Compensation and Pension Examination for PTSD
The approval of a claim for service-connected post-traumatic stress disorder (PTSD) results in priority access to VA health care and financial compensation. Veterans currently receive over $4 billion dollars annually in compensation for PTSD. The number of Veterans in 2010 with service-connected PTSD was 386,882, a 222 percent increase from 1999. The trend for rapidly rising costs of service-connected PTSD prompted an investigative report in 2005 by the VA Office of Inspector General. The report found that compensation for PTSD out-paced all other conditions and that wide regional variations exist in the rates of service-connected PTSD. The report attributed this wide variation across the network of VA medical centers in part to variation in compensation and pension (C&P) examinations.
In studies on PTSD, the Clinician-Administered PTSD Scale (CAPS) has been used in hundreds of research protocols, resulting in CAPS becoming the gold standard for diagnosis.1 Standardized administration is accomplished through carefully worded prompts and scale anchors with explicit behavioral referents. Initial prompt questions target each core symptom of PTSD, and followup prompts help clinicians clarify the linkage between symptom and trauma. Similarly, the World Health Organization Disability Assessment Schedule II (WHODAS-II) is a standardized interview of functional impairment.2 Given that these evidence-based, standardized, diagnostic tools are used routinely to enhance the validity of research studies on PTSD, the incorporation of these diagnostic methods may likewise produce greater accountability and consistency in the disability examination for PTSD.
A surprising lack of rigorous studies exists on evidence-based, standardized assessment for disability. We addressed this evidence gap by conducting a cluster randomized controlled trial in a sample of Veterans seeking PTSD disability compensation from the VA—the Enhancing Equitable and Effective PTSD (E3-PTSD) Disability Assessment Study. The trial compared typical clinical interviews with standardized assessments that incorporated the CAPS for PTSD diagnosis and the WHODAS-II for functional impairment. We expected that Veterans in the standardized assessment condition would receive more complete and accurate assessment of the DSM-IV-TR diagnostic components of PTSD and related functional impairment compared with Veterans in the usual practice condition.
Our study found that administering a standardized disability assessment resulted in more complete assessment of functional impairment and diagnostic coverage of PTSD. Standardized assessment elicited an increase in relevant information for each of the core diagnostic criteria, and nearly eliminated variation between examiners and medical centers. Furthermore, the study found that standardized assessment substantially diminished the uncertainty in diagnosis, and increased concordance of diagnosis with the NC-PTSD experts.
The CAPS added 15-20 minutes to the assessment process. A majority of the clinicians found the CAPS useful and would support making it a routine part of the assessment (56 percent support/25 percent oppose/19 percent ambivalent). The vast majority of clinicians did not find the WHODAS useful and would oppose making it a routine requirement. Clinicians’ primary objection was that the WHODAS was not specific enough for functional impairments attributable to PTSD.
Reflections and Looking Forward
In a survey of VA clinical examiners, we found that the CAPS or other structured interview methods are rarely used in Veteran C&P disability assessment.3 The more routine and common practice is the open-ended, unstructured clinical interview concurrent with the use of a report writing template. The findings of our study indicate that evidence-based, standardized disability assessment for PTSD would enhance the clinician’s determination of a PTSD diagnosis and functional impairment, and make the disability examination process more reliable and valid.
The E3-PTSD study was formulated to meet the need of the Veterans Benefits Administration and the Veterans Healthcare Administration to inquire about variations in the C&P examination process. We encountered challenges in navigating the two worlds of research and operations, and in overcoming the hurdles of multiple Institutional Review Boards. We also faced difficulty in embedding a study within pure facility operations of C&P and the realities of completing examinations within a 30-day window of time. During the course of the study, we had to adjust to volatile events resulting in suspension and then surveillance of PTSD research, and contend with policy changes on conceding PTSD stressors. These challenges resulted in slowing study enrollment and then flooding VHA with PTSD examinations. As HSR&D moves toward more partner service-directed research, new studies will face similar challenges. In E3-PTSD, we submitted progress reports and held debriefings with the VA leadership. Our greatest impact to date has been the timely transfer of knowledge, which has allowed leadership to properly debate the study implications and incorporate them into consideration and formulation of policy.