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entitled 'Post-Traumatic Stress Disorder: DOD Needs to Identify the 
Factors Its Providers Use to Make Mental Health Evaluation Referrals 
for Servicemembers' which was released on May 11, 2006.

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United States Government Accountability Office:

GAO:

Report to Congressional Committees:

May 2006:

Post-Traumatic Stress Disorder:

DOD Needs to Identify the Factors Its Providers Use to Make Mental 
Health Evaluation Referrals for Servicemembers:

GAO-06-397:

GAO Highlights: 

Highlights of GAO-06-397, a report to congressional committees.

Why GAO Did This Study: 

Many servicemembers supporting Operation Enduring Freedom (OEF) and 
Operation Iraqi Freedom (OIF) have engaged in intense and prolonged 
combat, which research has shown to be strongly associated with the 
risk of developing post-traumatic stress disorder (PTSD). GAO, in 
response to the Ronald W. Reagan National Defense Authorization Act for 
Fiscal Year 2005, (1) describes DOD’s extended health care benefit and 
VA’s health care services for OEF/OIF veterans; (2) analyzes DOD data 
to determine the number of OEF/OIF servicemembers who may be at risk 
for PTSD and the number referred for further mental health evaluations; 
and (3) examines whether DOD can provide reasonable assurance that 
OEF/OIF servicemembers who need further mental health evaluations 
receive referrals. 

What GAO Found: 

DOD offers an extended health care benefit to some OEF/OIF veterans for 
a specified time period, and VA offers health care services that 
include specialized PTSD services. DOD’s benefit provides health care 
services, including mental health services, to some OEF/OIF veterans 
for 180 days following discharge or release from active duty. 
Additionally, some veterans may purchase extended benefits for up to 18 
months. VA also offers health care services to OEF/OIF veterans 
following their discharge or release from active duty. VA offers health 
benefits for OEF/OIF veterans at no cost for 
2 years following discharge or release from active duty. After their 2-
year benefit expires, some OEF/OIF veterans may continue to receive 
care under VA’s eligibility rules.

Using data provided by DOD, GAO found that 9,145 or 5 percent of the 
178,664 OEF/OIF servicemembers in its review may have been at risk for 
developing PTSD. DOD uses a questionnaire to identify those who may be 
at risk for developing PTSD after deployment. DOD providers interview 
servicemembers after they complete the questionnaire. A joint VA/DOD 
guideline states that servicemembers who respond positively to three or 
four of the questions may be at risk for PTSD. Further, we reviewed a 
retrospective study that found that those individuals who provided 
three or four positive responses to the four PTSD screening questions 
were highly likely to have been previously given a diagnosis of PTSD 
prior to the screening. Of the 5 percent who may have been at risk, GAO 
found that DOD providers referred 22 percent or 2,029 for further 
mental health evaluations. 

DOD cannot provide reasonable assurance that OEF/OIF servicemembers who 
need referrals receive them. According to DOD officials, not all of the 
servicemembers with three or four positive responses to the PTSD 
screening questions will need referrals for further mental health 
evaluations. DOD relies on providers’ clinical judgment to decide who 
needs a referral. GAO found that DOD health care providers varied in 
the frequency with which they issued referrals to OEF/OIF 
servicemembers with three or more positive responses; the Army referred 
23 percent, the Marines about 
15 percent, the Navy 18 percent, and the Air Force about 23 percent. 
However, DOD did not identify the factors its providers used in 
determining which OEF/OIF servicemembers needed referrals. Knowing the 
factors upon which DOD health care providers based their clinical 
judgments in issuing referrals could help explain variation in the 
referral rates and allow DOD to provide reasonable assurance that such 
judgments are being exercised appropriately.

What GAO Recommends: 

GAO recommends that DOD identify factors that its providers use in 
issuing referrals for further mental health evaluations. DOD concurred 
with GAO’s recommendation, but disagreed with GAO’s finding that DOD 
has not provided reasonable assurance that servicemembers who need 
referrals for further mental health evaluations receive them. DOD 
identified factors that may affect referrals, but did not provide data 
on how its providers apply these factors. VA concurred with the facts 
related to VA in the report. 

[Hyperlink, www.gao.gov/cgi-bin/getrpt?GAO-06-397].

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Cynthia A. Bascetta at 
(202) 512-7101 or bascettac@gao.gov. 

