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Appendix E
Adequacy of the Comprehensive Clinical
Evaluation Program: A Focused Assessment
CONCLUSIONS AND RECOMMENDATIONS
*
A great deal of time and effort has been expended evaluating DoD's
Comprehensive Clinical Evaluation Program. It has been reviewed by the
President's Advisory Committee, the General Accounting Office, the Office of
Technology Assessment, the Institute of Medicine, and many other
organizations. As more is learned, it becomes easier to focus on the kinds of
questions He CCEP should be asking. As Dr. Penelope Keyl said in her work-
shop presentation on the development of good screening instruments, progress
made over time will necessitate new generations of screening instruments. This
does not imply that the first instrument developed is bad, but rather that time
leads to new knowledge, which leads to the ability to improve Me instrument.
Such is the case with the CCEP. Over tune, the CCEP and other programs
have generated information that has led us to focus on areas of importance for
those concerned about the health consequences of Persian Gulf deployment.
This information has enabled us to take a closer look, to make a more thorough
examination of the system, and to identify areas in which change will be of
benefit. The committee believes that such change is healthy, that it reflects
growth, and that it should be a natural part of any system having as one of its
goals the delivery of high-quality heals care services.
This appendix is excerpted from the Institute of Medicine report, Adequacy of the
Comprehensive Clinical Evaluation Program: A Focused Assessment, Washington,
D.C.: National Academy Press, 1997.
105
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ADEQUACY OF THE VA PERSIAN GULF REGISTRY AND UCAP
Change also occurs with individuals. It may be that as time passes or new
information is released, some of those who have already participated in the
CCEP will develop new concerns or problems. The committee hopes that DoD
will encourage these individuals to return to the CCEP for further evaluation
and diagnosis.
The committee wishes to emphasize that it is impressed with the dedication
and concern exhibited by DoD personnel with whom committee members met.
These individuals are knowledgeable regarding Persian Gulf issues and willing
to learn more about identifying and resolving areas of concern for improving the
health of active-duty personnel deployed to the Gulf.
MEDICALLY UNEXPLAINED SYMPTOM SYNDROMES
The committee spent some time deliberating on the precise meaning of
"difficult to diagnose" or "ill deemed" as a description of a category of
conditions. When labeling something as difficult to diagnose, one usually
means that special expertise is required to arrive at a diagnosis, but many of
these conditions do not require such expertise. Chronic fatigue syndrome,
fibromyalgia, and multiple chemical sensitivity are symptom complexes that
have a great deal of overlap in the symptoms present In each condition but are
well defined clinically, even if they are medically unexplained. Despite the fact
that they are medically unexplained, they may cause significant impairment and
they are illnesses that are only understood through time, that is, it requires the
passage of time and the evaluation of responses to treatment to arrive at these
diagnoses. The committee decided, therefore, to refer to this spectrum of
illnesses as medically unexplained symptom syndromes. This spectrum of
illnesses may include those which are etiologically unexplained, lack currently
detectable pathophysiological changes, and/or cannot currently be diagnostically
labeled.
These medically unexplained symptom syndromes are often associated with
depression and anxiety. There remains a debate about how to distinguish these
syndromes from psychiatric diagnoses, but it is clear that they are not simply
psychiatric diagnoses. However, since most of the recommended treatments for
medically unexplained symptom syndromes overlap with the pharmacological
and behavioral treatments for psychological conditions or psychiatric diagnoses,
the committee believes that it is important to identify and evaluate the symptoms
associated with these conditions and then treat those symptoms.
The committee recommends that when patients presenting with
medically unexplained symptom syndromes are evaluated, the provider
must have access to the full and complete medical record, including
previous use of services. The presence of such information is important
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APPENDIXE
107
because adequate evaluation of these disorders involves a longitudinal
perspective that includes response to treatment.
In the area of medically unexplained symptom syndromes, it is sometimes
not possible to arrive at a definitive diagnosis. It may be possible, however, to
treat the presenting complaints or symptoms. The committee recommends
that in cases where a diagnosis cannot be identified, treatment should be
targeted to specific symptoms or syndromes (e.g., fatigue, pain, depression).
