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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 Francisco
CEO, Neuron Valley Networks Inc.
Treatment, Rehabilitation and
Disability Determination for Mental
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
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
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
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
– 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
• 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
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
– lower subjective well-being
– interpersonal violence
Evaluating Screening and Diagnostic
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
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
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
• 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,
• b117
Intellectual functions (verbal
• b126
Temperament and personality
functions (shy versus socially
• b130
Energy and drive functions
ICF Specific Mental Functions
Attention functions (maintain focus)
Memory functions (short-term, working
Emotional functions (self-control of
Higher-level cognitive functions
Mental functions of language
(understand and express)
Calculation functions (numerical
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
– Body Structures
– Activities
– Participation
– Environmental factors
ICF Components
• Specific mental functions of language
– b167.3 severe impairment
• Performance problem in current
– 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
– 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
Adopt standardized diagnostic classifications, e.g.
ICD, ICF, AMA Guides to the Evaluation of
Permanent Impairment, DSM-IV for mental
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
• 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 serviceconnected 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
• 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
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, stressinoculation 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.
• 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
The Future of Disability in America,
PTSD Compensation and Military Services
A 21st Century System for Evaluating Veterans for
Disability Benefits,
Contact Information
Saul 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 216
Corte Madera, CA 94925
Fax: 415.925.6002
Email: [email protected]