Alleged Army gunman’s former patients need follow-up care, observers say

If your doctor went on a killing spree, you might question the kind of care he provided, especially if he was ministering to your mental health. Thus, after law enforcement officials took Army psychiatrist Maj. Nidal Malik Hasan into custody at Fort Hood, Texas, last Thursday after he allegedly shot dozens of fellow soldiers and civilians, killing 13, service medical personnel should have started contacting patients formerly treated by the doctor, experts say.

"First, I'd get a list of all the patients he'd ever treated and get in contact with them," said Dr. Thomas P. Lowry, a psychiatrist who served two years as a doctor in the Air Force and then held the top psychiatry positions at four hospitals before retiring in 1999. It's important to know how the doctor's former patients perceived him and understand the care they received, he said.

Dr. Jonathan Shay, who spent 20 years as a Veterans Affairs Department psychiatrist specializing in the treatment of combat trauma before retiring last year, said some of Hasan's former patients might worry that the stories they shared in therapy sessions could have contributed to the doctor's state of mind, or even feel some responsibility for the killings.

"To potentially save some lives that might be lost to suicide among his former patients, the crucial thing is for the clinical leadership to [find other mental health care providers] who also knew the patients that Hasan had and to take the time to talk to the people who knew these patients and if possible, to work through them to take a reading on how [the patients] were digesting these terrible events," Shay said.

It's not clear if that is happening. When asked what steps the service is taking to ensure proper medical care of the patients under Hasan's care at Walter Reed Army Medical Center in Washington and Darnall Army Medical Center at Fort Hood, Army spokeswoman Col. Catherine Abbott said she could not provide that information.

"All these issues will be looked at as part of the Army's examination of itself," Abbott said. Officials at Walter Reed and Darnell also declined to comment on the issue or provide any information about what kind of care the former patients are receiving.

"You cannot be sure that it's even happening," Shay said.

Army officials declined to say how many patients Hasan saw in his duties. Psychiatrists typically treat the most vulnerable soldiers who have suffered devastating losses, physically and emotionally. According to Hasan's Virginia medical license, which he apparently last updated on Oct. 13, the 39-year-old doctor saw patients five days a week at Darnell. Previously, between June 2003 and July 2009, he completed his medical residency and a fellowship program at Walter Reed, where he also would have treated patients.

On Thursday, military prosecutors charged Hasan with 13 counts of premeditated murder.

How the Army approaches these former patients is critical, Shay said. An order from Washington or the Pentagon to track down former patients is not likely to be effective. "That is a prescription for the patients running or clamming up or just bullshitting the [questioner]. These kinds of knee-jerk, institutional responses are not likely to be safe or effective and in the end probably will not produce much, except to be able to say to the secretary of the Army we're doing everything we can," he said.

Hopefully, Shay said, Hasan's former patients were being treated in settings where they worked with multiple health care providers and not just Hasan: "In my view, the best practices always involve a cohesive team where multiple [mental health professionals] get to know and have a relationship with the psychologically injured veteran, and it's not one person out there alone."

"I think it's critical that the mental health people at the lowest level of the hierarchy really get in the saddle and figure out who knew these soldiers and on a person-to-person basis, check in with them," Shay said.

Shay, a former adviser to the Army on mental health policy, also is the author of two books that deal with the experiences of combat veterans: Achilles in Vietnam: Combat Trauma and the Undoing of Character (Simon and Schuster, 1995) and Odysseus in America: Combat Trauma and the Trials of Homecoming (Scribner, 2003).

Determining adequate psychiatric treatment is less straightforward than other medical care, Lowry said. "Surgery is surgery. Whether you're in Sicily or Albania, the gallbladder is on the right, the appendix down in one corner, et cetera. But psychiatry obviously is very culture-bound. I'm not sure how somebody who thinks al Qaeda is a good thing [as has been reported by some news outlets] is supposed to counsel soldiers who have been shot up by Islamists," Lowry said.

Even if officials were to determine that soldiers received inadequate care under Hasan, it's unlikely the Army would be held liable in any medical malpractices suits, lawyers say.

Under the Feres Doctrine, which stems from a 1950 Supreme Court decision, active-duty service members are barred from suing the government for the negligence of other service members. (Spouses, dependents and retirees can file claims for medical negligence.) It's likely that most, if not all, of Hasan's patients were on active duty.

"Any active-duty member killed or injured because of the [doctor's] actions is barred [from suing] as are the next of kin. All injured parties are limited to the benefits afforded to any other soldier by the military and VA programs," wrote Richmond-based attorney Richard Gasperini in an e-mail response to a question from Government Executive. Gasperini specializes in military medical malpractice cases.

Jack Olender, principal trial lawyer at Jack H. Olender and Associates, P.C., a top malpractice law firm in Washington, said, "It may be that the government will have the good sense to waive the immunity" in this case. "I think there are acts of negligence by the government that would certainly justify suits by the families of the people that were killed."

Meanwhile, the Army faces serious challenges in meeting the psychological needs of troops, among them a severe shortage of mental health professionals to administer to a growing need. A study by the RAND Corp.'s Center for Military Health Policy Research last year estimated that of the 1.64 million service members who had been deployed to Iraq or Afghanistan, about 300,000 suffered from post-traumatic stress disorder or major depression, and 320,000 experienced a probable traumatic brain injury during their deployment.

Only about half of the troops who met the criteria for current PTSD or major depression had sought help from a physician or mental health provider in the previous year, RAND found. Of those reporting probable traumatic brain injury, 57 percent had not been evaluated by a physician.

"Even when individuals receive care, too few receive quality care," the study found. "Of those who have a mental disorder and also sought medical care for that problem, just over half received a minimally adequate treatment."