[End of section]

Contents:

Letter:

Results in Brief:

Background:

For Veterans, DOD Offers a Benefit for a Specific Period of Time and VA 
Offers Various Health Care Services:

Based on DOD Data, About 5 Percent of OEF/OIF Servicemembers May Have 
Been at Risk for Developing PTSD and Over 20 Percent Received Referrals:

DOD Cannot Provide Reasonable Assurance That OEF/OIF Servicemembers Who 
Need Mental Health Referrals Receive Them:

Conclusions:

Recommendation for Executive Action:

Agency Comments and Our Evaluation:

Appendix I: Scope and Methodology:

Appendix II: Comments from the Department of Defense:

Appendix III: GAO Contact and Staff Acknowledgments:

Tables:

Table 1: TRICARE Beneficiary Costs Through TAMP:

Table 2: VA Specialized Outpatient and Inpatient PTSD Treatment 
Programs:

Figures:

Figure 1: Portion of the DD 2796 Used by DOD Health Care Providers to 
Indicate a Referral for a Further Mental Health or Combat/Operational 
Stress Reaction Evaluation Is Needed:

Figure 2: OEF/OIF Servicemembers Who May Have Been at Risk for 
Developing PTSD, by Military Service Branch:

Figure 3: Referral Rates for Mental Health or Combat/Operational Stress 
Reaction Evaluation for OEF/OIF Servicemembers Who May Have Been at 
Risk for Developing PTSD, by Military Service Branch:

Abbreviations:

AMSA: Army Medical Surveillance Activity: 
CHCBP: Continued Health Care Benefit Program: 
DMDC: Defense Manpower Data Center: 
DOD: Department of Defense: 
NDAA: National Defense Authorization Act for Fiscal Year 2005:  
OEF: Operation Enduring Freedom: 
OIF: Operation Iraqi Freedom: 
PTSD: post-traumatic stress disorder: 
TAMP: Transitional Assistance Management Program: 
TRS: TRICARE Reserve Select: 
VA: Department of Veterans Affairs:

United States Government Accountability Office:
Washington, DC 20548:

May 11, 2006:

Congressional Committees:

Servicemembers returning from the military conflicts in Afghanistan and 
Iraq--Operation Enduring Freedom (OEF) and Operation Iraqi Freedom 
(OIF),[Footnote 1] respectively--have engaged in intense and prolonged 
combat, which research has shown to be strongly associated with the 
risk for developing PTSD.[Footnote 2] PTSD can occur after experiencing 
or witnessing a life-threatening event and is the most prevalent mental 
health disorder resulting from combat. Mental health experts state that 
early identification and treatment of symptoms through education, peer 
and family support, therapy, or medications may lessen the severity of 
the condition and improve the overall quality of life for those with 
PTSD.

The Department of Defense (DOD) uses a questionnaire to screen OEF/OIF 
servicemembers after their deployment outside of the United States has 
ended.[Footnote 3] The questionnaire assesses servicemembers' physical 
and mental health and includes four questions that are used to identify 
those who may be at risk for developing PTSD. In conjunction with 
completion of the questionnaire, each OEF/OIF servicemember is 
interviewed by a DOD health care provider who reviews the completed 
questionnaire and discusses with the servicemember any deployment- 
related health concerns, including mental health concerns. From among 
those who may be at risk for PTSD or other mental health conditions, 
these DOD health care providers then determine which servicemembers 
need referrals for a further mental health evaluation. Providers use a 
section of the post-deployment screening questionnaire to indicate when 
a servicemember needs a referral.[Footnote 4]

OEF/OIF servicemembers can obtain mental health evaluations, as well as 
any necessary treatment for PTSD, while they are servicemembers--that 
is, on active duty--or when they transition to veteran status after 
being discharged or released from active duty.[Footnote 5] DOD provides 
mental health evaluations and treatment for PTSD to servicemembers, 
including OEF/OIF servicemembers, and the department also provides 
these mental health benefits for OEF/OIF veterans through an extended 
health care benefit created for this population. The Department of 
Veterans Affairs (VA) also provides mental health benefits to OEF/OIF 
veterans as part of health care services that it offers to these and 
other veterans. In this report, we use the term OEF/OIF servicemembers 
when we refer to those returning from the OEF/OIF conflicts who are 
screened for PTSD and may receive referrals during active duty. We use 
the term OEF/OIF veterans when we refer to those returning from the 
OEF/OIF conflicts who, after being discharged or released from active 
duty, are eligible for DOD and VA mental health benefits and could 
access the departments' services.

