Since last summer, the Army has been examining whether its medical professionals have been systematically underdiagnosing Post-Traumatic Stress Disorder among soldiers. A report the service released Friday concludes the answer is no, but it also found plenty of room for improvement in the military’s processes for handling behavioral health issues.
The questions about the Army’s handling of PTSD cases first arose when more than a dozen soldiers filed complaints with the Army and with members of Congress, saying they’d been initially diagnosed with PTSD but had their conditions improperly downgraded to personality disorders by doctors at Madigan Army Medical Center near Seattle. They were then discharged. In response, Army Secretary John McHugh ordered an inspector general investigation and created a new task force to assess the Army’s behavioral health evaluation processes.
“I think the headline here is that there is no systemic issue of soldiers being disadvantaged in our disability process,” Lt. Gen. Patricia Horoho, the Army’s surgeon general told reporters during the release of the task force’s corrective action plan. “The Army is committed to taking care of our soldiers that have given so much to our nation during the last 12 years of war.”
Army revalidates 88 percent of its diagnoses
To conduct the review, the Army reexamined the records of 154,000 patients who had been diagnosed with four separate behavioral conditions since 2001, including PTSD. The examination wound up revalidating 88 percent of the original diagnoses. “This revalidation rate is extraordinary when you compare it to the diagnostic revalidation rates from the civilian sector,” Horoho said. “And the good news is that 80 percent of those that have a PTSD diagnosis remain on active duty. Only 20 percent are going through our Integrated Disability Evaluation System (IDES). That says PTSD is a diagnosis that can be treatable.”
After soldiers began to complain about downgraded diagnoses at the Madigan hospital at Joint Base Lewis-McChord, the Army began reviewing patient records of mental health cases that had been handled there. Out of 257 soldiers whose diagnoses had been downgraded at Madigan, 147 soldiers would up having their original diagnoses restored during the review.
“If a diagnosis had been changed, they contacted that service member and offered to have a reevaluation done. I think every service member had the best opportunity possible to have their record have a second review and then go through the disability process if it was found that there was a question,” Horoho said.
The commander of the hospital was placed on administrative leave during the investigation. He has since been reinstated; the Army concluded that Madigan’s variance from diagnoses at other military treatment facilities was the result of inconsistent standards across the Army rather than malice.
While the reviews found no evidence of wrongdoing in Washington State, they did find plenty of room for improvement in the mechanisms the Army uses to diagnose behavioral health issues and how it hands soldiers over to the Department of Veterans Affairs when they’re no longer able to serve as a result of their conditions.
Inspector general makes 22 recommendations
The inspector general’s version of the story makes 22 separate recommendations for improvement. It found there had been a general failure across the Army to comply with a single set of standards for using the joint Integrated Disability Evaluation System that DoD and VA share to assess a soldier’s disability a single time. Army officials said their own internal review has already begun to address the variability in how various corners of the service deal with mental health evaluations by centralizing authority under the Army’s vice chief of staff for personnel, Lt. Gen. Harold Bromberg.
“The Army will be better postured next time there’s a deployment to provide care to soldiers and families,” said Sam Retherford, the Army’s deputy assistant secretary for manpower and reserve affairs. “We’ve learned so much in the last several years, and having IDES fall under one lead agent will let Gen. Bromberg orchestrate all the numerous Army agencies and coordinate with VA to improve efficiency. There’s much more transparency in the process.”
Out of several dozen recommendations yielded by the Army study and approved by McHugh, one deals specifically with making the disability evaluation system more transparent to the individual soldier going through the process, which currently takes more than a year. The directive tells the Army’s personnel chief to work with the service’s chief information officer to build a single tracking application to cut down on confusion about where a soldier is in the long process.
“Commanders, users and practitioners as well as the soldier will be able to go in there and see where the soldier is in the process and see progress,” Retherford said. “The Department of Defense has taken this on across all the services, and has a task force ongoing right now to see how we would continue that and transfer that data over to the VA when a soldier’s discharged. The intent would be an IT system that would integrate with all the services and the VA, where the data would be standard and controlled by authoritative data sources.”
The IDES system currently takes about 400 days to completely transition a soldier with disabilities from the Army to the Department of Veterans Affairs. Despite pressure from Congress to speed up the process, it’s hovered at around that point for years.
But Bromberg insisted the number is on its way down.
“Eighteen months ago we were doing massive xeroxing of boxes of paper, we’ve now gone to electronic systems. We’ve partnered with VA at every step and co-located services to make things easier to navigate. So the numbers are coming down, and last month was the first month where the input into the system actually equaled the output,” he said. “The goal from DoD is 295 days, but what we’re mainly focused on is care for the soldier. If it takes a few more days right now, that’s fine. We want to make sure the soldier is taken care of all the way through the system, they understand the system, and they’re getting the care they need.”
Secretary of Army aims to provide better consultation, guidance and coordination
Among the other problems the report documented was that Army bases don’t have a person on site within most local commands or bases who is dedicated to overseeing behavioral health issues, despite the many problems they can cause: suicide, alcohol abuse, drug abuse, and child and spouse abuse. Each installation needs someone with a view of all those programs to make recommendations to the commander, the report said. McHugh said in a statement that the Army will work to place behavioral health experts “at the command and installation levels to provide better consultation, guidance, coordination and recommendations to improve behavioral health care for our soldiers.”
The task force found that of the soldiers surveyed, 37 percent had never received any information about the Army’s disability evaluation system or had to seek the information out on their own. It also said it was confusing and inefficient for troops to navigate the vastly different disability systems maintained by the Army and the Veterans Administration.
Sen. Patty Murray (D-Wash.), the former chairwoman of the Senate Veterans Affairs Committee who pressed the Army to investigate the diagnoses at Madigan, said the improvement plan was welcome, but the changes it calls for should have been addressed long ago.
“I am pleased that the Army completed this review and has vowed to make fixes over the next year, though I am disappointed it has taken more than a decade of war to get to this point,” Murray said in a statement. “Many of the 24 findings and 47 recommendations in this report are not new. Creating a universal electronic health record, providing better rural health access, and standardizing the way diagnoses are made, for instance, have been lingering problems for far too long. Our service members and their families deserve better.”