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CREW v. U.S. Department of the Army: Regarding PTSD Diagnoses: 5/24/2011 - Part7

CREW v. U.S. Department of the Army: Regarding PTSD Diagnoses: 5/24/2011 - Part7

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Published by CREW
On April 17, 2009 Citizens for Responsibility and Ethics in Washington (CREW) filed a Freedom of Information Act (FOIA) request with the Department of the Army, seeking records related to guidance given to army staff and contractors regarding the diagnosis of post traumatic stress disorder (PTSD). CREW seeks these records to raise public awareness about the process behind the diagnosis of PTSD and the pressure being placed on doctors to diagnose related anxiety disorders as a cost-cutting measure. The request was filed after Salon.com obtained a June 2008 taped conversation between an Army staff sergeant and an Army psychologist, in which the psychologist revealed he had been pressured not to diagnose PTSD. On July 31, 2009, CREW filed a lawsuit against the Army, CREW v. Dep't of the Army, challenging the Army's failure to produce records in response to CREW's FOIA request seeking documentation of Army guidance that discourages diagnoses of post traumatic stress disorder (PTSD). The Veterans Affairs has issued similar guidance that CREW also is seeking to document through a FOIA request that is also the subject of pending litigation.
On April 17, 2009 Citizens for Responsibility and Ethics in Washington (CREW) filed a Freedom of Information Act (FOIA) request with the Department of the Army, seeking records related to guidance given to army staff and contractors regarding the diagnosis of post traumatic stress disorder (PTSD). CREW seeks these records to raise public awareness about the process behind the diagnosis of PTSD and the pressure being placed on doctors to diagnose related anxiety disorders as a cost-cutting measure. The request was filed after Salon.com obtained a June 2008 taped conversation between an Army staff sergeant and an Army psychologist, in which the psychologist revealed he had been pressured not to diagnose PTSD. On July 31, 2009, CREW filed a lawsuit against the Army, CREW v. Dep't of the Army, challenging the Army's failure to produce records in response to CREW's FOIA request seeking documentation of Army guidance that discourages diagnoses of post traumatic stress disorder (PTSD). The Veterans Affairs has issued similar guidance that CREW also is seeking to document through a FOIA request that is also the subject of pending litigation.

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Published by: CREW on May 25, 2011
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PTSD Diagnostic Concept

• Traumatic experience leads to:
• Threat of death/serious injury • Intense fear, helplessness or horror

• Symptoms (3 main types)
• Reexperiencing the trauma (flashbacks, intrusive thoughts) • Numbing & avoidance (social isolation) • Physiologic arousal ("fight or flight")

• Which may cause impairment in
• Social or occupational functioning

• Persistence of symptoms
mTBI may be associated with PTSD, especially in the context of Blast or other weapons injury
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What is TBI?
• Traumatic Brain Injury is a disruption of brain function that results from a blow or jolt to the head or a penetrating head injury • TBI can be categorized as mild, moderate, severe, or penetrating • Mild TBI Concussion - the term concussion is preferred because mild TBI is distinctly different from moderate, severe and penetrating TBI • The majority (>99%) of all TBls occurring in OIF/OEF are likely concussions; -85% of TBls treated are mild • 300,000 sports related concussions each year in the US • The prognosis is excellent provided that Soldiers receive education and reassurance that they will recover • It is important to reduce the likelihood of another concussion while still symptomatic from the first one

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Behavioral Health: Where We've Been
• Robust surveillance in theater and upon return - Mental Health Advisory Teams (MHAls) - Post Deployment Health Assessment and Re-Assessment • Difficulties with access to care • Stigma about mental health care despite: - Chain teach on PTSD and IBI with 900,000 Soldiers in 2007 - Beyond the Front and Shoulder to Shoulder in 2009 • Increasing surveillance of PTSD and IBI • Rising suicide rate (multiple reasons: fractured relationships, alcohol abuse). • Services to help only partially integrated - Numerous helping agencies, including medical, behavioral health, chaplains, Family programs

• Close collaboration with DCoE (Defense Center of Excellence)

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Behavioral Health: Where We Are
• Evolving Comprehensive Behavioral Health Strategy
Comprehensive Soldier Fitness Army's Campaign Plan for Health Promotion, Risk Reduction & Suicide Prevention (ACPHP) Child and Adolescent Center of Excellence (Madigan)

• Army Family Covenant • Army PH spend plan
The Army has implemented over 45 initiatives under the categories of access to care, resiliency, quality of care, and surveillance

Funding: $120M obligated in FY 08, expecting $145M obligations in FY09, POM funds FY10-15 • Improved access to care
48% increase in behavioral health providers since 2007 Number of visits has more than doubled since 2003 Battlemind lifecycle products fielded to TRADOC (Basic Battlemind)

• Stigma reduction • New policies to screen for PTSD and TBI • Extensive unit and population-based research • Returned focus on Operation Enduring Freedom (OEF)
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Behavioral Health: Where We Are Going
• Mature Behavioral Health Strategy
- Comprehensive Soldier Fitness - MEDCOM Behavioral Health Campaign Plan (BHCP) - Army's Campaign Plan for Health Promotion, Risk Reduction & Suicide Prevention (ACPHP)

