the majority of living veterans, but claims also are being made by former service personnel of earlier conflicts as well as personnel who served in the first Gulf War and in the current conflicts in Iraq and Afghanistan. There likely will be many more claims from the latter group in the future, so how this issue is resolved now will eventually affect many active duty personnel.

A thorough, initial evaluation by an experienced professional is crucial to improving PTSD compensation decisions, the committee said. These exams determine whether former service members are experiencing PTSD and how severe it is. Currently, the time devoted to the evaluations varies widely as does the amount of detail examiners provide to the raters who determine the appropriate level of compensation. Moreover, many veterans denied compensation eventually receive it after applying for re-evaluation, sometimes multiple times. Ensuring that every veteran making a claim receives a comprehensive evaluation could make the process more efficient.

The report offers a starting point to help VA devise new ratings criteria specific to PTSD. The committee emphasized the need to rate PTSD disability based on a fuller range of an individual's capacity to function, not just on his or her ability to work. The focus on occupational impairment in the current rating scheme penalizes veterans who can and do work despite their symptoms, and may serve as a disincentive to work, the report says.

Many disability claims are being submitted by veterans who have been out of military service for several years, which has prompted questions about how long after a traumatic event PTSD can manifest and whether standardized tests could detect dissembling if someone tried to make a fraudulent claim. The committee found abundant evidence that PTSD can develop at any time after exposure to trauma. It also can manifest as a relapsing condition or flare up after being suppressed and undiagnosed. Aging, loss of mental acuity, the death of friends or spouses, and other factors can trigger or exacerbate symptoms as well. Standardized tests can be a useful part of an assessment, but they are no substitute for a thorough clinical assessment by a trained professional, the committee concluded.

Combat exposure is not the only potential trigger for PTSD among service members; sexual assault is another form of trauma. The available information suggests that female veterans are less likely to receive compensation for PTSD, which may in part be due to the difficulty of substantiating exposure to traumatic events unrelated to combat, including sexual harassment or assaults that occurred during service. VA should make a concerted effort to gather data and provide reference materials to help disability raters better address the management of PTSD claims related to sexual assault during military service, the report says.

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