Doctors and mental health counselors face several frustrations in treating PTSD besides the malady itself, including government bureaucracy and the stigma surrounding the disease.
Doctors and mental health counselors say there are several effective treatments for the post-traumatic stress disorder that plagues military veterans, but a breakthrough to ease their fears about stepping forward to actually get therapy is elusive.
“I know I have had veterans ask us if they are at risk for losing their benefits if they undergo treatment,” said Dr. Candace Drake, a psychologist at Pensacola’s Joint Ambulatory Care Center, where hundreds of PTSD patients are treated. “And yes, I have to tell them, ethically.”
Even though psychological help through the Department of Veterans Affairs is free through the Veterans Healthcare Administration segment for which Drake works, decisions on eligibility for disability payments on which many PTSD patients heavily rely are made by a separate arm of the VA, the Veterans Benefits Administration.
The two branches of VA sometimes seem to be at odds. Drake, who counsels about 25 Pensacola area veterans each week, said, “There’s something off about the fact that financial decisions that we’re not involved in as providers are based on our documentation of treatment.”
The VA’s financial compensation for disabilities follows a rating system based on patient examinations by medical personnel. The lowest rating, 10 percent, currently pays $130.94 a month. Higher ratings are measured at a new level for every additional 10 percent awarded. For example, a rating of 50 percent pays $822.15, and veterans diagnosed with everything from PTSD to paralysis receive up to $2,858.24 monthly at 100 percent.
Staying out of touch
After PTSD sufferers are diagnosed and qualify for disability pay, the VA cannot compel them to seek treatment. As the number of cases has soared, up 42 percent between 2008 and 2012 to more than 500,000, the agency finds itself losing contact with many veterans. Paradoxically, a federal statute prohibits the VA from requiring treatment or examinations.
For many veterans, their PTSD compensation is their only income because their illness prevents them from functioning normally in a workplace environment.
Other frustrations face physicians and mental health counselors within the VA, and among the ranks of independent practitioners. Those frustrations include the agency’s lack of control over monitoring the effectiveness and possible impact of its prescriptions, including powerful anti-depressants.
The standards for re-evaluating patients taking such medications in the civilian community varies among those who are prescribing the drugs, but the typical period is in the range of one to six months. In sharp contrast, some veterans who are taking multiple prescriptions obtained from the VA say they sometimes go for years without any follow-up contact.
“The community standard for prescribers to re-evaluate is two months for a person who is being stabilized with medication,” said Robert Donofrio, a retired Navy veteran and psychiatric nurse practitioner in Pensacola who has counseled veterans with PTSD through his non-profit organization POE in Action, although he hasn’t worked at the VA. “Then you might gradually go to three months and then maybe six months,” he said.
But the reality is sometimes illustrated by cases like Elliott James, an Iraq veteran diagnosed with PTSD who said he was prescribed several medications including Zoloft that kept coming to him through the mail from 2005 to 2011 without a re-evaluation. Although James said medications did help him through a suicidal period, he eventually determined that, “Medication is not going to cure me.”
So without a counselor’s advice, he took action: “I had to tell them to stop sending them.”
Disconnecting over distrust
Some veterans who are dubious about their PTSD prescriptions are reluctant to request the VA discontinue mailing them drugs for fear the agency could interpret such a move as evidence that might lead to a reduction of benefits.
Further, there’s little the mental health practitioners can do to combat the stigma that surrounds PTSD: fears that employers won’t understand, the potential for breakdowns of family support, the complications of patients’ alcohol abuse and the looming threat of suicide by those who just can’t deal with it all anymore.
All of that is further complicated by the distrust that many veterans have for the VA.
Dr. Rick Spencer, a psychologist at Psychological Associates in Pensacola, whose specialties lie in child, adolescent, adult and forensic psychology, said the veterans’ misgivings about the VA arise partly because of the potential loss of financial benefits that could come from being treated for PTSD.
“Remember, the VA is providing two services — they’re treating, but they’re also providing the designation, which can be taken away,” Spencer said. “So that inherently creates potential conflict. And as a result of that potential conflict of interest, some veterans are going to distrust it.”
Tension trumps treatment
Ironically, Spencer said, veterans’ distrust of the VA adds yet another layer of anxiety to the tensions that PTSD patients already endure.
“One reason some of them come to an independent practitioner like myself is they feel more trust in the confidentiality in this arena,” he said.
To be sure, Spencer provides essentially the same manner of psychotherapy common in VA counseling. And he isn’t a critic of VA mental healthcare methods. “I have great respect for the VA” and its PTSD counselors. “They’re doing the best they can to treat it.”
