Thursday, April 9, 2009

"I am under a lot of pressure to not diagnose PTSD"

"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.

By Michael de Yoanna and Mark Benjamin

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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.


"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. David Rudd, the chairman of Texas Tech's department of psychology and a former Army psychologist, explained that every dollar the Army spends on a soldier's benefits is a dollar lost for bullets, bombs or the soldier's incoming replacement. "Each diagnosis is an acknowledgment that psychiatric casualties are a huge price tag of this war," said Rudd. "It is easiest to dismiss these casualties because you can't see the wounds. If they change the diagnosis they can dismiss you at a substantially decreased rate."

A recently retired Army psychiatrist who still works for the government, speaking on the condition of anonymity for fear of retribution, said commanders at another Army hospital instructed him to misdiagnose soldiers suffering from war-related PTSD, recommending instead that he diagnose them with other disorders that would reduce their benefits. The psychiatrist said he would be willing to say more publicly about the cases and provide specific names, but only if President Obama would protect him from retaliation.

Salon has dubbed the soldier in this article Sgt. X because he asked not to be identified for fear that it might affect the medical evaluation process meant to gauge his level of disability. He was highly reluctant to speak, but agreed to do so after learning Salon obtained the recording and other information about it from a medical worker at Fort Carson and a congressional aide.

The sergeant spoke with Salon in the presence of his Hogan & Hartson attorneys who are helping him to secure a proper disability discharge from the Army for PTSD and a brain injury, diagnoses now affirmed by independent doctors. Sgt. X never planned to go to the media -- he says, if asked, he will not talk further about the recording with news organizations.

Sgt. X probably received his traumatic brain injury when his Bradley Fighting Vehicle buckled in an explosion during his second deployment to Iraq in 2005-06. It was the worst of a handful of nearby blasts he'd survived, and it knocked him unconscious for 30 seconds.

When Sgt. X regained consciousness, he saw that the toes of another soldier had been sheared off. The tank hull had buckled and the inside had filled with smoke. Some of his fellow soldiers were soaked in blood..

Even after that, as a point of pride, the crew insisted on accompanying their disabled tank back to their headquarters. Besides causing his brain injury, the blast had exacerbated an injury to Sgt. X's hip, but he faced the problem with little complaint. He numbed the pain with Motrin. "You don't report problems," he said. "It's a stigma."

When Sgt. X returned from the war to Colorado Springs, though, he had a problem with anger. After he terrified his young son by screaming at him, Sgt. X's wife suggested he seek help.

Nearly breaking into tears while recounting the screaming bout to Salon, Sgt. X said he agreed to his wife's request and sought mental care for the first time in his 16-year military career. Sgt. X, like so many others on the post, went to the fourth floor of Evans hospital in search of mental-health assistance.

There is some evidence that Sgt. X's experience with McNinch represents part of a broader scandal, as suggested by the former Army psychiatrist who told Salon about identical problems at another post. Last year, VoteVets.org and Citizens for Responsibility and Ethics in Washington (CREW) released an e-mail from Norma Perez, a psychologist in Texas, to staff at a Department of Veterans Affairs facility there. In addition to the Army, that department also provides veterans with benefits. "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," Perez wrote in the e-mail dated March 20, 2008. She suggested the staff "consider a diagnosis of Adjustment Disorder." As opposed to those with PTSD, veterans with adjustment disorder, a temporary condition, typically do not receive disability payments from the government.

Then-Illinois Sen. Barack Obama fired a letter off to the V.A. about that previous controversy, calling the e-mail "outrageous," demanding an investigation. The Senate Veterans' Affairs Committee last June held a hearing on that e-mail. Perez claimed she sent that e-mail "to stress the importance of an accurate diagnosis." End of story.

VoteVets.org and CREW, the two groups who unearthed the V.A. e-mail, reacted viscerally to this new tape obtained by Salon. "This is further evidence our troops are not receiving the mental health treatment they need and deserve," said Melanie Sloan, CREW executive director. "The president and congressional leaders must hold those responsible accountable and make sure the message is sent far and wide that our returning troops are to be diagnosed as their symptoms, not the military's finances, dictate."

"We've heard all kinds of stories from vets who had trouble getting PTSD diagnoses," said VoteVets.org Chairman John Soltz. "It's crucial that we have department-wide investigations at the Departments of Defense and Veterans Affairs to determine if this came from someone high up, and how many troops and veterans were jilted out of a proper diagnosis from the government."

Many publications, including Salon, and even some government agencies have documented other instances of reluctance to recognize mental wounds caused by war at bases across the country.

  • A recent weeklong series in Salon showed how apparent resistance to identifying combat stress ends up grinding down the lowest-ranking troops, sometimes with deadly results. Those articles included, for example, the story of Pvt. Adam Lieberman, who suffered with severe symptoms of PTSD. For two years, the Army blamed his problems on a personality disorder, anxiety disorder or alcohol abuse but resisted diagnosing him with PTSD until after his suicide attempt last October.
  • The Government Accountability Office, Congress' investigative arm, last October questioned why 2,800 war veterans were labeled with personality disorder diagnoses, another cheap label the Army has been accused of plastering on soldiers instead of PTSD.
  • In November 2005 the Department of Veterans Affairs halted a review of 72,000 veterans who receive monthly disability payments for mental trauma from war. The department wanted to make sure the veterans were not faking their symptoms. Salon first exposed the review that August. Then Daniel L. Cooper, the V.A.'s undersecretary for benefits, told Salon at the time that, "We have a responsibility to preserve the integrity of the rating system and to ensure that hard-earned taxpayer dollars are going to those who deserve and have earned them." The department stopped the process a month after a Vietnam veteran in New Mexico, agitated over the review, shot himself to death in protest. .
  • In early 2005, Salon exposed a pattern of medical officials searching to pin soldiers' problems on childhood trauma instead of combat stress at Walter Reed Army Medical Center.

Salon will explore Thursday how the Army was made aware of Sgt. X's tape, how the Senate Armed Services Committee declined to conduct an investigation, and how the Army absolved itself of any blame for wrongdoing. A unit of the Army's Medical Command (which oversees Fort Carson's Department of Behavioral Health) conducted an "informal" investigation last summer that found potential "systemic" problems that could influence diagnoses, but determined that no one in the Army's Medical Command was to blame. In a report dated July 28, it specifically found that no Fort Carson or Medical Command staff "attempted to coerce or otherwise influence" diagnoses. This directly contradicts McNinch's statements on the tape and in his interview with Salon.

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