Screening, Diagnosis and Disability for Veterans with PTSD: Implications for the US Health Grid Saul Rosenberg, Ph.D.Assoc. Clinical Prof. of Medical Psychology University of California, San FranciscoCEO, Neuron Valley Networks Inc.

Treatment, Rehabilitation and Disability Determination for

Mental Disorders• Over 40 million Americans are affected by

one or more disabilities, but we have few standardized, reliable, valid, comparable and computable measures of functional impairment and disability.

• The reliable measures we do have are locked away in silos and are inaccessible to the wider community of health care providers and clinical investigators.

• As a result, we have no uniform way of collecting population-level data to guide policy decisions and to improve the quality of rehabilitation and disability determinations.

Knowledge Resources for Mental Health

• Computer-based administration of psychological tests and life history questionnaires.

• Assistive technologies for people with disabilities to take psychological tests on the computer.

• Controlled clinical vocabularies, terminologies and ontologies for representing mental health data.

• Standards for security and protection of data.• Ability to transport mental health data to

authorized users and to Electronic Health Records, Electronic Personal Records and clinical data repositories.

Population-level Screening for Mental Health Problems After Deployment

Study of over 200,000 Army soldiers and Marines who completed a brief postdeployment health assessment form (Hoge et. al. 2006), found a high demand for mental health services.– About 20% of active duty service members screened

positive for one of the mental health concerns.– Those veterans who screened positive for mental

health concerns were significantly more likely to separate from military services than those whose screened negative.

– 31% of Iraq war veterans had at least one outpatient mental health care visit within the first year after returning home.

Diagnosis of Postdeployment Mental Disorders • Study of over 100,000 veterans seen at

VA health care facilities (Seal et al 2007)– 25% received mental health diagnoses– PTSD was the most common diagnosis– 56% had two or more mental health

diagnoses– Youngest veterans (18-24 years) were more

likely to receive a PTSD or mental health diagnosis compared to veterans aged 40 and over.

Treatment and Rehabilitation Planning for Veterans with

PTSD• Mental pain and suffering from military

service-related PTSD in Vietnam Veterans extends beyond symptoms of the disorder (Zatzicki, Marmar & Weiss, et al, 1997). PTSD was associated with– impairments in social and vocational

functioning – lower subjective well-being– interpersonal violence

Evaluating Screening and Diagnostic Tests

• Tests have to be reliable (consistent), accurate (valid) and useful (provide data that affects clinical decision making).• Example: PTSD symptom level assessed with the Mississippi Scale for Combat-Related PTSD, a reliable and valid self-report test.

– Cutoff score of 94 yielded a prevalence rate for PTSD of 15%– Sensitivity of 75%– Specificity of 84%

• Compared to “gold standard” – diagnosis by expert clinician using a structured clinical interview.

Disability Determination for PTSD

• Institute of Medicine Report on Service-Connected Claims for Disability related to PTSD (IOM, 2007).

• Disability compensation for PTSD increased 148 percent from $1.2 billion to $4.28 billion between 1999 and 2004.

• The VA disability system focuses on the separate evaluation of each service-connected disorder; however studies show up to 80% of people with a PTSD diagnosis have depression or other mental disorder.

The Future of Disability in America Report from the Institute

of Medicine Charge to the IOM from the Centers for

Disease Control, Dept. of Education and the National Institutes of Health to evaluate how disability is managed in the US and to recommend improvements.

Concluded, “Immediate action is essential for the nation to avoid harm and to help people with disabilities lead independent and productive lives.”

The Future of Disability in America: Recommendations • IOM report recommended:

– Increase public funding for disability monitoring by federal agencies.

– Encourage agencies to standardize description and measurement of disabilities.

– Encourage adoption of World Health Organization’s International Classification of Functioning, Disability and Health (ICF).

World Health Organization’s International Classification of

Functioning Disability and Health (ICF)

• “Disability is not an attribute of an individual…an individual’s functioning is an interaction between the health condition, personal factors and the environment.”

• The goal of rehabilitation is the full participation of people with disabilities in all areas of life.

IOM Recommendations for Collaboration

• The National Institute on Disability and Rehabilitation Research, the National Institutes of Health, the Veterans Health Administration, the Centers for Disease Control and Prevention and other agencies should use the ICF framework.

• Agencies should collaborate to improve epidemiological, observational and experimental measures that emphasize functional capacities, quality of life and participation in work, school and community life.

Examples of ICF Global Mental Functions

• b110 Consciousness functions (alert, coma)

• b117 Intellectual functions (verbal reasoning)

• b126 Temperament and personality functions (shy versus socially

outgoing)• b130 Energy and drive functions

(motivation)

ICF Specific Mental Functions• b140   Attention functions (maintain focus)• b144   Memory functions (short-term,

working memory)• b152   Emotional functions (self-control of

emotion)• b164   Higher-level cognitive functions

(planning)• b167   Mental functions of language

(understand and express)• b172   Calculation functions (numerical

reasoning)

ICF Framework • ICF is a descriptive framework for

describing and coding different dimensions and domains using the same generic scale.– Body Functions (mental functions, seeing

functions)– Body Structures– Activities– Participation – Environmental factors

ICF Components• Specific mental functions of language

– b167.3 severe impairment • Performance problem in current

environment– d5101.1 mild difficulty bathing with

assistive devices available • Capacity (limitations without assistance)