But for some PTSD sufferers, Spencer said, their distrust of the VA system and fear of losing disability benefits is enough to keep them away from the agency.
“I think it’s probably because they have heard of others who lost their rating,” Spencer said.
If there’s anything PTSD patients don’t need, Spencer said, it’s another worry that can cause them to lose sleep. Insomnia and night terrors are common to PTSD sufferers. “I had one patient who came in 23 years after serving. I think he just wanted to get some sleep.”
The rate of suicides among veterans was about 18 per day in 2013, according to the VA. While firearms are the method in more than 50 percent of suicide cases, drug overdoses, including those involving prescription medications, are used in about one-third of the deaths and nearly two-thirds of the non-fatal attempts.
Sometimes PTSD symptoms become evident only after many years, as many Vietnam veterans have discovered. The characteristic of PTSD to hide is concerning to medical practitioners who wonder if re-evaluation may result in an over-optimistic new diagnosis due to what later proves to be a temporary remission.
“Just because you’ve been treated and you’re getting better doesn’t mean your PTSD is gone,” said Shirley Lewis-Brown, a retired Navy nurse. “You could have a trauma and be back on square one. PTSD is chronic. It doesn’t go away.”
1678: Swiss military physicians diagnose “nostalgia,” the first term to describe what would eventually be recognized as PTSD.
1700s: French surgeon Dominique Jean Larrey identifies three stages of what would eventually become known as PTSD.
1855: Dorthea Dix’s advocacy efforts lead to the opening of the Government Hospital for the Insane, and military physicians begin documenting mental issues among Civil War soldiers.
1905: The Russian Army recognizes “battle stress” as a medical condition.
1914: The term “shell shock” is coined to describe an assumed link between nervous and mental shock among British soldiers in World War I.
1917: Congress initiates plan to shift veterans compensation from a gratuity to an indemnity for physical and mental disabilities.
1919: Amendments clarify the new benefits for those whose service has impacted the veteran’s ability to work, instituting a policy of determining cash payments and services provided based on the percentage of impairment.
1919: Sigmund Freud writes the introduction to “Psycho-Analysis and the War Neuroses” by Sandor Ferenczi, Karl Abraham, Ernst Simmel, and Earnest Jones, based on Freud’s theory of “war neurosis.”
1922: The British government’s “Report of the War Office Committee of Inquiry into Shell-Shock” includes early treatment recommendations.
1939: U.S. military terminology begins to refer to the condition as “combat exhaustion.”
1943: A psychiatrist is added to the table of organization of each division of the military to address increased mental issues in the armed forces during World War II.
1943: Gen. George S. Patton is relieved of duty after slapping two soldiers recuperating from “combat stress” in a military hospital.
1945: U.S. Army training film for medical officers recommends sodium pentathol and suggestive therapy as treatments for combat exhaustion.
1946: The National Mental Health Act expands mental health facilities in the U.S.
1952: The first edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-I) includes “gross stress reaction.”
1965: Military battalions begin to include officers to treat psychological issues during the war in Vietnam.
1968: The DSM-II drops “gross stress reaction.”
1972: A New York Times op-ed by psychiatrist Chaim Shatan raises public awareness of “post-Vietnam syndrome.”
1979: The first Vet Centers are established to aid Vietnam War veterans facing “readjustment problems” that would later be identified as PTSD. Outreach expands to include veterans of World War II and the Korean War.
1980: PTSD is added to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).
1987: Diagnostic criteria revised in DSM-III-R, dropping the requirement that stressors be “outside the range of normal human experience.”
1991: Sertraline — brand name Zoloft — is approved by the US Food & Drug Administration (FDA) as safe and effective for treatment of major depression. This class of selective seratonin reuptake inhibitors (SSRIs) is one of the first medications to receive FDA approval for the treatment of PTSD.
1994: Diagnostic criteria revised in DSM-IV.
2000: Diagnostic criteria revised in DSM-IV-TR.
2009: Foa, Keane, Friendman and Cohen publish “Effective treatments for PTSD, Second Edition,” a comprehensive book on treatment of PTSD detailing therapeutic approaches and successes with cognitive-behavioral therapy and medication.
2013: Diagnostic criteria revised in DSM-V. It is no longer categorized as an anxiety disorder and is now in a new category, trauma- and stressor-related disorders.
Sources: U.S. Department of Veterans Affairs (ptsd.va.gov), History of PTSD website (historyofptsd.wordpress.com), Wikipedia.
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