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Originally published February 22, 2012 at 10:01 PM | Page modified February 22, 2012 at 11:19 PM

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Army reinstates PTSD diagnoses in six cases from Madigan

The Army Surgeon General has offered to expand those reviews to include other soldiers who feel they did not get fair treatment from Madigan.

Seattle Times staff reporter

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When an Army forensic psychiatric team at Madigan Army Medical Center examined Sgt. 1st Class Stephen Davis, it concluded the soldier who served in Iraq and Afghanistan had exaggerated his symptoms of post-traumatic stress disorder (PTSD) and had wrongly been diagnosed with the condition.

But a psychiatric team at Walter Reed National Military Medical Center recently reversed the Madigan diagnosis. It concluded the 45-year-old Davis had PTSD, which is expected to make him eligible for a retirement pension and health insurance for his wife and dependents.

"This isn't just about money and benefits to myself and my wife," Davis said Wednesday in a meeting with reporters at Sen. Patty Murray's office in Seattle. "It's doing what's right. Taking care of soldiers that are coming home."

Davis is one of 14 soldiers whose Madigan diagnoses were reviewed at Walter Reed as part of a wider investigation into the PTSD screening and treatment at the Western Washington medical center.

The Army Medical Command said Wednesday that six of those soldiers had PTSD diagnoses reinstated. The remaining eight soldiers, according to Walter Reed doctors, had behavioral-health conditions other than PTSD, including two who were never initially diagnosed with the condition.

Maj. Gen. Philip Volpe, head of the Western Regional Medical Command, said the results suggest there was variance in the way PTSD diagnoses were made. Madigan, he noted, was the only Army medical facility that routinely used a forensic psychiatric team for evaluations. Forensic psychiatrists often diagnose patients separately from treatment, and outside the military often are used as expert witnesses in lawsuits or criminal trials.

"The Army has the best interest of the Soldier in mind and views such practice variations as unacceptable. Nothing is more important to the Command team and me than ... keeping the Soldier's best interest at heart, always," Volpe said in a statement.

The Army Surgeon General has offered to expand those reviews to include other soldiers who feel they did not get fair treatment from Madigan.

Meanwhile, the commander of Madigan, Col. William Homas, and the head of the PTSD screening team, Dr. William Keppler, have been relieved of their duties during the investigation.

The probe also has exposed broader tensions among military and Department of Veterans Affairs (VA) health-care providers about how to diagnosis PTSD, a condition that results from experiencing a traumatic event and can cause recurrent nightmares, flashbacks and other symptoms.

An accurate diagnosis of PTSD is vital for soldiers and veterans seeking to heal from the mental wounds of war and qualify for benefits. It also is of keen interest to taxpayers who foot the escalating annual bill for treatment and disability payments.

The Seattle Times looked at the medical records of a mix of six soldiers and veterans who were screened for possible medical retirements at Madigan. (Only one of those cases was reviewed by Walter Reed doctors.)

They all had been deployed to combat zones, some repeatedly. All were initially diagnosed with PTSD by Army or VA medical providers and often underwent extensive treatment, only to have the Madigan team overturn their diagnoses. After interviews and administering tests, the Madigan team concluded five of them were exaggerating their symptoms and some had other conditions such as personality disorders.

"What they are saying is that I'm a liar, and that really angers me," said Tony Stephens, a Washington National Guard veteran from Poulsbo who had initially been diagnosed by the VA with PTSD after returning from Iraq. "They have stripped my honor from me." At this point, his case is not under review.

The five other soldiers who offered their medical records to The Seattle Times requested anonymity. Those include a soldier who, on his third tour of duty to a war zone, was evacuated because of a suicide attempt. After his return home, he said he slept so fitfully that he once attacked a beloved service dog that had awakened him from a nightmare.

"My (Madigan) report clearly states that I have a personality disorder. I'm a malinger and I overexaggerated my symptoms," the soldier said. "I find myself thinking I would rather be in a combat zone than dealing with all this."

