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Summer 2007 Vol. 7 No. 2

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Veterans and PTSD U.S. Army soldiers in Babil, Iraq, March 2005, DOD photo by Edward Martens, U.S. Navy

Ensuring Fair and Consistent Compensation

Battle fatigue, shell shock, combat neurosis -- it's been called many things over the years. Post-traumatic stress disorder (PTSD) is likely as ancient as war itself. The United States has long recognized the sacrifices of its military personnel by compensating veterans for disabilities suffered as a result of their service, such as loss of limbs, chronic disorders, and, more recently, mental conditions including PTSD.

In the past few years, PTSD in the military has risen to public prominence as surveys indicate relatively high rates among soldiers serving in Iraq and Afghanistan and media accounts feature wrenching stories of service members' struggles to cope with their mental battle scars. At the same time, veterans of previous conflicts have been filing disability claims for PTSD in greater numbers. The U.S. Department of Veterans Affairs (VA) recorded an almost 80 percent jump in claims between 1999 and 2004. These trends have sparked questions about when and how PTSD can happen as well as whether VA's current tools and methods for assessing veterans for PTSD disability and determining the level of compensation they merit are reliable and up to date.

Photo by Todd Goodman, courtesy U.S. ArmyTo ensure that all veterans receive consistent and appropriate assessments of the severity of their PTSD-related disability, the VA needs to develop new evaluation methods and rating criteria specific to PTSD to replace the overly general, "one-size-fits-all" standards it currently uses, says a new report by the Institute of Medicine and National Research Council. Unlike physical ailments with obvious symptoms, evaluation of PTSD severity entails greater subjectivity. Although mental disorders vary in their characteristics and effects, the VA rates the severity of all using criteria based on symptoms of schizophrenia and mood and anxiety disorders.

Hearing from veterans and clinicians that some PTSD evaluations last as little as 20 minutes, the committee that wrote the report also urged the agency to ensure that all claimants receive a complete and thorough assessment by professionals trained in spotting and assessing the symptoms of PTSD. These evaluations are important because they inform the nonclinical professionals who rate the severity of veterans' disabilities, which determines what level of compensation they will receive.

By federal statute, veterans with service-connected disabilities are eligible for payments intended to compensate for their loss of potential earning power. Severity ratings and payment amounts for PTSD and other mental conditions depend on how greatly a veteran's ability to work is impaired, with a maximum monthly tax-free benefit of $2,471 for a veteran without a spouse, children, or dependent parent. While beneficiaries with mental disorders may be able to hold full-time jobs even as their symptoms negatively affect other aspects of their lives, current rating criteria only award maximum compensation to those who do not work. This is a marked disparity with veterans who have physical impairments. They may still receive maximum disability benefits even as they engage in full-time employment thanks to assistive technologies and services.

The report urges 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 current emphasis on occupational impairment penalizes veterans who can and do work despite their symptoms, and does not acknowledge other potential negative outcomes of service-connected ailments, the committee said.

The committee also found abundant evidence that PTSD can develop at any time after exposure to trauma. Some cases that are labeled "late onset" may instead be flare-ups of low-level symptoms or may be longstanding conditions that have gone undiagnosed for years. Aging, loss of mental acuity, the death of friends or spouses, and other factors can trigger or exacerbate symptoms as well, which may explain in part the increase in claims from older veterans.   -- Christine Stencel

PTSD Compensation and Military Service. Committee on Veterans' Compensation for Posttraumatic Stress Disorder, Board on Military and Veterans Health, Institute of Medicine; and Board on Behavioral, Cognitive, and Sensory Sciences, Division of Behavioral and Social Sciences and Education (2007, 262 pp.; ISBN 0-309-10552-8; available from the National Academies Press, tel. 1-800-624-6242; $36.00 plus $4.50 shipping for single copies ).

The committee was chaired by Nancy C. Andreasen, Andrew H. Woods Chair of Psychiatry and director, Neuroimaging Research Center, Carver College of Medicine, University of Iowa, Iowa City. The study was funded by the U.S. Department of Veterans Affairs.

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Copyright 2007 by the National Academy of Sciences