They once identified false claims made by a soldier who lied about killing an innocent Iraqi girl in a ploy to gain a PTSD diagnosis, according to internal memos obtained by The News Tribune. It turned out the soldier had never deployed.

They also were known to diagnose PTSD in soldiers who had been given clean bills of health from other clinicians – the opposite of what the forensic psychiatry team members are accused of doing now.

“Quite frankly, they have an extensive track record for effectively diagnosing PTSD in hundreds if not thousands of active-duty military and Reserve personnel over the past several years without issue, and their success is unparalleled,” former Madigan commander retired Col. Jerome Penner told The News Tribune last week. He led the hospital until March 2011.

Now the once-golden unit based on the grounds of Joint Base Lewis-McChord is under fire as the Army carries out at least three separate investigations. The Army and elected leaders want to know whether the team adjusted behavioral health diagnoses for the right reasons, or whether it shortchanged service members who should get full PTSD benefits.

Forensic psychiatrists at Walter Reed Military Medical Center in Maryland have overturned six Madigan diagnoses from last year, and the Army has invited more soldiers to come forward and seek new opinions.

Washington Democrats Sen. Patty Murray and Rep. Norm Dicks want to know if the Madigan doctors limited PTSD diagnoses in a misguided effort to save money.

Their fears are rooted in fall presentations by Madigan’s Dr. William Keppler in which he urged colleagues to be good stewards of taxpayer dollars. Keppler told them a single PTSD diagnosis could cost as much as $1.5 million over time.

Careers are on the line. Madigan commander Col. Dallas Homas is on administrative leave. Keppler is barred from working with patients. Another forensic psychiatrist resigned, citing her concern that “all the investigations are a charade as the outcome has been predetermined.”

“I find that I can no longer work in a system that requires me to sacrifice my professional and moral principles to political expediency,” Dr. Juliana Ellis-Billingsley wrote Feb. 23.

The high-level Army officer leading the investigations knows Madigan well. Army Surgeon General Lt. Gen. Patricia Horoho was once a Madigan commander who in March 2009 endorsed the forensic psychiatry unit as an example of “best practices” in a briefing she and her staff gave to senior Army leaders at the Pentagon.

The forensic program was called “an innovative solution to meet increased demands” in a printed copy of the presentation.

Another briefing Horoho received in 2009 from Madigan’s then chief of psychiatry shows that the key doctors under scrutiny today worked in the forensic unit during Horoho’s Madigan tenure. Keppler was in charge of the unit in 2009, just as he was early this year when Horoho suspended his team’s work.

Records reviewed by The News Tribune show the forensic psychiatry unit has an extensive history dating to the middle of the Iraq War. It was known to the past four Madigan commanders, including one who predated Horoho.

“Right up until three weeks ago, Madigan was the shining example of what was right,” said retired Col. Mike Courts, who was familiar with the forensic psychology unit as the chief of staff for Lewis-McChord’s I Corps during its 2009-10 deployment to Iraq.

“Since when is the right diagnosis the wrong answer?” Courts asked.

Since the inquiries began, the Army has invited every soldier whose behavioral health diagnosis was changed at Madigan to get another review of their cases at Walter Reed.

Madigan last year identified 17 soldiers who disagreed with their final diagnoses, according to multiple sources who spoke on condition of anonymity. They were invited in January to have their cases reviewed.

Six had their PTSD diagnoses reinstated. Three opted not to take the Walter Reed review and eight had the Madigan results upheld.

A Madigan source speaking on condition of anonymity because of the pending investigation said the forensic psychiatrists diagnosed 44 cases of PTSD among soldiers whose records initially indicated they were healthy during the same period in 2011 from which the 17 contested cases were pulled.

Behavioral health diagnoses are important to former service members not only for their understanding of how they can seek treatment for war-related trauma, but also because they determine the level of disability benefits soldiers will receive for the rest of their lives. A PTSD diagnosis ensures soldiers will receive a lifetime disability rating of at least 50 percent.

A veteran with no children rated as 50 percent disabled because of PTSD would receive about $800 a month, while a veteran with no children and a diagnosis of 100 percent disabled by PTSD would receive $3,000 a month, according to Department of Veterans Affairs benefit scales.

The Rand Corp. in 2008 estimated that about 20 percent of combat veterans would show signs of post-traumatic stress or major depression. About one in seven Iraq and Afghanistan veterans have sought treatment for PTSD at VA hospitals.

Sen. Murray in an interview last week said she has discussed with Horoho whether the military could be diagnosing PTSD improperly. Murray is the chairwoman of the Senate Veterans Affairs Committee, and her views are shaped by experiences caring for Vietnam veterans at the Seattle VA.

She has pressed for answers at Madigan, and last week she learned from Defense Secretary Leon Panetta that the Pentagon would conduct a broader review of how the military diagnoses PTSD.

“I think it’s important to err on the side of the diagnosis that gives them the treatment they need,” Murray said.

The Army has not yet said how many soldiers who passed through Madigan are challenging their diagnoses.

Madigan in 2010 diagnosed 1,418 patients with PTSD, acute stress disorder and anxiety disorder – three common behavioral-health conditions that can be related to combat. Of the three, only PTSD is singled out for a guaranteed disability rating and accompanying pension. Over the past two years, the hospital diagnosed 1,699 soldiers with PTSD.

