From New York Times.com
By JAMES DAO
Is post-traumatic stress disorder underdiagnosed or overdiagnosed?
Many veterans advocates and mental health providers say it is underdiagnosed, and severely so. They assert that troops often try to mask the symptoms because they want to remain on active duty or eligible for deployment, or because they fear their careers will be ruined if they admit to psychological problems, these people say.
On the flip side, some mental health experts raise concerns that the diagnosis is often given without sufficient rigor — and that as a result, resources are expended on people who do not necessarily need them, to the detriment of those who do.
That latter view is often expressed privately because no one wants to appear insensitive to mental health problems when the military suicide rate is on the rise. Moreover, the Army is investigating whether its own doctors haveimproperly rescinded P.T.S.D. diagnoses because they were overly concerned about treatment costs.
But the reality is that many mental health experts believe both statements to be true. And the fact that there is a debate at all underscores widespread questions about the assessment tools used to diagnose P.T.S.D.
“One of the limitations of psychology is that it is based on self-reporting by the patient,” said Dr. Roger Pitman, a professor of psychiatry at Harvard Medical School. “Some might be motivated to exaggerate conditions to achieve benefits. We also know people are not the best reporters of their own internal condition.”
With that in mind, Dr. Pitman and a team of researchers brought together byDraper Laboratory, based in Cambridge, Mass., are seeking federal financing to begin a major project to develop a more objective system for diagnosing P.T.S.D.
The consortium’s goal will be to identify as many biological “markers” of the syndrome as possible, then use that data to create algorithms capable of pinpointing who has the disorder, and who does not.
Those “biomarkers,” as they are commonly known, would range from well-known measures of anxiety — blood pressure, sweat-gland activity and hormone levels, for instance — to more complex and obscure measures derived from DNA analysis or brain imaging from MRIs.
“Trauma can change the chemistry in your brain,” said Len Polizzotto, vice president for new programs at Draper. “We want to be able to objectively identify that. The only way to do that is to come up with this series of biomarkers that are objective assessments.”
“It’s not going to be one biomarker,” he continued. “No one will stand out. But the confluence of several, each by itself not enough to alert, will be determinative. That’s where the algorithms come in.”
Dr. Polizzotto estimated that the project would cost $50 million and take years to complete. He said the team was just beginning to apply for grants from federal agencies like the Department of Veterans Affairs, the Pentagon and the Department of Health and Human Services.
As a first step, the organization has recruited a consortium of prominent P.T.S.D. researchers from around the country, many associated with the V.A., including Dr. Matthew Friedman of the National Center for P.T.S.D., Rachel Yehuda of Mt. Sinai Hospital and Dr. Pitman, who spent 28 years working for the agency.
Those researchers have been broken into eight teams to develop test protocols in different areas, including hormones, genetics epidemiology, imagining, animal research, electrophysiology and biostatistics.
Dr. Pitman, the project’s lead medical expert, said the researchers wanted to recruit several thousand patients who had experienced trauma and then measure an array of biomarkers in them. Most of the subjects will probably be victims of automobile accidents, both civilians and military personnel.
By observing those subjects over time, the consortium hopes to determine which combination of biomarkers most accurately predicts the onset of P.T.S.D. symptoms.
The researchers say that algorithms based on extensive biomarker data will not only make diagnosis more accurate, but also allow researchers to evaluate treatments more effectively. With new treatments emerging constantly — from prescription medications to psychological therapies to alternative approaches like acupuncture, yoga and massage — such assessments are more important than ever, they say. And better assessments will make it easier to personalize treatment, mixing and matching drugs or therapies based on what works.
Dr. Pitman noted that better diagnostic tools would also enable doctors to spot more undiagnosed cases of P.T.S.D. But those tools would also help prevent overdiagnosis, he added, saying he had concerns that the word “trauma” had been trivialized and overused.
“One of our goals will be to see if we can characterize P.T.S.D. in a rigorous way that hasn’t been done yet,” Dr. Pitman said. “What we would like to do is have ways of validating the kind of trauma response that we think really is P.T.S.D., and kind that we wouldn’t consider P.T.S.D.”
Draper Laboratories began as a teaching laboratory at the Massachusetts Institute of Technology, focusing on guidance and navigation technologies for the Defense Department and NASA. In 1973, after M.I.T. came under criticism during the Vietnam War for the laboratory’s work on military projects, the university spun it off as an independent, nonprofit organization, which it remains today.