The Ronald W. Reagan National Defense Authorization Act for Fiscal Year 
2005 (NDAA)[Footnote 6] directed that we describe the mental health 
benefits available for OEF/OIF veterans. NDAA further directed that we 
examine the process DOD uses to refer OEF/OIF servicemembers who need 
further mental health evaluations. In this report, we (1) describe 
DOD's extended health care benefit for OEF/OIF veterans and VA's health 
care services for OEF/OIF veterans; (2) analyze DOD data to determine 
the number of OEF/OIF servicemembers who may be at risk for developing 
PTSD and the number of these servicemembers who were referred for 
further mental health evaluations; and (3) examine whether DOD can 
provide reasonable assurance that OEF/OIF servicemembers who need 
further mental health evaluations receive referrals for these 
evaluations.

To describe DOD's extended health care benefit and VA's health care 
services for OEF/OIF veterans, we reviewed DOD policies and the 
educational materials DOD provides to individuals on its health 
insurance benefits, including information on the length of coverage of 
these benefits. We also interviewed DOD officials and the military 
service branches about these benefits. In addition, we reviewed VA's 
policies, directives, and educational information on its health care 
services, including the mental health services that VA has available 
for OEF/OIF veterans. We reviewed the types of mental health services 
available through VA's health care system for OEF/OIF veterans. We also 
interviewed VA headquarters officials about these services.

To determine the number of OEF/OIF servicemembers who may be at risk 
for developing PTSD and the number of these servicemembers referred for 
further mental health evaluations, we analyzed DOD computerized data. 
We obtained from DOD a list of OEF/OIF servicemembers who (1) were 
deployed in support of OEF/OIF from October 1, 2001, through September 
30, 2004; (2) had since been discharged or released from active 
duty;[Footnote 7] (3) completed DOD's post-deployment screening 
questionnaire; and (4) had the record of their completed questionnaire 
available in a DOD computerized database. From this list, we identified 
178,664 OEF/OIF servicemembers who answered the four PTSD screening 
questions on DOD's post-deployment screening questionnaire, the DD 
2796.[Footnote 8] To determine the number of OEF/OIF servicemembers who 
may have been at risk for developing PTSD, we reviewed a clinical 
practice guideline for PTSD developed jointly by VA and DOD, which 
indicates that servicemembers who provide three or four positive 
responses to the four PTSD screening questions may be at risk for 
developing PTSD.[Footnote 9] We also reviewed a retrospective study 
that found that those individuals who provided three or four positive 
responses to the four PTSD screening questions were highly likely to 
have been previously given a diagnosis of PTSD prior to the 
screening.[Footnote 10] To determine the number of OEF/OIF 
servicemembers who received referrals from a DOD health care provider, 
we used information from the post-deployment questionnaires of the 
178,664 OEF/OIF servicemembers in our review. The questionnaires 
indicate whether a DOD health care provider issued a referral for a 
mental health or combat/operational stress reaction evaluation. We 
determined that DOD's data were sufficiently reliable for the purposes 
of the report.

To examine whether DOD can provide reasonable assurance that OEF/OIF 
servicemembers who need further mental health evaluations receive 
referrals, we reviewed DOD's policies and guidance, including guidance 
for DOD health care providers who use the DD 2796. We reviewed DOD's 
quality assurance program and spoke to a researcher about a DOD study 
on PTSD referrals to examine the extent to which DOD studies its 
providers' decisions to issue referrals. We interviewed DOD officials, 
including mental health clinicians involved with the DD 2796 and asked 
them about DOD's criteria for issuing referrals to those who may be at 
risk for developing PTSD.

NDAA also directed us to determine the number of OEF/OIF veterans who, 
because of their DOD provider-issued referrals, accessed DOD or VA 
health care services to obtain a further mental health or combat/ 
operational stress reaction evaluation. However, as discussed with the 
committees of jurisdiction, we could not use data from OEF/OIF 
veterans' DD 2796 forms to determine if veterans accessed DOD or VA 
health care services because of their mental health referrals. DOD 
officials explained that the referral checked on the DD 2796 cannot be 
linked to a subsequent health care visit using DOD computerized data. 
Therefore, we could not determine how many OEF/OIF veterans accessed 
DOD or VA health care services for further mental health evaluations 
because of their referrals.

For a complete discussion of our scope and methodology, see appendix I. 
We conducted our work from December 2004 through April 2006 in 
accordance with generally accepted government auditing standards.

