The psychiatry staff at Madigan Army Medical Center was not encouraged to overturn diagnoses of post-traumatic stress disorder to save the government money, according to investigation documents provided to NBC News.

The Army previously said it found no evidence of wrongdoing at the Tacoma, Wash., hospital, but had not released the investigation documents until Friday. As recently as last month, the Army said it would not share the findings and denied Freedom of Information Act requests by local media.

The investigation, conducted last spring, sought to determine whether or not the commander of Madigan, Col. Dallas Homas, exerted any “undue influence” on PTSD diagnoses. Homas was reinstated last July and the investigation documents contain numerous glowing reviews of his leadership and no indication that he pressed the staff to consider the cost of diagnosing a soldier with PTSD.

That claim stemmed from a 30-minute presentation given in September 2011 by the hospital’s chief of forensic psychiatry, in which he noted that a PTSD diagnosis could cost the government over $1.5 million in disability payments over a soldier’s lifetime.

The 100-page investigation document contains several interviews with Madigan staff members who say the comment was made in less than a minute and taken out of context.

When questioned about the remark, the commander explained that forensic psychiatrists must take into consideration all factors “that could bear on an individual’s diagnosis,” including financial gain, the document showed.

“... It is clearly being blown out of proportion and used to attack [redacted] and his team,” Homas said. “I have not seen any evidence that concern over saving government money is a driver of arriving or not arriving at a diagnosis.”

In the fall of 2011, some soldiers had complained that their PTSD diagnoses had been switched to conditions like anxiety disorder, which could have affected their medical retirement rating and the amount of their disability payments.

Homas pointed out during the investigation that while 14 soldiers were not diagnosed with PTSD, at least 44 soldiers who entered the medical retirement process were ultimately given that diagnosis.

“If this were about saving money, this section has failed has failed miserably,” he said.

The investigation interviews also revealed that some staff faced tense situations when giving a diagnosis.

“Sometimes some soldiers can get so upset that they might act out in some manner, perhaps expressing threats," the chief of behavioral health said to the investigator. "The easy thing to do is just give the patient what they want. The (forensic psychiatry) clinicians work very hard to do what is right.”

Homas said in his interview that some soldiers made death threats against forensic psychiatrists.

The investigating officer wrote that only two individuals, who were ombudsmen, made “unsubstantiated allegations” regarding the forensic psychiatric process. Both were suspicious of changes to soldiers’ PTSD diagnoses, but did not believe Homas advised staff to consider the cost as a factor.

The investigating officer agreed with Madigan staff that the ombudsmen had misunderstood the context of the Sept. 2011 comment.

One ombudsman said soldiers whose diagnoses were reviewed by the forensic psychiatric team were very distressed upon being told they did not have PTSD. In some cases, medical professionals previously told them they had the disorder.

That ombudsman said their lives had been “turned upside down” as a result, and that some evaluations contained language insinuating that the solders were liars and malingerers.

Though the forensic psychiatry team was essentially absolved by the report, the Army has stopped the practice of using such teams to vet PTSD diagnoses; Madigan was the only Army hospital to do so.

“The fact that the Army had to bring in new doctors to reinstate hundreds of PTSD diagnoses for local servicemembers and that they have implemented major behavioral health policy changes nationwide in the wake of the Madigan cases are clear evidence that problems existed on base in properly identifying the invisible wounds of war,” Sen. Patty Murray, D-Wash., said in a statement to NBC News. Murray pushed for the investigation into the PTSD diagnoses at Madigan.

As part of the investigation, a review of 431 Madigan cases — some of which had been overturned — led to PTSD diagnoses for 150 soldiers by last October. The Army recently said that Madigan’s variance rate for diagnoses was not outside the norm. 

Rebecca Ruiz is a reporter based in the Bay Area.

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The results of a months-long investigation into the reversal of post-traumatic stress disorder diagnoses at Madigan Army Medical Center are being kept confidential.

Earlier this month, Army Secretary John McHugh told reporters at Joint Base Lewis-McChord in Washington state that the Madigan findings would not be disclosed.

Days later, the Army denied Freedom of Information Act requests for documents related to the controversy made by three Seattle-area news organizations.

