From: gerald.ney@navy.mil
Sent: Mon, 10 Jul 2006 9:27 AM
Subject: VVA Statement Before Institute of Medicine Subcommittee on PTSD of Committee on Gulf War & Health

FYI,
============================
Gerald Alan Ney
Gerald.Ney@navy.mil
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Statement of VIETNAM VETERANS OF AMERICA
Submitted by Thomas J. Berger, Ph.D., Chairman
VVA National PTSD & Substance Abuse Committee
& Richard Weidman
Executive Director for Policy & Government Relations
Vietnam Veterans of America
Before the Subcommittee on PTSD of the Committee on Gulf War & Health: Physiologic, Psychologic, And Psychosocial Effects of Deployment-Related Stress Institute of Medicine Of the National Academy of Sciences
Regarding Post Traumatic Stress Disorder (PTSD) Diagnosis, Treatment, and Compensation
July 6, 2006
Distinguished members of the Subcommittee on Post Traumatic Stress Disorder of the Committee on Gulf War and Health: Physiologic, Psychological, and Psychosocial Effects of Deployment-Related Stress, Vietnam Veterans of America (VVA) thanks you for the opportunity to present our views on the current state of the clinical diagnoses and the disability compensation claims process as accorded our nation’s veterans suffering from PTSD.
Foremost, Vietnam Veterans of America applauds this Committee for its obvious concern about the mental health care of our troops and veterans that we saw evidenced at your first public meeting. The quality of your questions and demeanor indicated the both the sincerity and the sophistication of your concern.
No one really knows how many of our troops in Iraq and Afghanistan have been or will be affected by their wartime experiences. Despite the early intervention by psychological personnel, no one really knows how serious their emotional and mental problems will become, nor how chronic both the neuro-psychiatric wounds (particularly PTSD) and the resulting impact that this will have on their physiological health. However, recent reports have suggested that troops returning from service in Afghanistan and Iraq are suffering mental health problems at a rate higher than the levels seen in Vietnam War veterans. Other reports indicate that the service members who served in a war zone in Iraq or elsewhere are getting sick at a higher rate than those who were not deployed. In fact, VVA has no reason to believe that the rate of veterans of this war having their lives significantly disrupted at some point in their lifetime by PTSD will be any less than those estimated for Vietnam veterans by the National Vietnam Veterans Readjustment Study.
Results of the NVVRS demonstrated that some 15.2 percent of all male and 8.5 percent of all female Vietnam theater veterans were current PTSD cases (i.e., at some time during six months prior to interview). Rates for those exposed to high levels of war zone stress were dramatically higher (i.e., a four-fold difference for men and seven-fold difference for women) than rates for those with low-moderate stress exposure. Rates of lifetime prevalence of PTSD (i.e., at any time in the past, including the previous six months) were 30.9 percent among male and 26.9 among female Vietnam theater veterans.
Comparisons of current and lifetime prevalence rates indicate that 49.2 percent of male and 31.6 percent of female theater veterans, who ever had PTSD, still had it at the time of their interview. Thus the NVVRS was a landmark investigation in which a national random sample of all Vietnam Theater and era veterans, who served between August 1964 and May 1975, provided definitive information about the prevalence and etiology of PTSD and other mental health readjustment problems. The study over-sampled African-Americans, Latinos, and Native Americans, as well as women, enabling conclusions to be drawn about each subset of the veterans’ population.
The NVVRS enabled the American public and medical community first become aware of the documented high rates of current and lifetime PTSD, and of the long-term consequences of high stress war zone combat exposure. Because of its unique scope, the NVVRS has had a large effect on VA policies, health care delivery and service planning. In addition, because the study clearly demonstrated high rates of PTSD and strong evidence for the persistence of this disease, it was generally accepted that the VA would pursue a follow-up or longitudinal study of the original participants in this seminal research project.
In 2000 Congress, by means of Public Law 106-419, mandated the VA to contract for a subsequent report, using the exact same participants, to assess their psychosocial, psychiatric, physical, and general well being of these individuals. It would enable it to become a longitudinal study of the mortality and morbidity of the participants, and draw conclusions as to the long-term effects of service in the military period, as well as about service in the Vietnam combat zone in particular. The law requires that VA use the previous report as the basis for a longitudinal study.
In 2000 the VA solicited proposals for non-VA contractual assistance to conduct a longitudinal study of the physical and mental health status of a population of Vietnam era veterans originally assessed in the NVVRS.
It is apparent that a longitudinal follow-up to the NVVRS is necessary in order to meet the requirements of the law, and to do what just makes sense in both policy and scientific terms. However, not only has the VA failed to meet the letter of the law, there has been no effort to build upon the resources accumulated from this unique and comprehensive study of Vietnam veterans in a highly cost-efficient and scientifically compelling manner. More important, however, is that such a longitudinal study could provide clues about which VA health care services are effective and about ways to reach the veterans who receive inadequate services or do not seek them at all. And this has important consequences for America’s current and future veterans.
It is now clear that the VA is ignoring the law and the Congress, and plain refusing to do the study. The VA now has said in Congressional testimony says, “the Inspector General stopped the study” when in fact the IG has no line authority at all to do any such thing. The Undersecretary and the Secretary stopped the study.
At that same hearing on Research & Development on June 7, 2006, the VA also said that they could not do the study because they could only find 300 of the original more than 2,500 persons in the statistically valid random sample chosen by the Gallup Organization at a public cost of more than $1 million in 1984 dollars. If that were true (which strains credibility at best) then that would mean that 85% of that valid national sample has died in the past 25 years. VVA would suggest that this would be front-page news, if true.
Further, the VA has tried to claim they would be better off using the failed “Twins” study data base from the Centers for Disease Control and Prevention (CDC) because they do not want a longitudinal study, nor do they want to have validated the results of what the NVVLS may demonstrate in regard to very high mortality and morbidity of Vietnam veterans, especially those most exposed to combat.