Another soldier who had his diagnosis reversed was a combat medic who served in Afghanistan. Shortly after his arrival there, he responded to a suicide bomber who struck a bazaar, injuring 13 U.S. soldiers and more than 20 civilians. The following months were punctuated by other bloody bomb attacks.

He was evacuated before the end of his tour because of his nightmares, jumpiness and other symptoms of acute stress, including voicing thoughts of homicide, according to medical records.

The Madigan team found this soldier had an adjustment disorder but still met "psychiatric standards for retention" in the Army.

Benefits

During the earlier years of the wars in Afghanistan and Iraq, a PTSD rating generally did not result in a soldier's medical retirement.

Once out of the Army, those soldiers could still apply to the VA for a disability rating that would offer compensation. But they did not receive the pensions, family health insurance and other benefits of a medical retiree.

Army leaders, concerned about rising suicide rates and other signs of stress, have in recent years tried to reduce the stigma many soldiers who seek mental-health care face. Among other steps, the Army increased funding for treatment programs.

And in 2008, after Congress approved an overhaul of the military disability system, soldiers rated with PTSD qualified for a medical retirement.

Military retirements because of PTSD diagnoses then increased substantially, according to records provided by the Army Medical Command.

Part of the controversy around Madigan's program stems from a lecture last September by Keppler, Madigan's forensic psychiatric team leader. He spoke of the need for "good stewardship of the taxpayer dollars," and noted that a medical retirement could cost taxpayers up to $1.5 million.

Sen. Murray said Wednesday that, "If there were people in charge who felt their mission was not to make a correct diagnosis but to save money for the taxpayer ... that to me was absolutely wrong."

A medical-command ombudsman reported that Keppler referred to Madigan's forensic psychiatry team as the "gold standard" for testing for PTSD.

Yet as early as 2006, documents obtained by The Times indicate, the team was coming under scrutiny.

That year, Larry Larue, a Gulf War veteran, disputed the findings of a psychiatrist on the team that reversed the PTSD diagnosis given by another psychiatrist. Larue protested up the Army chain of command and to his congressman. He eventually was able to get a second review at Walter Reed, which concluded that Larue did have PTSD.

Skepticism

The forensic team, in case files reviewed by The Seattle Times, displays skepticism toward other providers working with PTSD patients.

In one note to a patient's file, a Madigan psychologist notes that malingering — feigning symptoms — among personal-injury claimants may range up to 59 percent. She writes, "Clinicians ... often do not suspect malingering and typically lack the training or tools to assess for malingering if they suspect it. Not surprisingly, they rarely find it."

The forensic team typically uses the Minnesota Multiphasic Personality Inventory to assess the severity of PTSD symptoms or whether a soldier is feigning symptoms.

Dr. David Tolin, director of the Anxiety Disorders Center at the Connecticut-based Institute of Living, was involved in a study that examined the responses of 377 male veterans to Minnesota test.

Tolin said the test consists of more than 500 true or false questions. Some are relatively straightforward, such as questions about sleep and anxiety. Others help detect patterns of exaggeration, such as answers that reflect what people think mental illness is like rather than what it actually is like.

Tolin does support having a separate team involved in screening patients whose diagnoses may result in financial benefits. That way, he says, doctors involved in treatment can focus on caring for their patients — not judging the accuracy of their symptoms.

While Tolin says malingering is a serious issue that often goes undetected, it's also important not to use the Minnesota test on its own to make a definitive diagnosis.

"It should be combined with a thorough clinical interview and behavioral observations," Tolin said.

Some soldiers interviewed by The Times said they had substantial interviews by Madigan's team.

But Davis says his lasted only 10 minutes.

"We are fighting the system now to change it," Davis said. "The soldiers want the respect they deserve, and the help they deserve for PTSD."

Hal Bernton: 206-464-2581 or hbernton@seattletimes.com

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