George Wright, an Army spokesman at the Pentagon, told NBC News that “concerns brought up in the Madigan matter will be addressed” in a separate forthcoming report by the Army's Task Force on Behavioral Health.

Wright said he had not viewed that document, which is an Army-wide review of mental health diagnoses as far back as 2001, and could not comment on what information it would include about the Madigan inquiry.

The Madigan investigation, completed last fall, sought to determine whether or not a team of forensic psychiatrists inappropriately changed soldiers’ PTSD diagnoses, perhaps to save the federal government money.

In a memo obtained last year by the Seattle Times, a Madigan Army Medical Center psychiatrist gave a presentation to colleagues in September 2011 in which he noted that a soldier medically retired with a PTSD diagnosis would collect $1.5 million in disability payments over his or her lifetime. The psychiatrist warned his colleagues against “rubber stamping” a PTSD diagnosis.

Around the same time, several soldiers screened at Madigan complained that their PTSD diagnoses had been switched to conditions like anxiety disorder, which could have affected their medical retirement rating and the amount of their disability payments. 

A subsequent review of 431 Madigan cases — some of which had been overturned — led to PTSD diagnoses for 150 soldiers by last October, according to the office of Sen. Patty Murray, D-Wash.

Murray pushed for the investigation into the PTSD diagnoses at Madigan — an Army hospital in Tacoma, Wash., that serves soldiers stationed at Joint Base Lewis-McChord — but has yet to see its findings. 

The Madigan investigation was reported by the Seattle Times in January 2012. In May, McHugh announced the Army-wide review, which is said to contain 24 findings and 47 recommendations, and now according to Wright, details related to Madigan. Murray is scheduled to be briefed on the review in the next few weeks, Matt McAlvanah, a spokesman for the senator, told NBC News.

Last year, Seattle-area news organizations asked to see documents related to the inquiry through Freedom of Information Act requests.

Request denied
Patricia Murphy, a reporter at KUOW Puget Sound Public Radio, said the Army denied the station’s attempts to obtain information and subsequently denied an appeal. The Army described the Madigan documents as “pre-decisional,” a legal privilege extended to documents that influence new rules and regulations. In a letter to the station, the Army said this designation is meant to “protect the quality of agency decisions by encouraging frank and open discussions of agency policy.”

Murphy said she understood that the documents might contain sensitive government and patient information, but was hopeful the Army could strike a balance for transparency. “We don’t care about the names,” Murphy told NBC News. “We care about the reasons they were doing this and whether or not this was a cultural issue at Madigan.”

The Army has said that Madigan was the only Army hospital to employ a team of forensic psychiatrists who vetted PTSD diagnoses and said it had stopped that practice.

Last February, it announced that the hospital’s commander, Col. Dallas Homas, was reassigned during the inquiry. The Army reinstated Homas several months later after finding that he did not "exert any undue influence on PTSD diagnoses." The Army provided that document to KUOW in response to a FOIA request. 

The Army also issued new guidelines for PTSD screening last April, discouraging staff from using testing to identify patients who might be "malingering" or faking their symptoms, an approach some soldiers claimed was utilized at Madigan. 

Despite these corrective actions, critics of the decision to withhold the Madigan findings say that transparency is key to restoring trust in the Army’s ability to accurately diagnosis and treat PTSD.

Tom Tarantino, chief policy director of the advocacy organization Iraq and Afghanistan Veterans of America and a former Army captain, said that keeping the report confidential reflected a “shocking amount of tone deafness.”

“I don’t want anybody to release information that violates HIPAA, privacy or endangers national security, but there has to be some sort of accountability,” Tarantino said. He also fears that withholding the findings sends the wrong signal to soldiers who worry that the problems at Madigan could be widespread and might not seek mental health care as a result.

“You have to actually show patterns of behavior and convince people that you’re willing to change.”

Wright said the Army wanted to make public its report on behavioral health “as soon as possible,” but that it was weighing the feasibility of the recommendations and how to implement them.

“We expect that work to be completed shortly,” he said, “and then we will be able to share not only the findings, but the way ahead.”

Rebecca Ruiz is a reporter based in the Bay Area.

Related:

• Home from war, troops face 'white-knuckled' first month
• Soldier Hard's hip-hop lyrics reveal PTSD's rough edges
• Hundreds of thousands of veteran spur free benefits