Results in Brief:

DOD offers an extended health care benefit to some OEF/OIF veterans for 
a specific period of time, and VA offers health care services that 
include specialized PTSD services. DOD's benefit provides health care 
services, including mental health services, to some OEF/OIF veterans 
for 180 days following discharge or release from active duty. 
Additionally, veterans may purchase extended benefits for up to 18 
months. VA also offers health care services to OEF/OIF veterans 
following their discharge or release from active duty. VA's health 
benefits include health care services, as well as specialized PTSD 
services. These specialized PTSD services are delivered by clinicians 
who have concentrated their clinical work in the area of PTSD 
treatment. These clinicians work as a team to coordinate veterans' 
treatments and offer expertise in a variety of disciplines, such as 
psychiatry, psychology, social work, readjustment counseling, and 
nursing. VA offers its health care services to OEF/OIF veterans at no 
cost for 2 years following discharge or release from active duty. After 
their 2-year benefit expires, OEF/OIF veterans may continue to receive 
VA care under VA's eligibility rules but may be subject to copayments.

Using data provided by DOD from the DD 2796 forms, we found that about 
5 percent of the OEF/OIF servicemembers in our review may have been at 
risk for developing PTSD, and over 20 percent of these servicemembers 
received a referral--that is, had a DD 2796 indicating that they needed 
a further mental health or combat/operational stress reaction 
evaluation. According to the clinical practice guideline jointly 
developed by VA and DOD, individuals who respond positively to three or 
four of the four PTSD screening questions may be at risk for developing 
PTSD. Using these criteria, we found that of the 178,664 OEF/OIF 
servicemembers in our study, DOD data indicate that 5 percent--9,145-- 
may have been at risk for developing PTSD. Of these, we found that 
2,029 or 22 percent were referred by DOD health care providers for 
further mental health or combat/operational stress reaction 
evaluations. Moreover, across the military service branches, DOD health 
care providers varied in the frequency with which they issued referrals 
to OEF/OIF servicemembers with three or more positive responses to the 
PTSD screening questions; the Army referred 23 percent, the Marines 
referred about 15 percent, Navy referred 18 percent, and the Air Force 
referred about 23 percent.

DOD cannot provide reasonable assurance that OEF/OIF servicemembers who 
need referrals for further mental health or combat/operational stress 
reaction evaluations receive them. Determining who needs a referral 
occurs when DOD health care providers interview servicemembers after 
they complete the DD 2796. DOD's guidance for health care providers 
using the DD 2796 advises the health care providers to give particular 
attention during the interview to those who completed the DD 2796 and 
answered positively to three or four of the four PTSD screening 
questions. According to DOD officials, not all of the OEF/OIF 
servicemembers with three or four positive responses will need 
referrals for further mental health evaluations. As directed by DOD's 
guidance for using the DD 2796, health care providers are to rely on 
their clinical judgment to decide which of these servicemembers need 
further mental health evaluations. However, DOD has not identified the 
factors its health care providers used to determine which OEF/OIF 
servicemembers needed referrals. While DOD has taken steps to monitor 
the post-deployment process, these steps are not designed to identify 
the factors upon which DOD health care providers base their clinical 
judgments in issuing referrals for further mental health or combat/ 
operational stress reaction evaluations. Knowing these factors could 
help explain the variation in the referral rates and allow DOD to 
provide reasonable assurance that such judgments are being exercised 
appropriately.

We recommend that DOD identify the factors that DOD health care 
providers use in issuing referrals for further evaluations for mental 
health or combat/operational stress reaction to explain provider 
variation in issuing referrals. In commenting on a draft of this 
report, DOD concurred with our conclusions and recommendation. DOD 
noted that it plans a systematic evaluation of referral patterns for 
the post-deployment health assessment through the National Quality 
Management Program. Despite its planned implementation of our 
recommendation, DOD disagreed with our finding that it has not provided 
reasonable assurance that OEF/OIF servicemembers receive referrals for 
further mental health evaluations when needed. Until DOD has better 
information on the factors its health care providers use when applying 
their clinical judgment, DOD cannot reasonably assure that 
servicemembers who need referrals receive them. DOD's plans to develop 
this information should lead to reasonable assurance that 
servicemembers who need referrals receive them. VA concurred with the 
facts in the draft report that related to VA services.

