标题：US Department of Veterans Affairs Disability Policies for Posttraumatic Stress Disorder: Administrative Trends and Implications for Treatment, Rehabilitation, and Research
摘要：An accumulating body of empirical data suggests that current Department of Veterans Affairs (VA) psychiatric disability and rehabilitation policies for combat-related posttraumatic stress disorder (PTSD) are problematic. In combination, recent administrative trends and data from epidemiological and clinical studies suggest theses policies are countertherapeutic and hinder research efforts to advance our knowledge regarding PTSD. Current VA disability policies require fundamental reform to bring them into line with modern science and medicine, including current empirically supported concepts of resilience and psychiatric rehabilitation. Department of Veterans Affairs (VA) psychiatric disability compensation and rehabilitation policies for combat-related posttraumatic stress disorder (PTSD), although well intentioned, are more than 60 years old 1 and seriously flawed. We review administrative trends and epidemiological and clinical studies to advance the argument that current VA psychiatric disability policies are countertherapeutic and likely undermine efforts to develop and evaluate PTSD interventions for veterans. The number of veterans receiving VA disability payments for PTSD increased 79.5% from 1999 to 2004, whereas those receiving payments for other disabilities increased only 12.2%. 2 This and other recent VA administrative trends indicating rapid expansion of PTSD disability compensation among veterans (see the box on this page) are troubling for various reasons. Recent Department of Veterans Affairs (VA) Administrative Trends Regarding Posttraumatic Stress Disorder (PTSD) Disability From 1999 to 2004, the number of veterans receiving VA disability payments for PTSD increased 79.5% (from 120 265 to 215 871), whereas those receiving payments for other disabilities increased only 12.2%. 2 From 1999 to 2004, total PTSD disability payments rose 148.8% (to $4.3 billion annually), whereas payments in other disability categories increased by only 41.7%. 2 Most veterans’ self-reported symptoms of PTSD become worse over time until they reach 100% disability, at which point an 82% decline in use of VA mental health services occurs; no change in use of VA medical health service occurs. 2 In a recent review of disability award files, 25% of files were found lacking compelling evidence of combat exposure, putting the monetary risk of potential fraud at $19.8 billion. 2 Among veterans seeking mental health treatment in VA clinics, most (up to 94%) concurrently apply for PTSD disability benefits. 3 Only about half of those veterans who apply for PTSD disability are seeking psychiatric care at the time of their disability application submission. 4 A nearly 2-times regional difference in the rate of approved PTSD disability claims is found across the nation; this variation is not explained by differences in PTSD symptom severity or psychiatric comorbidity, suggesting inconsistent evaluation standards or procedures. 2 , 5 , 6 In 2006, the VA took an average of 657 days for appeals resolution of disability claims. 5 As epidemiological data from community samples have shown, the prevalence of PTSD declines sharply (> 50%) over time. 7 – 9 Furthermore, recent, more rigorous estimates of PTSD prevalence among Vietnam War veterans are about 40% 7 to 65% 10 lower than original estimates, and there may be proportionally few cases of severe functional impairment in veterans with PTSD. 11 , 12 Many treatment-seeking veterans (53%), 13 especially those seeking disability compensation, show clear symptom exaggeration or malingering on psychological tests and forensic interviews. 3 , 13 – 15 Some veterans’ reports of combat exposure change over time as a function of reported PTSD symptom severity, 16 – 18 and some misrepresent combat exposure or war-zone deployment altogether. 19 , 20 Thus, disability incentives may distort accurate clinical evaluation. Many VA clinicians doubt the sincerity of veterans’ PTSD complaints, suspecting their treatment involvement is intended primarily to help obtain or maintain disability payments. 21 , 22 This may impede compassionate and effective care. Veterans with a PTSD diagnosis benefit far less 23 – 25 from treatment compared with other patients with PTSD (e.g., rape victims). 23 , 26 , 27 A recent meta-analysis found that 67% of the patients who completed psychotherapy for PTSD no longer met criteria for the disorder at posttreatment, 23 but little evidence of efficacy was found among veteran samples. Furthermore, we are aware of no administrative data showing clinical improvement among veterans receiving treatment in VA programs. This is consistent with data showing that disability benefits unintentionally discourage full participation in vocational rehabilitation and result in significantly worse rehabilitation outcomes. 28 As Hadler 29 (p2397) observed, “if you have to prove you are ill, you can’t get well.” The VA does not widely offer evidence-based vocational rehabilitation services for veterans with PTSD. Current policies and services are not in line with clinical evidence-based practices or psychiatric rehabilitation principles and programs. 30 Instead, they are countertherapeutic, because physical, social, and employment activities are palliative, 21 and veterans’ PTSD symptoms worsen when they stop working. 31 Disability incentives may undermine the integrity of the PTSD knowledge base. 14 , 15 , 32 – 35 An expert consensus panel recommended excluding compensation-seeking veterans from clinical research because of the likely bias created by disability incentives. 36 This recommendation has been largely ignored, perhaps because up to 94% 3 of treatment-seeking veterans also seek compensation, making it difficult for clinical researchers to recruit participants who are not seeking compensation. Thus, current disability policies likely undermine our ability to develop and evaluate PTSD interventions for veterans exposed to combat trauma, as well as to study other phenomenological aspects of the disorder. Veterans deserve appropriate psychiatric treatment, rehabilitation services, and disability benefits necessary to readjust to civilian life. Yet the VA has signally failed to benefit from the lessons of 20th-century military psychiatry regarding social expectations and incentives. 37 – 40 We may be instilling counterproductive social expectations that war-zone deployment will make veterans psychiatrically disabled, 41 potentially a self-fulfilling prophecy. 42 A review of British government war pension files from the Boer War through World War II suggested that disability incentives for combat-related psychiatric problems “inhibit the natural process of recovery and consolidate distressing symptoms.” 43 (p378) Resilience is the most common response to trauma 44 – 46 ; most survivors of combat or rape never develop PTSD. 7 , 47 Yet VA policies are potentially harmful in encouraging chronically ill patient roles. The VA’s disability policies require fundamental reform to create an effective, responsive, and flexible safety net for veterans with PTSD. We must ensure that veterans receive the best possible services and that finite resources are not misallocated and do not foster invalidism. Our goal should be work-force reintegration, incorporating current principles of psychiatric rehabilitation: vocational rehabilitation, assertive community treatment, supported employment, recovery-focused interventions, and disincentives-to-work principles (a set of principles that are thought to provide disincentives for people to participate in the workforce at maximum capacity). 30 , 48 , 49 There is good evidence of success in policies and strategies for facilitating psychiatric rehabilitation among even the most severely mentally ill. The US Government Accountability Office also has recommended fundamental change, informed by current science, medicine, technology, and labor conditions, 5 and the Institute of Medicine has called for comprehensive research to inform policy decisions. 1 Appropriately revised disability policies would help neutralize concerns about symptom exaggeration, combat misrepresentation, unreliable evaluation procedures, and distortion of research findings. They also would reduce current disincentives to participate in and benefit from treatments efficacious for civilians with PTSD. Our returning warriors deserve to live as productive members of society. The VA should reconsider its disability policies to help veterans realize this goal.