If these symptoms and conditions are left untreated, they can become chronic
and potentially disabling. The committee recommends that the CCEP be
encouraged to identify patients in this spectrum of illnesses early in the
process of their disease. In addition, primary care providers should identify
the patients' functional impairments so as to be able to suggest treatments
that will help improve these disabilities.
STRESS
In this group of medically unexplained symptom syndromes it is important
to recognize and acknowledge that the problems and stress facing the patient
will continue to be difficult. Stress is a major issue in the lives of patients
within this spectrum of illness. Stress need not be looked at so much as a
causative agent, but rather as a part of the condition of the patient that cannot be
ignored. With these medically unexplained symptom syndromes, the potential
for stress proliferation is great among both the person deployed to the Persian
Gulf and the family members.
Media attention and reports by the military to Gulf War veterans that toxic
exposure could have occurred are very stressful events, regardless of anyone's
efforts to explain what happened. Such announcements carry with them
stressful burdens for the veteran. The stress associated with these reports of and
worry over toxic exposures needs to be recognized and addressed.
Research has shown that stressors have been associated with major
depression, substance abuse, and various physical health problems. Those de-
ployed to the Gulf were exposed to a vast array of different stressors that carry
with them their own potential health consequences. Current collection of
exposure information does not adequately address an investigation of traumatic
events to which the deployed soldier may have been exposed. The committee
recommends that the CCEP contain questions on traumatic event exposures
in addition to the exposure information currently being collected. This
would include the addition of open-ended questions that ask the patient to
list the events that were most upsetting to him or her while deployed.
Positive responses to questions regarding such events, as well as to other
exposure questions, should be pursued with a narrative inquiry, which
would address such items as the specific nature of the exposure; the
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ADEQUACYOFTHEVAPERSIANGULFREGISTRYANDUCAP
duration; the frequency of repetition; the dose or intensity (if appropriate);
whether the patient was taking protective measures and, if so, what these
measures were; and the symptoms manifested.
Other suggestions for questions that could be added to the CCEP include
the following: When did you first have questions or worries about being
exposed? When did you first hear other information on possible exposures?
What were your responses to that information? Providers in the CCEP need to
take a history that includes some narrative to allow the veteran to express how
he or she feels.
It is always important to understand and acknowledge that the patients'
complaints are real. It is certainly important for providers in the CCEP to do so
when attempting to identify and address the health concerns of Persian Gulf
veterans. Furthermore, no matter what additional information may be forth-
coming about potential exposures to toxins and their effects, the committee
recommends that DoD providers acknowledge stressors as a legitimate but
not necessarily sole cause of physical symptoms and conditions.
The committee believes that there are certain jobs undertaken in the midst
of war that, by their very nature, result in high stress (e.g., grave registration
duty). The effect of stress associated with these jobs can be mitigated if
approached properly. The committee recommends that the DoD provide
special training and debriefing for those who are engaged in high-risk jobs
such as those associated with the Persian Gulf experience. Every soldier
who goes to war will be subjected to major disturbing events since war by its
very nature involves death and destruction. The committee recommends that
DoD provide to each about-to-be deployed soldier risk or hazard
communication which is well developed and designed to provide
information regarding what the individual can expect and the potentially
traumatic events to which he or she might be exposed.
The committee wishes to emphasize that the accurate diagnosis of patients
with medically unexplained symptom syndromes and/or conditions induced or
exacerbated by upsetting events requires the expenditure of time, time in which
the provider and the patient interact. It is not possible to hand the patient a
questionnaire and expect that all necessary information will be revealed. In a
world of time constraints and tightly scheduled appointments, the committee
recommends that adequate time must be provided during initial
interactions with patients in the CCEP in order to ensure that all pertinent
information is forthcoming. The committee believes that the patient-physician
interaction should be fostered, and the perception that evaluation is directed by
the clock should be avoided.