Background:

PTSD can develop following exposure to combat, natural disasters, 
terrorist incidents, serious accidents, or violent personal assaults 
like rape. People who experience stressful events often relive the 
experience through nightmares and flashbacks, have difficulty sleeping, 
and feel detached or estranged. These symptoms may occur within the 
first 4 days after exposure to the stressful event or be delayed for 
months or years.[Footnote 11] Symptoms that appear within the first 4 
days after exposure to a stressful event are generally diagnosed as 
acute stress reaction or combat stress. Symptoms that persist longer 
than 4 days are diagnosed as acute stress disorder. If the symptoms 
continue for more than 30 days and significantly disrupt an 
individual's daily activities, PTSD is diagnosed. PTSD may occur with 
other mental health conditions, such as depression and substance abuse. 
Clinicians offer a range of treatments to individuals diagnosed with 
PTSD, including individual and group therapy and medication to manage 
symptoms. These treatments are usually delivered in an outpatient 
setting, but they can include inpatient services if, for example, 
individuals are at risk of causing harm to themselves.

DOD's Post-Deployment Process and Screening for PTSD:

DOD's screening for PTSD occurs during its post-deployment process. 
During this process, DOD evaluates servicemembers' current physical and 
mental health and identifies any psychosocial issues commonly 
associated with deployments, special medications taken during the 
deployment, and possible deployment-related occupational/environmental 
exposures. The post-deployment process also includes completion by the 
servicemember of the post-deployment screening questionnaire, the DD 
2796. DOD uses the DD 2796 to assess health status, including 
identifying servicemembers who may be at risk for developing PTSD 
following deployment.[Footnote 12] In addition to questions about 
demographics and general health, including questions about general 
mental health, the DD 2796 includes four questions used to screen 
servicemembers for PTSD. The four questions are:

Have you ever had any experience that was so frightening, horrible, or 
upsetting that, in the past month, you:

* have had any nightmares about it or thought about it when you did not 
want to?

* tried hard not to think about it or went out of your way to avoid 
situations that remind you of it?

* were constantly on guard, watchful, or easily startled?

* felt numb or detached from others, activities, or your surroundings?

The completed DD 2796 is reviewed by a DOD health care provider who 
conducts a face-to-face interview to discuss any deployment-related 
health concerns with the servicemember. Health care providers that 
review the DD 2796 may include physicians, physician assistants, nurse 
practitioners, or independent duty medical technicians--enlisted 
personnel who receive advanced training to provide treatment and 
administer medications. DOD provides guidance for health care providers 
using the DD 2796 and screening servicemembers' physical and mental 
health. The guidance gives background information to health care 
providers on the purpose of the various screening questions on the DD 
2796 and highlights the importance of a health care provider's clinical 
judgment when interviewing and discussing responses to the DD 2796.

Health care providers may make a referral for a further mental health 
or combat/operational stress reaction evaluation by indicating on the 
DD 2796 that this evaluation is needed. When a DOD health care provider 
refers an OEF/OIF servicemember for a further mental health or combat/ 
operational stress reaction evaluation, the provider checks the 
appropriate evaluation box on the DD 2796 and gives the servicemember 
information about PTSD. The provider does not generally arrange for a 
mental health evaluation appointment for the servicemember with a 
referral. See figure 1 for the portion of the DD 2796 that is used to 
indicate that a referral for a further mental health or combat/ 
operational stress reaction evaluation is needed.

Figure 1: Portion of the DD 2796 Used by DOD Health Care Providers to 
Indicate a Referral for a Further Mental Health or Combat/Operational 
Stress Reaction Evaluation Is Needed:

[See PDF for image] 

Source: DOD.

[End of figure]

DOD and VA Health Care Systems:

DOD's health care system, TRICARE, delivers health care services to 
over 9 million individuals. Health care services, which include mental 
health services, are provided by DOD personnel in military treatment 
facilities or through civilian health care providers, who may be either 
network providers or nonnetwork providers. A military treatment 
facility is a military hospital or clinic on or near a military base. 
Network providers have a contractual agreement with TRICARE to provide 
health care services and are part of the TRICARE network. Nonnetwork 
providers may accept TRICARE allowable charges for delivering health 
care services or expect the beneficiary to pay the difference between 
the provider's fee and TRICARE's allowable charge for services.

VA's health care system includes medical facilities, community-based 
outpatient clinics, and Vet Centers. VA medical facilities offer 
services which range from primary care to complex specialty care, such 
as cardiac or spinal cord injury. VA's community-based outpatient 
clinics are an extension of VA's medical facilities and mainly provide 
primary care services. Vet Centers offer readjustment and family 
counseling, employment services, bereavement counseling, and a range of 
social services to assist veterans in readjusting from wartime military 
service to civilian life.[Footnote 13] Vet Centers are also community 
points of access for many returning veterans, providing them with 
information and referrals to VA medical facilities.

