Clinical Topics   /   PTSD

Mental-Health Screenings Questioned After Shooting

USM By U.S. Medicine
April 9, 2012

By Sandra Basu

WASHINGTON — In the wake of a killing spree that left 17 Afghan civilians dead last month, questions were raised about whether the U.S. military is effectively diagnosing neurological and psychiatric problems that can become ticking time bombs in war zones.

While the mass killing dominated headlines, the Army also was grappling with a controversy over possible underdiagnosis of behavioral health problems at military facilities and an unprecedented suicide rate that underscored the difficulty of containing these issues.

In the aftermath of the Kandahar killings, U.S. Defense Secretary Leon E. Panetta spoke to Marines at Camp Leatherneck in the Helmand province and vowed not to allow the tragedy to accelerate the American withdrawal from Afghanistan. “We will be challenged by our enemies. We will be challenged by ourselves. We will be challenged by the hell of war itself,” he said. Photo by Sgt. Andrea Olguin.

Army Staff Sgt. Robert Bales, who was being held at a U.S. military prison, was officially charged with murdering 17 Afghan civilians, among other charges. After the massacre, lawmakers and others were asking whether mental-health issues are being properly identified in troops.

His attorney, John Henry Browne of Seattle, said Bales had been injured during his three previous deployments, including a serious foot injury and head trauma, and did not want to go on a fourth tour. Brown said his client’s  “mental state” would be an issue in his defense.

Following the incident, co-founder and co-chair of the Congressional Brain Injury Task Force, Rep. Bill Pascrell Jr. (D-NJ) wrote to Defense Secretary Leon Panetta requesting details about the accused soldier’s injury, diagnosis and return to active duty.

Pascrell noted that “whether PTSD or TBI are connected in any way to this horrific loss of innocent life in Afghanistan” is a question that would be answered by a full and thorough investigation. He said, however, that he has “become increasingly concerned that the [DoD’s] system for identifying servicemembers with traumatic brain injuries has not been working.”

Identifying PTSD, Other Issues

Identifying troops with mTBI, PTSD and other mental-health issues has been a growing concern over the years, especially with an extremely high suicide rate plaguing the military.

A study released last month, examining relative risks of suicide associated with mental-health disorders in the Army, reported that a total of 255 active-duty soldiers committed suicide from 2007 through 2008. Of the 255 suicide cases, 44 had a previous hospitalization from January 2007 to December 2008, and 128 (50%) had a previous ambulatory visit for a mental-health disorder during that period.

The study also reported that suicides among U.S. Army personnel rose 80% between 2004 and 2008.

“This increase, unprecedented in more than 30 years of U.S. Army records, suggests that approximately 40% of suicides that occurred in 2008 may be associated with post-2003 events following the major commitment of troops to Iraq in addition to ongoing operations in Afghanistan,” the researchers wrote.

Further fueling controversy was a recent Army announcement that it was investigating how more than 1,000 troops initially were evaluated for behavioral-health problems at Madigan Army Medical Center in Tacoma,WA. Some soldiers had argued that their diagnoses were changed so that they would qualify for a lesser amount in disability compensation.

The Army said last month that about 285 soldiers would receive letters inviting them to Madigan Army Medical Center or a military-treatment facility near their residence for reevaluations, which were taking place after a behavioral-health team conducted a review of the medical records of 1,500 soldiers seen by Madigan’s Forensic Psychiatry Service since 2007. Of those, about 285 patients were found to have had their diagnoses changed from PTSD.

“This deliberate outreach program will also include those individuals who have already left military service and rejoined the civilian work force. Soldiers and veterans who were seen by Madigan’s Forensic Psychiatry Service for a medical evaluation and have concerns or questions, are encouraged to call the 24/7 warrior and family hotline supported by the U.S. Army Medical Command’s Medical Assistant Group,” according to an announcement from the Western Regional Medical Command.

Last month, Army Surgeon General Maj. Gen. Patricia Horoho, RN, told the House Appropriations Subcommittee of Defense that the reevaluations were spurred after 17 soldiers came forward with concerns that their behavioral-health diagnoses had been negated after being examined by the forensic psychiatry department at Madigan Army Medical Center. A psychiatric team from Walter Reed National Military Medical Center reevaluated the cases and changed most back to the original diagnosis, she said.

“As they were being reevaluated, we found that there was a brief provided by one of the forensic scientists that alluded to a focus on compensation and the cost of PTSD,” she said. “Because of that and other concerns, I initiated an investigation to look at both the climate and the practices and variance and to make sure we were fairly treating our servicemembers and providing them the best care possible. That investigation is ongoing,” she said.

She said that an inspector general’s assessment also has been initiated across Army Medicine to make sure there were no variance or systemic issues. Both of those assessments, she said, should be completed shortly.

Subcommittee members wanted to know if there was a common standard across the services to diagnose PTSD. Horoho said that there are uniform guidelines in the diagnosis of PTSD that the services follow, in addition to uniform training across DoD.

“There is a common standard for diagnosing PTSD,” she said. “There is the clinical judgment that is part of that, because it is not a hard science. We do have standards, but we also have the clinical judgment of each provider that is providing that behavioral healthcare.”

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