The hospital has one of the largest staffs of behavioral health professionals in the Army with 227 specialists. It’s the largest Army hospital in the West, and its resources are sometimes parceled out to medical centers from Alaska to California. It’s also a hub for complicated cases as it supports a new center for ill and wounded soldiers at Lewis-McChord.

Its size is one reason Madigan had the dedicated forensic psychiatry unit, Courts said.

Madigan sources said other Army hospitals have forensic psychiatrists on staff, but the Army Medical Command declined to say how or where they work until Horoho completes the investigations.

The Army Medical Command says “Madigan is the only facility that routinely utilized a forensic psychiatry service in the (medical retirement) evaluation process and is not reflective of Army medicine standards.”

Courts said the forensic psychology unit had value and provided a higher degree of accuracy in PTSD diagnoses than other Army hospitals could achieve.

“I want soldiers who have been injured or impacted by war to receive the benefits they deserve,” he said. “The pie is this big, and we if divide it with people who are not suffering legitimate symptoms, we have less for the soldiers who need the help.”

So far, the public has been supportive of growing programs for PTSD and combat trauma. In January, the Government Accountability Office reported the Defense Department spent $2.7 billion on PTSD and traumatic brain injury programs between 2007 and 2010. The report said the Pentagon had not explained clearly if these programs were successful or redundant.

Another Madigan source who spoke to The News Tribune on condition of anonymity because of the pending investigations said the forensic psychiatry team had grown in scope recently and taken resources from front-line clinicians.

The team had four employees in 2009, but it had more doctors when Horoho suspended it. Sources said it has eight today, down from nine before Ellis-Billingsley’s resignation.

More forensic reviews contributed to a backlog in cases that bogged down the medical retirement process for some service members, critics said.

Furthermore, some clinicians at Madigan disagreed with how the forensic team treated soldiers, contending the psychiatrists with the final say on diagnoses had a negative attitude.

That alleged bias showed through in how soldiers who’ve contested diagnoses from the forensic team described their experiences. They did not understand why they received contradictory assessments and sometimes felt diminished by the process.

One nine-year veteran who spoke on condition of anonymity because he’s still in uniform as he pursues a medical retirement for a back injury said he was blindsided by a forensic psychologist’s determination that he did not have PTSD.

“I didn’t go crazy (from symptoms) but I have issues and people who are close to me can see that,” he said. He plans to seek a new diagnosis from Walter Reed.

The reviews at Walter Reed are done with service members face-to-face. It’s not clear if Madigan’s forensic psychiatrists always met soldiers in personal interviews. Horoho told a House subcommittee that the Madigan team sometimes made decisions “administratively” based on case files.

Madigan sources said those cases were rare and tended to happen when clinicians from the Department of Veterans Affairs reached different conclusions from active-duty Army doctors. That can happen because retiring soldiers might begin the process of registering for VA benefits before they leave the service.

Some Madigan doctors apparently were skeptical of the VA diagnoses, which were sometimes conducted by private contractors with less experience working with the military, according to one memo.

In some cases, Madigan psychiatrists found candidates for medical retirements who lied about deployments or who posted information on social media web sites that contradicted what they told clinicians.

Madigan forensic psychiatrists were expected to carry out personality tests to determine whether a patient was misleading a clinician. They were to interview patients and ensure that commanders had verified the soldier’s deployment history, according to a summaries of their standards.

One test used by the Madigan doctors was the Minnesota Personality Inventory, which helps psychologists assess whether someone is exaggerating or downplaying symptoms.

In the civilian world, the test is often used in civil court cases in which plaintiffs seek financial damages for traumatic events. It’s used to a varying extent by the military and by the VA in assessing a service member’s disability.

Forensic psychologist Steve Rubenzer in 2006 published a study in which he wrote that front-line clinicians often do not suspect that their patients have financial motives for seeking PTSD diagnoses.

His study on malingering in personal injury cases was cited by Madigan doctors in memos they wrote to commanders after the Army surgeon general launched the latest investigations.

“Clinicians may not know that a patient has (motivation to mislead a psychiatrist for financial gain), often do not suspect the possibility of malingering, and typically lack the training or tools to assess malingering even if they suspect it. Not surprisingly, they rarely find it.” Rubenzer wrote six years ago in a passage cited by a Madigan doctor.

Rubenzer said that common notions of PTSD have changed since the Vietnam War; many civilians expect most soldiers will be debilitated in combat, and that those experiences would prevent them from holding down steady work outside of the military.

“Those are two huge leaps,” he said.

The memos obtained by The News Tribune showed Madigan doctors were bristling at suggestions that they slanted their diagnoses to cut costs.

“There has been no pressure by command to limit disability awards to soldiers, just a desire on the part of Madigan psychiatrists and psychologists to produce he most accurate description of soldiers current medical condition,” Madigan medical retirement board physician Dr. Paul Whittaker wrote in a Feb. 16 memo to commanders.

Another doctor who once supervised Madigan’s psychiatry department felt his peers were being pilloried for doing the jobs they were asked to do by their commanders.

“My perception is that they are getting punished in the media at a minimum for doing their best in making the right diagnosis,” former Madigan Chief of Psychiatry Col. Kris Peterson wrote Feb. 6. “It is dismaying.”

Adam Ashton: 253-597-8646

adam.ashton@thenewstribune.com

blog.thenewstribune.com/military

Twitter: @tntmilitary