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APPENDIX E
109
SCREENING
Depression is a condition that is common in primary care. Most individuals
who experience depression continue to function, but if they are left untreated,
their conditio deteriorates. Unlike many of the medically unexplained
symptom sy: Ames, there are effective treatments for depression. The data
presented indicate rising rates of depression among those examined in the CCEP
but no evidence that individuals are being properly diagnosed or treated
according to currently accepted clinical practice guidelines. there are many
self-rated screening tests (e.g., the Beck Depression Inventory [BDI], the Zung
Scale, the Center for Epidemiological Studies-Depression Scale [CES-D], the
Inventory to Diagnose Depression [IDD]) that could be used as a first-level
screen at the primary care level.
The committee recommends that there be increased screening at the
primary care level for depression. Every primary care physician should
have a simple standardized screen for depression. If a patient scores in the
significant range, this person should be referred to a qualified mental
health professional for further evaluation and treatment. If depression is
identified, there has to be more questioning on exposure to traumatic
problems.
There has been a great deal of concern evinced about the possibility of
widespread PSTD in those deployed to the Persian Gulf. Most of the
individuals identified as having PTSD are diagnosed following a structured
interview at Phase II. However, the committee believes that there are those who
have some of the symptoms of PTSD or of depression but are not true PTSD
cases yet might be helped with treatment oftheir symptoms.
The committee recommends that any individual who reports any
significant PTSD symptoms and/or a significant traumatic stressor should
be referred to a qualified mental health professional for further evaluation
and treatment.
Substance abuse or misuse problems are prevalent in primary care. In
addition, individuals with untreated depression or with medically unexplained
symptom syndromes may have an enhanced risk of substance abuse. (See
Appendix I for examples of screening instruments.) The committee recom-
mends, therefore, that every primary care physician should have a simple,
standardized screen for substance abuse. Every individual who screens
positive should be referred for further treatment and evaluation.
There are certain areas in which baseline assessments are of immense value
in the clinical evaluation of an individual patient's status (e.g., pulmonary
function and neurobehavioral testing). Changes in neurocognitive and peri-
pheral nerve function are measured by comparing the individual's current status
to a baseline measure. This is also true for measuring complaints of memory
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ADEQUACY OF THE VA PERSIAN GULF^GISTRYAND UCAP
impairment. Individual baseline information is necessary because the variability
across individuals is too great to identify a generalized "normal" screening level.
The committee recommends that DoD explore the possibility of using
neurobehavioral testing at entry into the military to determine whether it is
feasible to use such tests to predict change in functioning or track change in
function during a soldier's military career.
PROGRAM EVALUATION
Most patients in the CCEP receive a diagnosis after completing a Phase I
examination; some are referred to Phase II for evaluation; and a few have gone
on to participate in the program at the Specialized Care Center. Information
presented to the committee indicates that there is great variation across regions
in the percentage of patients who are diagnosed as having primary psychiatric
diagnoses. A determination of the reasons for this variation should be made.
Although there may be many reasons, one explanation could relate to the
consistency with which procedures for diagnosis and referral are implemented
from facility to facility. The committee recommends that an evaluation be
conducted to examine (1) the consistency with which Phase I examinations
are conducted across facilities; (2) the patterns of referral from Phase I to
Phase II; and (3) the adequacy of treatment provided to certain categories
of patients where there is the potential for great impact on patient outcomes
when effective treatment is rendered (e.g., depression).
This effort could be facilitated by the development and use of clinical
practice guidelines such as those currently being developed by the Department
of Veterans Affairs and many medical specialties. Clinical practice guidelines
are systematically developed statements that assist practitioners and patients in
decision making about appropriate health care for specific clinical
circumstances (IOM, 19921. The process of developing these guidelines could
also serve as an opportunity for increased learning for providers since their
participation is crucial to successful implementation.
The Specialized Care Center at Waltei Reed Army Medical Center has
provided evaluation and treatment to 78 patients. A great deal of effort and
thought has gone into the development of a program designed to help the patient
understand his or her conditions and engage in behaviors most likely to result in
improvement. The committee was asked to assess the effectiveness of this
center within the context of medically unexplained symptom syndromes, stress,
and psychiatric disorders. As the committee began its discussion of the
effectiveness of the Specialized Care Center it became apparent that such an
assessment was dependent on a number of factors that have not been well
defined. What is the goal of the center is it treatment, research, or education?