DOD's Quality Assurance Program:

In January 2004, DOD implemented the Deployment Health Quality 
Assurance Program.[Footnote 14] As part of the program, each military 
service branch must implement its own quality assurance program and 
report quarterly to DOD on the status and findings of the program. The 
program requires military installation site visits by DOD and military 
service branch officials to review individual medical records to 
determine, in part, whether the DD 2796 was completed. The program also 
requires a monthly report from the Army Medical Surveillance Activity 
(AMSA), which maintains a database of all servicemembers' completed DD 
2796s.[Footnote 15] DOD uses the information from the military service 
branches, site visits, and AMSA to develop an annual report on its 
Deployment Health Quality Assurance Program.[Footnote 16]

For Veterans, DOD Offers a Benefit for a Specific Period of Time and VA 
Offers Various Health Care Services:

DOD offers an extended health care benefit to some OEF/OIF veterans for 
a specific period of time, and VA offers health care services that 
include specialized PTSD services. For some OEF/OIF veterans, DOD 
offers three health care benefit options through the Transitional 
Assistance Management Program (TAMP) under TRICARE, DOD's health care 
system. The three benefit options are offered for 180 days following 
discharge or release from active duty. In addition, OEF/OIF veterans 
may purchase health care benefits through DOD's Continued Health Care 
Benefit Program (CHCBP) for 18 months. VA also offers health care 
services to OEF/OIF veterans following their discharge or release from 
active duty. VA's health benefits include health care services, 
including specialized PTSD services, which are delivered by clinicians 
who have concentrated their clinical work in the area of PTSD treatment 
and who work as a team to coordinate veterans' treatment.

DOD Offers Mental Health Benefits to OEF/OIF Veterans for 180 Days or 
More:

Through TAMP, DOD provides health care benefits that allow some OEF/OIF 
veterans to obtain health care services, which include mental health 
services, for 180 days following discharge or release from active 
duty.[Footnote 17] This includes services for those who may be at risk 
for developing PTSD. These OEF/OIF veterans can choose one of three 
TRICARE health care benefit options through TAMP. While the three 
options have no premiums, two of the options have deductibles and 
copayments and allow access to a larger number of providers. The 
options are:

* TRICARE Prime--a managed care option that allows OEF/OIF veterans to 
obtain, without a referral, mental health services directly from a 
mental health provider in the TRICARE network of providers with no cost 
for services.

* TRICARE Extra--a preferred provider option that allows OEF/OIF 
veterans to obtain, without a referral, mental health services directly 
from a mental health provider in the TRICARE network of providers. 
Beneficiaries pay a deductible and a share of the cost of services.

* TRICARE Standard--a fee-for-service option that allows OEF/OIF 
veterans to obtain, without a referral, mental health services directly 
from any mental health provider, including those outside the TRICARE 
network of providers. Beneficiaries pay a deductible and a larger share 
of the costs of services than under the TRICARE Extra option.

See Table 1 for a description of the beneficiary costs associated with 
each TRICARE option.

Table 1: TRICARE Beneficiary Costs Through TAMP:

Annual deductible; TRICARE Prime (managed care): None; 
TRICARE Extra (preferred provider): $50-$150 (individual) and $100-$300 
maximum (family), depending on military rank; 
TRICARE Standard (fee-for- service): $50-$150 (individual) and $100-
$300 maximum (family), depending on military rank.

Cost share after deductibles for mental health visits; TRICARE Prime 
(managed care): Outpatient: None; 
TRICARE Extra (preferred provider): Outpatient: 15% of the fee 
negotiated by TRICARE contractor after the deductible is met; 
TRICARE Standard (fee-for-service): Outpatient: 20% of allowable 
charges for covered services after the deductible is met.

TRICARE Prime (managed care): Inpatient: None; 
TRICARE Extra (preferred provider): Inpatient: greater of $20/day or 
$25 minimum charge per admission; 
TRICARE Standard (fee-for-service): Inpatient: greater of $20/day or 
$25 minimum charge per admission. 

Source: DOD.

[End of table]

In addition, OEF/OIF veterans may purchase DOD health care benefits 
through CHCBP for 18 months.[Footnote 18] CHCBP began on October 1, 
1994, and like TAMP, the program provides health care benefits, 
including mental health services, for veterans making the transition to 
civilian life. Although benefits under this plan are similar to those 
offered under TRICARE Standard, the program is administered by a 
TRICARE health care contractor and is not part of TRICARE. OEF/OIF 
veterans must purchase the extended benefit within 60 days after their 
180-day TAMP benefit ends. CHCBP premiums in 2006 were $311 for 
individual coverage and $665 for family coverage per month.