• Continue to improve health surveillance as new issues arise • Continue to improve access to care
- Integrated behavioral health and primary care - Telemedicine implemented nationally and internationally - Revised force structure with increased behavioral health providers

• Reduce stigma
Defense Center of Excellence (DCoE) leading anti-stigma campaign: Real Warriors

• New treatments, research, and clinical guidelines for PTSD, TBI and pain management

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Army TBI Program
• Based on Army T81 Task Force recommendations • Close collaboration with DCoE and DV81C (Defense Veterans Brain Injury Center) • Purpose: To establish a standardized, comprehensive program that provides a continuum of integrated care and services for Soldiers and patients with T81 from point-of-injury to return to duty or transition from active duty and/or return to highest functional level. • Desired End State: State-of-the-art, continuously improving care for Soldiers, beneficiaries, and their Families with T81 within Army MTFs, according to their TBI program capability level, in order to QPtimize functional outcomes and return to duty. Every medical facility is validated to provide TBI care congruent with the level of care provided at the facility. When necessary, this care is provided in conjunction with Department of Veteran's Affairs (OVA) and TRICARE partners.
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Tal: Where We Are
• Funding: $122M obligated in FY 08, expecting $100M obligations in FY09, POM funds FY10-15 • Staffing: 332 funded staff on hand to support T81 care • Action Plan: 36 of 48 recommendations and 95 of 115 tasks addressed • Army T81 Program Components
- Early identification, evaluation, management, treatment, documentation, and coding of Soldiers and patients with TBI - Neurocognitive testing - Tele-health assets - Education and training for Soldiers, leaders, patients, MHS providers, community health care providers, Family members, and others - Strategic communications and marketing - Research - TBI Program Validation-1 0 fully validated, 21 initially validated
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TBI: Where We Are Going
• Continue emphasis on point of injury identification and intervention for concussion • Evolution of models of care based on program evaluation • Continue growth of primary care management capabilities for the majority of patients with concussion • Standardize documentation templates • High quality education materials for multiple audiences • Collaboration with National Intrepid Center of Excellence (NICoE) • Telemedicine implemented nationally and internationally • New treatments and research • Long term facilities planning recommendations

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Next Steps
• Advocacy for importance of Behavioral Health and 181 . Issues • Support for the Family • Recruiting and retention of Behavioral Health and IBI Providers • Research on epidemiology, prevention, interventions • Grow the Army • Continued collaboration with 000 • Continued focus on theater issues

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INFORMATION PAPER DASG-HSZ 15 Sep 2008 SUBJECT: Post Traumatic Stress Disorder 1. Purpose . To provide information on the incidence and prevalence of Post Traumatic Stress Disorder (PTSD) and to understand the impact of PTSD on the force . 2. Facts. a. We can safely estimate that between 5 and 10 percent of Soldiers who are deployed have symptoms of PTSD. Over the past 4 years, there were approximately 32,022 diagnosed cases of PTSD broken down by calendar year as follows: CY03 1,020; CY04 - 3,845: CY05 - 6,554; CY06 - 6,845; and CYO? - 10,523. We estimate that the number of newly identified PTSD cases for CY08 will be around 12,000. PTSD is usually treated as an outpatient diagnosis, and seldom requires a medical board. The vast majority of Soldiers diagnosed with PTSD will remain on active duty. b. Military research shows that approximately 15% of Soldiers deployed during OIF have PTSD symptoms and another 10 to 15% percent will experience other behavioral health problems that could benefit from treatment. The MHATs have shown that longer deployments, multiple deployments, greater time away from base camps, and combat intensity all contribute to higher rates of PTSD, depression, and marital problems. The MHAT V also showed that Soldiers in BCTs deployed to Afghanistan are now experiencing levels of combat exposure and mental health rates equivalent to Iraq. c. Comparable surveys in the post-deployment period have shown that rates of mental health problems, particularly PTSD, remain elevated and even increase during the first 12 months after return home, indicating that 12 months is insufficient lime to reset the mental health of Soldiers after a year-plus combat tour. d. Five to 6% of Soldiers are generally referred to behavioral health based on their Post Deployment Health Assessment. Approximately 12% of Soldiers are referred to behavioral health based on the Post Deployment Health Reassessment. e. All Soldiers (AD, USAR, and ARNG) were mandated to participate in training on mild TBI and PTSD. The "Chain Teach" product was designed to provide an overview and understanding of concussion injuries and Post Combat Stress Reactions that may result in PTSD. There are a number of other training programs for Soldiers and Families available at www.battlemind.army.mil or www .behavioralhealth.army .mil. f. Using $125M in supplemental funds, the Army has implemented over 45 initiatives under the categories of access to care, resiliency, quality of care, and surveillance. Significant among these is the hiring of over 200 behavioral health providers to augment behavioral health services worldwide across Army installations.

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