Evolution of Department of Defense Disability Evaluation and Management of Posttraumatic Stress Disorder and Traumatic Brain Injury

Since 2001, the United States has been engaged in continuous com­bat operations in Iraq, Afghanistan, and other theaters. Many service members have sustained injuries or developed medical conditions as a consequence of combat or military service and are thus no longer able to serve. The process by which the U.S. Department of Defense (DoD) evaluates service members and determines whether they should be medically discharged has changed considerably since 2001; major changes to the disability evaluation system (DES), in particular, were implemented beginning in 2007. Simultaneously, DoD also implemented new policies in response to what have become known as “signature injuries” of the wars in Iraq and Afghanistan: posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). This study reviews major policy changes to DES between 2001 and 2018 with a particular focus on changes to policies related to the screening and treatment of PTSD and TBI. A companion report (Krull et al., 2021) presents an analysis of how rates of diagnoses for these conditions and referrals to DES have changed over the same time period (i.e., 2001 to 2018).

Service members who become wounded, ill, or injured while serving may seek and receive treatment for up to one year following diagnosis, or until further recovery is relatively predictable, whichever comes first. If at that point service members’ medical condition(s) prevents them from performing the duties of their office, grade, rank, or rating, or if the medical condition(s) poses a risk to them, a medical provider may refer them for disability and retention evaluation (Department of Defense Instruction 1332.18, 2016). After being referred, the service member begins with a medical exam that is conducted by the U.S. Department of Veterans Affairs (VA). Then, the DoD medical evaluation board (MEB) determines if the service member meets medical retention standards according to his or her branch of service. If MEB finds that the service member meets medical retention standards, he or she is returned to duty. If the service member does not meet medical retention standards, the case is forwarded to the DoD physical evaluation board (PEB) to determine if the service member is fit for duty—meaning that despite any medical conditions, the service member is still able to do his or her job. Service members who are found fit for duty are returned to duty; service members who are found unfit have their cases forwarded to VA, where every medical condition identified in the medical exam is assigned a disability rating. Compensation from DoD includes only those conditions that make the service member unfit for duty in its rating, whereas VA compensates for all service-related conditions identified in the medical exam. Unfit service members are then medically separated or retired, and disability benefits, for those eligible to receive them, begin within 30 days of discharge.

Disability Evaluation Policy Changes Since 2007

Prior to 2007, service members were evaluated and, if necessary, medically discharged through DoD's DES. Discharged service members then applied for disability and health care benefits from VA and were evaluated a second time by VA. Because DoD and VA conducted separate evaluations, according to different criteria, the disability determination would often differ, which created inefficiencies and confusion for transitioning service members.

In 2007, a Washington Post article raised questions about the housing conditions and quality of care for service members being treated for combat-related conditions at Walter Reed Army Medical Center (Priest and Hull, 2007). The investigation came on the heels of high-profile media accounts of the psychological toll of deployments to Iraq and Afghanistan. In response to this confluence of events, DoD, Congress, and the George W. Bush administration launched investigations, task forces, and commissions to determine the evaluation and treatment needs of service members returning from the global War on Terror—including the efficiency and consistency of DES. To provide oversight and coordination of the various commissions and groups examining wounded warrior issues, the Secretaries of Veterans Affairs and Defense established the Wounded, Ill, and Injured Senior Oversight Committee (SOC) in 2007 (U.S. Department of Veterans Affairs and U.S. Department of Defense, 2009). Collectively, these groups called for significant changes to the disability evaluation process. For example,