Reserve and National Guard OEF/OIF veterans who commit to future 
service can extend their health care benefits after their CHCBP or TAMP 
benefits expire by purchasing an additional benefit through the TRICARE 
Reserve Select (TRS) program.[Footnote 19] As of January 1, 2006, 
premiums under TRS are $81 for individual coverage and $253 for family 
coverage per month.

DOD also offers a service, Military OneSource, that provides 
information and counseling resources to OEF/OIF veterans for 180 days 
after discharge from the military.[Footnote 20] Military OneSource is a 
24-hour, 7-days a week information and referral service provided by DOD 
at no cost to veterans. Military OneSource provides OEF/OIF veterans up 
to six free counseling sessions for each topic with a community-based 
counselor and also provides referrals to mental health services through 
TRICARE.

VA Offers Health Services, Including Specialized PTSD Services, to OEF/ 
OIF Veterans:

VA also offers health care services to OEF/OIF veterans, and these 
services include mental health services that can be used for evaluation 
and treatment of PTSD. VA offers all of its health care services to 
OEF/OIF veterans through its health care system at no cost for 2 years 
following these veterans' discharge or release from active 
duty.[Footnote 21],[Footnote 22] VA's mental health services, which are 
offered on an outpatient or inpatient basis, include individual and 
group counseling, education, and drug therapy.

For those veterans with PTSD whose condition cannot be managed in a 
primary care or general mental health setting, VA has specialized PTSD 
services at some of its medical facilities. These services are 
delivered by clinicians who have concentrated their clinical work in 
the area of PTSD treatment. The clinicians work as a team to coordinate 
veterans' treatment and offer expertise in a variety of disciplines, 
such as psychiatry, psychology, social work, counseling, and nursing. 
Like VA's general mental health services, VA's specialized PTSD 
services are available on both an outpatient and inpatient basis. Table 
2 lists the various outpatient and inpatient specialized PTSD treatment 
programs available in VA.

Table 2: VA Specialized Outpatient and Inpatient PTSD Treatment 
Programs:

Outpatient treatment program: PTSD Clinical Team; 
Description of service: 
* Group and one-on-one evaluation, education, counseling and 
psychotherapy; 
Number of facilities with specialized PTSD treatment program: 152.

Outpatient treatment program: Substance Use and PTSD Team; 
Description of service: 
* Education, evaluation, and counseling with a focus on veterans with 
both substance abuse and PTSD; 
Number of facilities with specialized PTSD treatment program: 10.

Outpatient treatment program: Women's Stress Disorder Treatment Team/ 
Military Sexual Trauma Team; 
Description of service: 
* Individual evaluation, counseling, and psychotherapy for women; 
* Group counseling and psychotherapy for women; 
* Mostly women, may include small number of men separate from women; 
Number of facilities with specialized PTSD treatment program: 17.

Outpatient treatment program: PTSD Day Hospital; 
Description of service: 
* Social, recreational, and vocational activities and counseling; 
Number of facilities with specialized PTSD treatment program: 11.

Inpatient treatment program: Evaluation and Brief Treatment Unit; 
Description of service: 
* Evaluation, education, and psychotherapy for PTSD; 
* Duration of service: 14 to 28 days; 
Number of facilities with specialized PTSD treatment program: 4.

Inpatient treatment program: Specialized Inpatient PTSD Unit; 
Description of service: 
* Evaluation, education, and counseling for substance use and PTSD 
psychotherapy; 
* Duration of service: 28 to 90 days; 
Number of facilities with specialized PTSD treatment program: 5.

Inpatient treatment program: PTSD Residential Rehabilitation Program; 
Description of service: 
* Residential service providing evaluation, education, and counseling 
to help veterans resume a productive involvement in community life; 
* Duration of service: 28 to 90 days; 
Number of facilities with specialized PTSD treatment program: 14.

Outpatient treatment program: Women's Trauma Recovery Program; 
Description of service: 
* Residential service with an emphasis on interpersonal skills for 
veterans with PTSD; 
* Duration of service: up to 60 days; 
Number of facilities with specialized PTSD treatment program: 2.

Outpatient treatment program: PTSD Domiciliary; 
Description of service: 
* Residential program providing integrated rehabilitative and 
restorative care with the goal of helping veterans with PTSD achieve 
and maintain the highest level of functioning and independence 
possible; 
* Duration of service: about 85 days; 
Number of facilities with specialized PTSD treatment program: 8. 

