A False Dilemma and an Unfair Characterization of Veterans

To the Editor: In a commentary in the January issue, Frueh (1) contended that Department of Veterans Affairs (VA) policies provide an incentive for secondary gain and illness behavior, resulting in a high number of disability claims for mental disorders and poor treatment response among veterans with posttraumatic stress disorder (PTSD). Further, he implied that there are two types of veterans with PTSD: those who respond favorably to treatment because they are not receiving disability compensation and those who do not respond favorably to treatment because they are receiving disability compensation. This false dichotomy unfairly characterizes veterans and fails to recognize that evidence-based treatments for PTSD do not work equally for everyone, even among veterans who are not receiving disability compensation for PTSD (2). Frueh’s position may only serve to stigmatize the many veterans who genuinely work hard to ameliorate their PTSD with limited success.

Among other factors, veterans’ treatment response may be contingent upon initial symptom severity and other general medical comorbidities. Therefore, evidence-based treatments, even when they result in substantial symptom improvements, may not be adequate to achieve full symptom remission or eliminate disability among veterans with severe PTSD. Naturally, we would expect PTSD symptom levels to be strongly associated with disability levels, with the most symptomatic and disabled veterans more likely to receive disability compensation.

Other research not cited by Frueh has found that disability compensation for PTSD does not affect veterans’ clinical outcomes or treatment dropout rates. One study even found that veterans who had been awarded service-connected PTSD disability status maintained or increased their utilization of mental health services after receiving their disability rating (3). Murdoch and colleagues (4) found that after six years of ongoing benefits, veterans who had service-connected PTSD disability status experienced clinically important reductions in PTSD symptoms and less poverty and homelessness, compared with applicants whose disability claims had been denied. Two clinical trials, which found that veterans with PTSD can benefit from the two evidence-based treatments being disseminated within the VA, demonstrated that PTSD compensation status did not affect treatment response (5,6). Admittedly, however, more research is needed.

Frueh suggested that the VA faces a “dilemma of logic” in which it is not reasonable to simultaneously provide treatment and disability compensation to veterans with PTSD that is related to their military service. This false dilemma fails to recognize symptom severity and legitimately limited treatment response and could lend support to depriving veterans of well-deserved financial assistance while they make sincere and repeated attempts to reduce the burden of mental illness with standard or emerging treatments for PTSD.

Unquestionably, it is productive to maintain an open dialogue on the VA’s disability compensation system and efforts to disseminate and implement evidence-based treatment for PTSD as long as that dialogue includes a thorough examination of all the available empirical evidence. In contrast, it is counterproductive to disparage VA disability policies and treatment efforts without clear supporting evidence. We do a great disservice to disabled veterans by assuming that anyone who does not respond favorably to treatment must not be motivated to change. Rather, unless shown or told otherwise, we should assume that our veterans remain interested in treatment, and we should continue to provide them with the best care possible.