The Defense Department aims to create a more accepting environment for service members seeking help for post-traumatic stress disorder in its latest behavioral health guidelines, according to a pair of documents obtained by The News Tribune.
The Army Medical Command released its new policy in April in the thick of an investigation at Madigan Army Medical Center. The probe centered on a team of doctors known as forensic psychiatrists who sometimes downgraded behavioral health diagnoses for soldiers receiving medical retirements.
The Pentagon published another set of guidelines in August, presumably after the Madigan investigations concluded. It lifts some language from the Army policy and compels a standard approach to PTSD across all the Armed Forces.
Both documents discourage doctors from relying heavily on medication to treat PTSD, favoring therapy over drugs. They note that a class of psychoactive drugs called benzodiazepines carries "risks that exceed benefits."
They stress that doctors should not become overly focused on the possibility that patients might embellish symptoms to gain disability benefits. That was an issue at Madigan, where critics said the forensic psychiatrists reversed PTSD diagnoses out of an exaggerated concern that patients were misrepresenting their symptoms.
The Army guidelines state that PTSD tends to be underdiagnosed and undertreated because of a stigma in the military that discourages troops from seeking help for mental health issues.
"The majority of service members do not seek treatment, and many who do seek treatment drop out before they can benefit," reads an April 10 memo signed by former Army Medical Command Chief of Staff Herbert Coley.
The new guidelines de-emphasize one of the two main criteria doctors use to diagnose PTSD -- that patients feel a sense of overwhelming "fear, helplessness or horror" during a traumatic event.
That requirement was laid out in a manual of mental disorders that sets the standards psychiatrists and psychologists use when they meet with patients.
Both the Army and the Department of Veterans Affairs are moving away from that diagnostic criterion, because they found that service members tend to be unwilling to admit to feeling a sense of "helplessness" in combat.
"Fear" is another symptom that doesn't always register with service members.
"Although they may experience fear internally, they are trained to fall back on their training skills," Coley wrote in the April memo.
Meanwhile, they suffer other symptoms of PTSD, such as reliving disturbing memories, being easily startled and feeling emotionally numb.
An updated version of the manual is due out later this year, and the military anticipates the criteria for diagnosing PTSD will change in it.
Coley wrote that Army Medical Command anticipates the manual will revise the PTSD criteria from focusing on a specific traumatic event, such as witnessing a fatal explosion, to experiencing less dramatic "repetitive threats" that soldiers often face in war zones.
Coley's memo contrasts with PTSD guidelines the Army and the VA used in recent years. One Army Medical Command briefing on diagnosing PTSD from 2008, for instance, stresses that a service member must experience a traumatic event and that the soldier must obtain a witness or Army documentation to prove the incident took place before a doctor could endorse a PTSD diagnosis.
"Trust but verify," the briefing says, urging doctors to contact platoon sergeants or officers to back up testimony from their patients.
VA memos from that time period are even more explicit in their emphasis on patients feeling helpless in a single event.
"Mere service in combat zone (is) not enough to support a diagnosis of PTSD," a 2006 VA briefing says.
"A person must have been exposed to a traumatic event in which the person experienced or witnessed ... an event that involved actual or threatened death or serious injury," it says.
Both of the earlier VA and Army PTSD guidance documents were obtained by the nonprofit Citizens for Responsibility and Ethics in Washington. The organization pursued them through the Freedom of Information Act after learning of complaints at an Army hospital in Colorado where doctors felt pressured not to diagnose PTSD.
The organization submitted another FOIA request for the Army's most recent PTSD guidance and for investigations into patient complaints at Madigan. The Army denied the request, as it has done for similar appeals from The News Tribune, The Seattle Times and public radio station KUOW.
Army leaders say they resolved issues at Madigan, but they have declined thus far to describe any changes they've made aside from curtailing the widespread use of forensic psychiatrists at the hospital south of Tacoma.
Forensic psychiatrists are commonly used in court cases to make an objective opinion about a defendant's state of mind.
At Madigan, the forensic doctors sometimes gave PTSD diagnoses to patients who came to them with diagnoses for less serious conditions. They also looked for service members who embellished their combat records to obtain benefits, and occasionally caught soldiers in lies, according to Madigan documents The News Tribune obtained last year.
Four years ago, Army leaders endorsed Madigan's forensic psychiatrists as an example of "best practices" in military medicine because the extra research they carried out resulted in a higher degree of diagnostic accuracy.
Their ascendency crashed at Madigan early last year when an Army inspector general obtained a briefing that urged doctors to consider the long-term costs to taxpayers of a PTSD diagnosis, suggesting the Army would pay out $1.5 million in benefits over a soldier's lifetime for that diagnosis.
Some doctors in the hospital had already expressed concerns that the forensic psychiatrists' drive to root out fraud and malingering was causing Madigan to mistreat patients who should have received help.
The new Army guidelines move toward a more broad-minded view of PTSD.
"There really has been a big change," said one Madigan doctor who spoke on the condition of anonymity out of concern for his career.
Others bristle at the suggestion they downgraded diagnoses to save money.
"Our interest was in diagnostic accuracy, not in monetary issues," said Juliana Ellis-Billingsley, a forensic psychiatrist who resigned last year when she became convinced the Army was "fixing" diagnoses to appease political leaders.
Senior Army officers insist Madigan was the only military hospital to rely on forensic psychiatrists so extensively.
Yet the second Defense Department memo obtained by The News Tribune maintains a role for them in behavioral health medicine.
The memo, signed by Assistant Secretary of Defense Jonathan Woodson, says doctors should continue to consult with forensic psychiatrists or forensic psychologists in certain cases.
"Where profound symptom embellishment or malingering seems manifest, consider consultation with experts in such matters, such as forensic psychiatrists or forensic psychologists," reads Woodson's Aug. 24 memo.
Ellis-Billingsley said that guidance resembles her former purpose at Madigan.
Army Medical Command spokeswoman Maria Tolleson said the service still has "a limited number" of forensic behavioral health specialists. She said they no longer participate in disability evaluations as they did at Madigan. Instead, they're consulted in legal cases and certain administrative hearings.
The Army in November announced that it changed diagnoses for 267 former Madigan patients, including 150 who received PTSD diagnoses. Their cases were considered under the new Army guidelines.
Woodson wrote that differences in diagnoses should be expected even among experienced behavioral health specialists.
"Diagnostic variance among highly competent clinicians is inevitable," he wrote. "Clinical diagnosis is both an art and a science."