The Unintended Consequences of the Current PTSD Diagnosis

This is the last in my series of posts on the ethics of treating posttraumatic stress disorder (PTSD) (the first simply outlined ethical issues for military mental-health personnel; then I wrote about the right time to send a service member back into combat; how to maintain confidentiality between a service member and the mental-health professional; and why the military’s best mental-health programs are not available to everyone in uniform).

Now I want to discuss the good and bad consequences of automatically giving a 50% disability rating for PTSD.

I hesitate to post on this, as I know that there will be folks out there who say I am “trying to save the Army money by screwing the vets out of what rightfully belongs to them.”

Know that this is not my intention: I am all for vets receiving the disability that is due them.

But to automatically give 50% disability for one particular diagnosis creates a major incentive to get that diagnosis — and keep it.

I repeat: the issue for me, and many of my colleagues, is not whether the veterans deserve disability after an unrelenting 11 years of war. It is whether one diagnosis — PTSD — deserves more than schizophrenia, or bipolar disorder, or depression. And whether that automatic disability does more harm than good by discouraging patients from getting better.

This is not a new issue. Questions of fairness regarding veterans’ disability were a major issue in World War I, both in the U.K. and the U.S. And disability compensation has continued to be an issue in every war since then, especially following Vietnam.

In my experience, there are two types of service members: those who will not go near the mental-health issue because of worry about their career and those who are already getting out, who are encouraged by the system to stay to get that PTSD diagnosis.

Before I go on, let me give a little background. If service members are medically discharged from the military, they go before a medical-evaluation board, which makes a recommendation as to whether they are medically unfit for duty. Then they go to a physical-evaluation board, which makes the determination and gives them a disability rating.

If you receive a rating of at least 30%, then you are medically retired. This means that you essentially receive 30% (or more) of your base pay, plus the benefits of a retiree. Retiree benefits include free health care at a military hospital, on a space-available basis.

In the old days (prior to about 2007), PTSD was not adequately compensated for. Patients received maybe 5% or 10% for PTSD. There would normally be a severance package and no medical retirement.

The disability system is in the process of changing, so that there will be one combined disability process. It used to be that the Department of Veterans Affairs (VA) disability process was a totally separate one. First you got your rating from the military, then from the VA. That latter rating was almost always higher. The disability rating is periodically reviewed by the VA. In practice the disability stays the same or increases as the veteran ages, and the disability gets worse.

PTSD now receives an automatic 50% disability rating from the Army, no matter how mild or severe the symptoms are. In my experience, the VA rating is the same or greater. For a private, that works out to about $1,000 a month.

Some argue that this automatic disability is not helpful. It creates an incentive for all military members to get the diagnosis of PTSD, rather than depression or anxiety. It also creates a disincentive to getting better.

One of my colleagues wrote, after seeing my draft for this blog post:

Why wouldn’t we expect to see epidemic rates of PTSD in a force at war for 10 years, with unprecedented deployment and combat exposure? Why should we be so carefully scrutinizing the diagnosis of mental illness after deployment, when we continue to happily overlook obvious mental illness as we screen for deployability? And why should veterans who have deployed multiple times have to justify receiving 50% of their enlisted salary, when officers who have managed to avoid deployment can retire after 20 comfortable years with 75%?

If the argument is fundamentally an economic one, there are better opportunities for savings elsewhere. The current disability system is a small price to pay for the sacrifices this generation has endured on our behalf. If the argument is fundamentally one of diagnostic validity affecting treatment and prognosis, we will need a larger evidence base to substantiate this level of concern.

I think he missed my point, and perhaps the readers of this post will too. What I am trying to get at is the issue of automatically giving a single diagnosis a particular rating. And not giving the same for all the other psychological reactions to war, including grief and depression.

I do think that this is an incredibly important issue, which we, as a nation, need to discuss. As usual, I say that this is not just an Army or VA issue, but also a national one. How do we want to compensate our vets, who have served in combat, whether or not they meet the technical definition of having PTSD?