WASHINGTON, D.C. - U.S. Senator Daniel K. Akaka (D-HI), Chairman of the Veterans' Affairs Committee, sent a letter to Veterans Affairs Secretary James Peake today, in response to a recently disclosed email from a VA mental health professional which suggested that time and money could be saved if VA stopped diagnosing veterans with post-traumatic stress disorder.  Akaka also made a statement on this matter earlier today, calling the email "disturbing and disappointing." 

A copy of the letter is copied below:

May 16, 2008

The Honorable James B. Peake, MD

Secretary of Veterans Affairs

810 Vermont Avenue

Washington, DC  20420

Dear Secretary Peake:

I am writing regarding recent events at the Temple, Texas, VA Medical Center.  The suggestion that diagnoses of PTSD should be avoided due to cost and time considerations is deeply troubling, and merits close investigation.

VA has a responsibility to take seriously the effects of combat trauma, yet there are some who fail to appreciate the significance of this responsibility.  The sentiment expressed in an email by the Program Coordinator for the PTSD Clinical Care Team at the Temple VAMC is clearly inappropriate, and I applaud your strong statement reiterating VA's commitment to proper screening and diagnosis.  Further, I share your hope that this is indeed isolated to a single facility and practitioner.

I have asked the Office of the Inspector General to undertake an immediate review of the diagnosis patterns at Temple, and the role that Department guidelines for the diagnosis and treatment of PTSD may have played in those patterns.  I have also asked the IG to examine the Compensation and Pension decisions based on Compensation and Pension exams performed at the Temple VAMC for any irregularity.

I know you understand how imperative it is that VA conducts Compensation and Pension exams and decisions according to evidence based clinical guidelines.  Without a thorough exam, an appropriate decision is impossible.  The report from the Institute of Medicine (IOM) entitled Post Traumatic Stress Disorder: Diagnosis and Assessment (2006) stated that "An optimal assessment of a patient consists of a face-to-face interview in a confidential setting with a health professional experienced in the diagnosis of psychiatric disorders...[T]he process of diagnosis and assessment will likely take at least an hour or could take many hours to complete."  VA's own Best Practice Manual for Posttraumatic Stress Disorder Compensation and Pension Examinations recommends a three hour time allotment for completing an initial PTSD examination, with additional time needed for complex cases.

Unfortunately, Committee oversight indicates widespread inadequate evaluation of veterans claiming service-connection for PTSD due to combat exposure and military sexual trauma.  Recently, two Compensation and Pension examination reports indicated that exams last between 30 and 35 minutes.  Veterans often report to the Committee that during exams they were not asked about their military experience and received superficial evaluations.  Veterans' advocates report the reluctance of some VA examiners to provide a diagnosis of PTSD, even for veterans previously diagnosed with PTSD.  VHA managers have expressed the view that "the VISN does not get any funding to do Compensation and Pension examinations." 

These reports are deeply unsettling.  I know that you agree with me that it is entirely inappropriate to attempt to save time or money by limiting the quality of medical examinations and the support given to Compensation and Pension units at VA medical centers.

To fully address the quality of Compensation and Pension exams and decisions, I suggest that a team of experts from the National Center for PTSD conduct a comprehensive study of the issues at hand.  Such a study should review examinations for PTSD from a statistically valid national sample to assess 1) the amount of time taken to conduct PTSD examinations; 2) the adequacy of the examination, including the need for any additional testing of claimants; 3) the number of cases in which a "rule out PTSD" diagnosis was provided; and 4) whether or not another diagnosis was provided to veterans in cases where the evidence suggested that a diagnosis of PTSD is determined to be more appropriate.

Furthermore, as Chairman of the Committee with oversight jurisdiction over these matters, I request that VA provide to the Committee all records from January 1, 2001, to the present relating to any and all guidance given to any VA staff regarding the diagnosis of PTSD in veterans.  "Guidance" includes formal and informal guidance, advice, and recommendation, regardless of format or medium.

I also ask, to avoid future problems, and to ensure proper conduct of Compensation and Pension exams and decisions, that you issue guidance to VHA and VBA clinicians, administrators, and support personnel to ensure that sufficient care and time is spent on each Compensation and Pension exam and decision.

I appreciate your strong repudiation of the Temple VAMC psychologist's email, and your commitment to serving veterans.  The trauma of combat can leave veterans with serious and long-term invisible wounds, and VA's mission is to care for those veterans.  VA must err on the side of presuming that those who have been exposed to service in a theater of war may be marked by that service.  Our commitment to veterans demands nothing less.

Thank you for your attention to these issues.  I look forward to working with you to ensure that veterans are getting the care and benefits they deserve.

Sincerely,

Daniel K. Akaka

Chairman

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