As even while the military’s own studies clearly show that one-third of the Iraq and Afghanistan troops have sought mental health services during their first year home, the legitimacy of veterans’ claims that they suffer from PTSD is under the gun by a small number of media savvy skeptics, whose views are not generally shared by mainline PTSD experts.
For example, Dr. Sally Satel, a former assistant professor of psychiatry at Yale's School of Medicine (with a concurrent appointment as a staff psychiatrist at the West Haven VAMC) from 1985 to 1993, and now “resident scholar” at the American Enterprise Institute, has waged a campaign to discredit PTSD as a valid diagnosis. In public statements she portrays veterans who suffer from PTSD as looking for easy disability payments that provide an incentive for staying sick rather than getting well, with the implication that sick veterans are welfare cheats. In addition to her claims of veteran fraud, Dr. Satel has also opined that cases of delayed onset of PTSD “are rare to non-existent” and that “PTSD is an acute, not chronic, disease and only rarely should there be a need to give long-term disability”.
Part of Satel's approach is to try to undercut, discredit, and diminish the Vietnam Veteran's Readjustment Study by questioning how 50% of the veterans could be reporting symptoms when 'only 15% were assigned to combat units'. This question signals either appalling historical ignorance of what happened in Vietnam or slippery distortion, or both. . In 2004 Satel said, 'What is generally put forth as an established truth--that roughly one-third of returnees from Vietnam suffered psychological problems--is at best highly debatable.' But, in 2005, when the Army surgeon general reported that 30% of soldiers who returned from Iraq had developed mental health problems, Satel did not attempt to argue differently.
In fact, Dr. Satel has offered no data to support her opinions. Studies done at the National Center for PTSD confirm the delayed onset of PTSD, as well as the fact that mental health utilization is actually higher for veterans granted disability claims than for those who apply and are turned down. Furthermore, VVA doubts that the journalistic op/ed stuff Satel writes about PTSD could show up in reputable scholarly journals where a decent peer review process would shred her facile, superficial assertions. By now it should be clear that her intended audience is politicians and policy-makers, not academics who have standards for what constitutes credible research and scholarship. VVA would also argue that use of the standardized and validated PTSD diagnostic assessment tools in the “Best Practices Manual for PTSD…” would pick up any fractious PTSD disability claims and provide for better guidance in developing individualized treatment plans.
VVA notes the absence of VA research outside of that conducted at the National Center for PTSD on the physiological manifestations of PTSD and co-morbid medical/health conditions such as that conducted by Dr. Joseph Boscarino (1). For the veteran suffering from acute, long-term PTSD, can one reverse the endocrine changes that occur? Or reverse physical changes in the brain? Of course not… But without such research efforts, the VA will continue to labor under the fallacy that “PTSD is all in your head…”

VVA acknowledges that the culture of the VA mental health system itself may play a yet undefined role in this current debate over PTSD and VA compensation. For example, the studies of Sayer and Thuras (1), as well as Kimbrell and Freeman (2) suggest that VA clinicians had a more negative view of the treatment engagement of veterans who were seeking compensation and of clinical work with these patients in comparison with those veterans not seeking compensation and those certified as permanently disabled and thus not needing to reapply for benefits. The longer VA clinicians had been working with veterans who had PTSD, the more extreme were these negative perceptions.
What is clear to us is that these clinical “researchers” are not even aware that their patients seek service connection so that the veteran will not have to pay for medical treatment for a condition that they believe resulted from their military service. This, and the sense of validation are often more important to the individual veteran that any compensation payment he or she may derive (and deserve!) as a result of this psychiatric wound(s) that are every bit as real as a gun shot wound, if properly diagnosed according to the VA’s own “Best Practices Manual.”
There are numerous other points that we wish to make to you before you wrap up this project, but we will close here for now with urging that this panel strongly recommend that VA complete the National Vietnam Veteran Longitudinal Study (NVVLS) exactly as directed by Public Law 106-419. Because that sample is not limited to those who use VA, the results will validate the prevalence of PTSD in the last previous large generation of combat veterans.
Thank you for your kind attention. I will be pleased to answer any questions you may have.

References

1. Boscarino, J. A. 2006. Post-traumatic stress disorder and mortality among U.S. Army veterans 30 years after military service. Ann. Epidemiol. 16: 248-258.
2. Sayer, N. A. and Thuras, P. 2002. The influence of patients’ compensation-seeking status on the perception of veteran’s affairs clinicians. Psychiatry. Serv. 53: 210-212.
3. Kimbrell, T.A. and Freeman, T. W. 2003. Clinical care of veterans
seeking compensation. Psychiatry. Serv. 54:910-911.