• The President's Commission on Care for America's Returning Wounded Warriors was established by President George W. Bush to examine the care provided to returning service members “from the time they leave the battlefield through their return to civilian life” (President's Commission on Care for America's Returning Wounded Warriors, 2007). Among other recommendations, the final report recommended significantly restructuring and simplifying the DoD and VA disability and compensation systems.
• An Independent Review Group commissioned by the Secretary of Defense to review rehabilitative care and administrative processes at Walter Reed Army Medical Center and the National Naval Medical Center recommended the establishment of a center of excellence for the treatment of PTSD and TBI and a complete overhaul of DES (Independent Review Group, 2007).
• The Veterans Disability Benefits Commission was established to examine and assess how VA compensated veterans for service-connected disabilities and deaths. Its final report showed that the evaluation system was confusing, even to some raters, and that changes were needed (Christensen et al., 2007). A related Institute of Medicine (IOM) Committee report recommended changes to the Veterans Affairs Schedule for Rating Disabilities (VASRD), including a recommendation that it compensate for not only lost earnings but also nonwork disability and loss of quality of life (McGeary et al., 2007).

The National Defense Authorization Act (NDAA) for fiscal year (FY) 2008 authorized DoD to launch pilot programs to improve the DES, laying the groundwork for the Integrated Disability Evaluation System (IDES) (Pub. L. 110–181, §1644). Incorporating the recommendations of the various commissions and task forces, DoD and VA jointly launched a pilot program to evaluate whether VA should conduct medical exams during the disability evaluation process, with DoD maintaining control over the determination of ability to serve. The goal of the pilot was to reduce processing times and redundancies in the system, as well as eliminate variation across military branches. The program successfully demonstrated the efficiency of integrated processes and was officially adopted in 2011.

As required by other language in the FY2008 NDAA, DoD directed the strict adoption of the VASRD DoD-wide. Disability ratings are consequential for service members because they serve as the basis for qualification for medical retirement. With the adoption of VASRD, service members who are determined to be unfit because of “mental health disorders due to traumatic stress” (e.g., PTSD) receive a minimum 50 percent disability rating and are placed on the Temporary Disability Retired List (TDRL) and reevaluated within six months. Previously, service members who were found unfit because of PTSD were assigned a disability rating based on functional impairment.

Policy Changes Specific to Posttraumatic Stress Disorder and Traumatic Brain Injury

Since the start of the conflicts in Iraq and Afghanistan, significant changes in our understanding of PTSD and TBI have resulted in policy changes within the military health system. As studies highlighted an increase in the prevalence of PTSD and TBI among service members who had deployed to combat zones (Hoge et al., 2004; Milliken et al., 2007; Tanielian et al., 2008), the presidential and DoD commissions that led to changes in DES also recommended that additional attention and resources be devoted to detecting and treating PTSD, TBI, and mental health issues in general.

In response, DoD implemented numerous programs, initiatives, and new policies designed to increase detection of these conditions and ensure that service members received high-quality treatment. Service members who deploy to a theater of combat are now required to complete health assessments both before and after a deployment. These required assessments are a valuable tool for tracking PTSD, TBI, and other mental health conditions.

After the implementation of IDES and the revised VASRD policy, there were still concerns about whether service members with PTSD were receiving accurate disability evaluations. In 2008, a group of veterans filed a class action lawsuit alleging that the PEB had not adhered to the 50 percent disability rating standard (Sabo v. United States, 2011). That same year, Army Medical Command found that providers at one military treatment facility (MTF) had changed service members’ diagnoses to something other than PTSD due to suspicion that service members were exaggerating their PTSD symptoms to qualify for disability benefits (Moisse, 2012; Ashton, 2013). An investigation of another military installation revealed that service members who exhibited behavioral health problems associated with TBI and PTSD after being exposed to traumatic events were being given less-than-honorable discharges (Zwerdling, 2015). In response to these events, there was a broad re-review of disability cases for service members whose disability ratings or determinations had been called into question.

Conclusion

While DES has been in existence since 1947, the period from 2001 to 2018 was characterized by particularly significant changes—not only in DES itself but also in the understanding and treatment of PTSD and TBI. A companion report (Krull et al., 2021) describes trends in diagnoses of PTSD and TBI over this same period, along with trends in disability evaluation outcomes, such as disability ratings and final dispositions. This study provides context for considering those trends, potential additional initiatives and policy changes, and the implications of the new landscape for assessing and evaluating these signature injuries of the Iraq and Afghanistan wars.