– d5101.2 moderate difficulty without the use of assistive device for personal help

A 21st Century System for Evaluating Veterans for Disability Benefits (IOM)

• Current purpose of veteran’s disability program is compensation for lost earnings

• The VBA program should compensate for three consequences of service-connected injuries– work disability– loss of ability to engage in non-work

activities– loss in quality of life

IOM Recommendations to Improve Disability

Examinations• Train examiners and raters on computer-based templates • Adopt standardized diagnostic classifications, e.g. ICD, ICF, AMA Guides to the Evaluation

of Permanent Impairment, DSM-IV for mental disorders • Comprehensive health care needs assessment of veterans separating from military service • Conduct research on the reliability and validity of the Rating Schedule • Conduct evaluations of training and certification of examiners and raters

PTSD Compensation and Military Service (IOM)

• The amount of payments to beneficiaries during Fiscal Years 1999 to 2004, increased 148.8 percent from $1.72 billion to $4.28 billion.

• While veterans being compensated for PTSD represented only 8.7 percent of all claims, they received 20.5 percent of all compensation benefits. (IOM, 2007).

PTSD Compensation and Military Service (IOM) Report Findings• As many as 80 percent of people who

have a diagnosis of PTSD also have major depressive disorder or some other psychiatric disorder.

• Problem: The VA disability system is built around the separate evaluation and compensation of each diagnosed service-connected disorder. No scientific literature on separating the symptoms of PTSD from those of another existing mental disorder.

IOM Recommendations on PTSD Disability Exams

• Develop a standardized training program for clinicians conducting compensation and pension psychiatric evaluations.

• Emphasize diagnostic criteria for PTSD and comorbid conditions with overlapping symptoms as delineated in the DSM

• Include example cases that illustrate appropriate documentation of exam results for disability rating purposes.

Traumatic Brain Injury • Overlapping symptoms and impairments

between TBI and PTSD include difficulties with sustained attention and concentration.

• Depression is common co-morbid condition following traumatic psychological and brain injuries.

• Important to not just screen for TBI based on self-report tests and clinician screening but to test actual cognitive functioning with standardized neuropsychological tests.

Individual Differences in Vulnerability to Combat-Related

PTSD• PTSD is a frequent but not inevitable

consequence of combat.• Wide individual differences exist in

vulnerability to develop PTSD and in protective factors that buffer the effects of combat stress.– Vulnerability factors include: prior trauma,

poor social support network, maladaptive coping mechanisms

– Protective/resilience factors include: reaching out to social support network, positive coping

Seven Recommendations 1. Promote interagency collaboration to develop,

implement and evaluate computerized psychological tests to screen for PTSD, Depression, Alcohol Abuse and other mental disorders.

2. Develop computerized testing to quantify cognitive functioning pre-deployment; The best way to diagnose and plan rehabilitation and to determine disability, especially for TBI, is to have a pre-deployment baseline of cognitive functioning.

3. Fund the development of data standards, controlled clinical vocabularies, terminologies, ontologies and tools for semantic interoperability for representing, storing and sharing information about mental, behavioral, substance abuse and neuropsychiatric disorders.

Seven Recommendations 4. Develop and test predictive models for

suicide risk and interpersonal violence risk. 5. Develop and test preventative methods,

stress-inoculation training, positive coping strategies e.g. The Army’s BATTLEMIND program.

6. Apply research findings to clinical guidelines and protocols for providers and examiners at the point of service.

7. Develop databases, knowledge bases, clinical data repositories and populate them with computable psychological, behavioral and mental health data.

References • Hoge, C.W,Auchterlonic,J.L & C. Milliken (2006) Mental Health

Problems, Use of Mental Health Services, and Attrition From Military Service After Returning From Deployment to Iraq or Afghanistan JAMA, March 1, 2006, Vol 295, No.9 p. 1023.

• Seal, K.H., D Bertenthal, C.R. Miner, S. Sen & C Marmar (2007) Bringing the War Back Home: Mental Health Disorders Among 103788 US Veterans Returning From Iraq and Afghanistan Seen at Dept of Veterans Affairs Facilities. Arch. Internal Medicine vol 167, No. 5, March 12, 2007.

• Zatzick, D.F., C.R. Marmar, D.S. Weiss, W.S. Browner, T.J. Meltzler, J. M. Golding, A. Steward, W.E. Schlenger, K.B. Wells (1997). Posttraumatic Stress Disorder and Functioning and Quality of Life Outcomes in a Nationally Representative Sample of Male Vietnam Veterans. Amer. J. Psychiatry, 154:12 December, 1997,p. 1690.

• World Health Organization, International Classification of Functioning, Disability and Health (ICF). 2001.

Institute of Medicine Reports on Disability

• The Future of Disability in America, http://books.nap.edu.catalogue/11898.html

• PTSD Compensation and Military Services

• A 21st Century System for Evaluating Veterans for Disability Benefits, http://books.nap.edu/catalog/11885.html

Contact InformationSaul Rosenberg, Ph.D.

Saul Rosenberg, Ph.D.Associate Clinical Professor and Research Psychologist Dept. of Psychiatry, University of California, San Francisco ▬▬CEO, Neuron Valley Networks Inc.21 Tamal Vista Blvd., Suite 216Corte Madera, CA 94925▬▬Tel: 415.925.3086Fax: 415.925.6002Email: saul@rosenbergphd.com