Pressure Not to diagnose PTSD at the U.S. Army and Department of Veterans Affairs
NOTE: The following is one of a series of case studies produced by the Union of Concerned Scientists' Scientific Integrity Program between 2004 and 2010 to document the abuses highlighted in our 2004 report, Scientific Integrity in Policy Making.
The U.S. Army allegedly pressured psychologists not to diagnose Post-Traumatic Stress Disorder (PTSD) to free the Army from providing long-term, expensive care for soldiers. The Department of Veterans Affairs (VA) has also been implicated in pressuring staff to misdiagnose veterans with the aim of cutting costs.
Pressure not to diagnose PTSD at the U.S. Army
Post-traumatic Stress Disorder (PTSD) is an anxiety disorder that results from a terrifying experience, such as an intense military or combat experience.1 Symptoms of PTSD include re-living the traumatic experience, feeling numb, difficulties sleeping, and feeling easily startled, fearful, and irritable.2
Evidence indicates that the Army’s disability process is marred by pressure not to diagnose Post-traumatic Stress Disorder (PTSD). In order to be discharged from the Army and receive disability and health care benefits, service members must navigate the disability evaluation process, in which they receive a rating from evaluation boards. The ratings influence the amount and type of disability benefits the service members receive.3
Case of "Sgt. X": Doctor admits experiencing pressure to misdiagnose PTSD
In June 2008, an Army service member obtained an explicit confession demonstrating that the Army pressured a staff psychologist to change their clinical diagnoses.4 "Sgt.X," a service member who served in Iraq and spoke with Salon Media Group on condition of anonymity, went to seek treatment for a brain injury and PTSD5 at Fort Carson Army Post near Colorado Springs, Colorado after returning from overseas. At an appointment with psychologist Douglas McNinch in June 2008, Sgt.X brought a tape recorder.6 Sgt.X asked McNinch why he had told the evaluation board that Sgt.X had an "anxiety disorder" instead of PTSD. If discharged from the Army with an "anxiety disorder," Sgt. X would receive a significantly lower amount of benefits than if he was discharged with PTSD.7
In reply to his question, McNinch stated, "I will tell you something confidentially that I would have to deny if it were ever public. Not only myself, but all the clinicians up here are being pressured to not diagnose PTSD and diagnose anxiety disorder NOS [instead]." Apparently Army medical boards were "kick[ing] back" diagnoses of PTSD. McNinch continued by telling Sgt.X that his wasn’t the only case of misdiagnosis due to pressure. McNinch said that he "and other [doctors] are under a lot of pressure to not PTSD. It’s not fair…now the V.A. is jumping on board, saying, 'Well, these people don’t have PTSD,' and stuff like that."
In an interview with Salon, McNinch said that the former head of Fort Carson’s Department of Behavioral Health, an army psychiatrist, pressured him not to diagnose PTSD. He mentioned the difficulty of being a civilian in a military setting. In addition, McNinch also felt pressure not to diagnose brain injuries. When he arrived, McNinch was told he "was overdiagnosing brain injuries." He was also told that "we are just counting people. We don’t plan on treating them." After Salon told him that he would be quoted in an article and that Salon had recorded the interview, McNinch said he would deny that the interview occurred.8
Salon also spoke with a retired Army psychiatrist, on condition of anonymity, who stated that commanders at another Army hospital told him not to diagnose soldiers with PTSD; he was pressured to diagnose them with other conditions that would cost the Army less in soldiers’ benefits.9
David Rudd, the chairman of Texas Tech’s department of psychology and a former Army psychologist, agrees with the notion that the Army is misdiagnosing PTSD due to monetary concerns. Rudd stated that "Each diagnosis is an acknowledgement that psychiatric casualties are a huge price tag of this war…It is easiest to dismiss these casualties because you can’t see the wounds. If they change the diagnosis they can dismiss you at a substantially decreased rate."10
To investigate the allegations of pressured improper diagnoses, the Army conducted an internal investigation.11 The Army’s report concludes that there was no command pressure that would influence the outcome of evaluations. However, the report also mentions "evidence of potential systemic pressures inherent in Army physical disability evaluation processes” that could lead to health providers avoiding “a diagnosis of PTSD on medical boards contrary to their clinical judgment."12
Pressure not to diagnose PTSD at the Department of Veterans Affairs
The U.S. Army is not the only place where evidence suggests mental health staff have been pressured not to diagnose PTSD because of monetary considerations. The Department of Veterans Affairs (VA), which is charged with providing services and benefits to veterans, was also implicated in pressure to misdiagnose.13
In spring 2008, psychologist Norma Perez, who at the time was the coordinator of a PTSD clinical team in a Texas VA medical center,14 sent an email to staff with the subject "Suggestion."15 Perez stated that "Given we are having more and more compensation seeking veterans, I’d like to suggest that you refrain from giving a diagnosis of PTSD straight out. Consider a diagnosis of Adjustment Disorder….Additionally, we really don’t or have time to do the extensive testing that should be done to determine PTSD."16
In testimony to the Senate Committee on Veteran’s Affairs, Perez explained her email by stating she was attempting to provide guidance to her staff "because veterans were receiving conflicting messages" regarding their diagnoses.17 Perez admitted that she "did not adequately convey" her message, but her goal was to "improve the quality of care our veterans received."18
1. United States Department of Veterans Affairs (VA). 2009. What is PTSD? National Center for PTSD Fact Sheet.
2. VA 2009; National Institute of Mental Health. 2009. What are the symptoms of PTSD? National Institute of Mental Health.
3. Government Accountability Office. 2008. Military Disability System: Increased Supports for Servicemembers and Better Pilot Planning Could Improve the Disability Evaluation Process. September; Priest, D. & Hull, A. 2007. Soldiers face neglect, frustration at army’s top medical facility. Washington Post, February 18.
4. de Yoanna, M. & Benjamin, M. 2009. "I am under a lot of pressure to not diagnose PTSD." Salon.com, April 8.
11. Benjamin, M. & de Yoanna, M. 2009b. Tale of the secret army tape. Salon.com, April 9.
12. “This report does not find pressure to change clinical diagnoses.” Page from the Executive Summary of Army’s investigation into Evans Army Community Hospital. Salon.com.
13. Yen, H. 2008. VA denies money a factor in PTSD diagnoses. Associated Press, June 3. Available online from an advocacy site.
14. Senate Committee on Veteran’s Affairs. 2008. Oversight Hearing on Systemic Indifference to Invisible Wounds. June 4.
15. Yen 2008; Citizens for Responsibility and Ethics in Washington (CREW). 2008. CREW and VoteVets release email telling VA staff to “refrain from giving a diagnosis of PTSD straight out.” May 15.
16. Yen 2008; CREW 2008.