Should a major consideration in the center's evaluation be the cost of services?
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APPENDLsf E
111
Should the numbers of those receiving care be taken into consideration, and if
so, what are the barriers to patients accessing this level of care?
The committee concluded that at this time, it is not possible to conduct a
fair or adequate evaluation of the Specialized Care Center. The committee
recommends that a short-term plan (perhaps 5 years) be developed for the
Specialized Care Center that would specify goals and expected outcomes.
Based on such a plan, an evaluation could then be undertaken to assess the
effectiveness of the center.
COORDINATION WITH THE VA
Given that many now receiving services in the DoD health care system will
eventually move to the VA health care system, it is important to have good
communication between DoD and the VA. This may be particularly true in the
areas of medically unexplained symptom syndromes and psychiatric disorders,
where accurate diagnosis and assessment of response to treatment are important
for positive patient outcomes. The committee recommends that DoD explore
ways to increase communication with the VA, particularly as it relates to
the ongoing treatment of patients.
Both patients and providers would benefit from increased educational
activity regarding Persian Gulf health issues. Provider turnover within DoD is a
factor that must be taken into consideration when examining the special health
needs and concerns of active-duty personnel who were deployed to the Persian
Gulf. Although efforts at provider education were extensive at the time the
CCEP was implemented, three years have passed and many new providers have
entered the system. These individuals should be oriented to the special needs,
concerns, and procedures involved, and all providers should be updated
regularly.
The VA has developed a number of approaches to provider education.
Interactive satellite teleconferences are available periodically for medical center
staff to discuss particular issues of concern. The VA conducts quarterly national
telephone conference calls, directs periodic educational mailings to Persian Gulf
Registry providers in each health facility, and conducts an annual conference on
the health consequences of Persian Gulf service. The committee recommends
that DoD examine the activities and materials for provider education
developed by the VA to determine if some of the items might be used as
educational approaches for DoD providers.
Although the topics of ongoing educational efforts are best determined by
DoD on a periodic basis, the committee recommends that DoD mount an
effort designed to educate providers to the fact that conditions related to
stress are not necessarily psychiatric conditions. The committee recom-
mends that depression be a topic of education for all primary care
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ADEQUACY OF THE VA PERSIAN GULF~GISTRYANDUCAP
providers, with emphasis on the facts that depression is common, it is
treatable, and individuals who experience depression can continue to
function.
The committee wishes to reemphasize the fact that the CCEP is not a
research protocol but rather a program designed to diagnose the health problems
of those who served in the Persian Gulf. As such, information obtained through
the CCEP should not be used to answer research questions. It is appropriate,
however, to use the data and narrative information obtained Dom the CCEP to
inform the clinical treatment process. In doing so, the committee believes that it
is important to unbundle diagnostic categories. For example, tension headache
is classified as a somatoform disorder within the category of psychiatric
. .
c .lagnosls.
In addition, a tremendous amount of qualitative infonnation could be used
in developing case studies to help providers better understand diagnostic and
treatment approaches that appear effective at improving individual patients'
conditions.
The committee recommends that CCEP information be used to develop
case studies that will help educate providers about Persian Gulf health
problems. There are a number of ways in which these case studies could be
shared including presentation during professional meetings.
There is also a need for education and communication with individuals who
were deployed to the Gulf and with their families. These individuals are
concerned about the potential impact of Persian Gulf deployment on their
health, whether or not their health concerns will affect their military careers,
their ability to obtain health insurance once they leave the service, and a number
of other issues that need to be addressed.
A variety of mechanisms are available for providing such information
including individual post newsletters, the Internet, mailings to those in the
Registry, and public forums. It is especially important to provide a forum for
discussion each time new infonnation is released on possible exposures. The
committee recommends that DoD develop approaches to communication
and education that address the concerns of individuals deployed to the
Persian Gulf and their families.
Representative terms from entire chapter:
persian gulf