Source: VA, March 2006.

[End of table]

In addition to the 2-year mental health benefit, VA's 207 Vet Centers 
offer counseling services to all OEF/OIF veterans with combat 
experience, with no time limitation or cost to the veteran for the 
benefit. Vet Centers are also authorized to provide counseling services 
to veterans' family members to the extent this is necessary for the 
veteran's post-war readjustment to civilian life. VA Vet Center 
counselors may refer a veteran to VA mental health services when 
appropriate.

Based on DOD Data, About 5 Percent of OEF/OIF Servicemembers May Have 
Been at Risk for Developing PTSD and Over 20 Percent Received Referrals:

Using data provided by DOD from the DD 2796s, we found that about 5 
percent of the OEF/OIF servicemembers in our review may have been at 
risk for developing PTSD, and over 20 percent received referrals for 
further mental health or combat/operational stress reaction 
evaluations. About 5 percent of the 178,664 OEF/OIF servicemembers in 
our review responded positively to three or four of the four PTSD 
screening questions on the DD 2796. According to the clinical practice 
guideline jointly developed by VA and DOD, individuals who respond 
positively to three or four of the four PTSD screening questions may be 
at risk for developing PTSD. Of those OEF/OIF servicemembers who may 
have been at risk for PTSD, 22 percent were referred for further mental 
health or combat/operational stress reaction evaluations.

About 5 Percent of OEF/OIF Servicemembers May Have Been at Risk for 
Developing PTSD:

Of the 178,664 OEF/OIF servicemembers who were deployed in support of 
OEF/OIF from October 1, 2001, through September 30, 2004, and were in 
our review, 9,145--or about 5 percent--may have been at risk for 
developing PTSD. These OEF/OIF servicemembers responded positively to 
three or four of the four PTSD screening questions on the DD 2796. 
Compared with OEF/OIF servicemembers in other service branches of the 
military, more OEF/OIF servicemembers from the Army and Marines 
provided positive answers to three or four of the PTSD screening 
questions--about 6 percent for the Army and about 4 percent for the 
Marines (see fig. 2). The positive response rates for the Army and 
Marines are consistent with research that shows that these 
servicemembers face a higher risk of developing PTSD because of the 
intensity of the conflict they experienced in Afghanistan and 
Iraq.[Footnote 23]

Figure 2: OEF/OIF Servicemembers Who May Have Been at Risk for 
Developing PTSD, by Military Service Branch:

[See PDF for image] 

Source: GAO analysis of DOD data. 

Note: This figure is based on the number of OEF/OIF servicemembers in 
our review who were deployed from October 1, 2001 through September 30, 
2004 and answered positively to three or four of the four PTSD 
screening questions on the DD 2796.

[End of figure]

We also found that OEF/OIF servicemembers who were members of the 
National Guard and Reserves were not more likely to be at risk for 
developing PTSD than other OEF/OIF servicemembers. Concerns have been 
raised that OEF/OIF servicemembers from the National Guard and Reserve 
are at particular risk for developing PTSD because they might be less 
prepared for the intensity of the OEF/OIF conflicts.[Footnote 24] 
However, the percentage of OEF/OIF servicemembers in the National Guard 
and Reserves who answered positively to three or four PTSD screening 
questions was 5.2 percent, compared to 4.9 percent for other OEF/OIF 
servicemembers.[Footnote 25]

Twenty-two Percent Who May Have Been at Risk for Developing PTSD 
Received Referrals:

Of the 9,145 OEF/OIF servicemembers who may have been at risk for 
developing PTSD, we found that 2,029 or 22 percent received a referral-
-that is, had a DD 2796 indicating that they needed a further mental 
health or combat/operational stress reaction evaluation. The Army and 
Air Force servicemembers had the highest rates of referral--23.0 
percent and 22.6 percent, respectively (see fig. 3). Although the 
Marines had the second largest percentage of servicemembers who 
provided three or four positive responses to the PTSD screening 
questions (3.8 percent), the Marines had the lowest referral rate (15.3 
percent) among the military service branches.

Figure 3: Referral Rates for Mental Health or Combat/Operational Stress 
Reaction Evaluation for OEF/OIF Servicemembers Who May Have Been at 
Risk for Developing PTSD, by Military Service Branch:

[See PDF for image] 

GAO: GAO analysis of DOD data. 

Note: This figure is based on the number of OEF/OIF servicemembers in 
our review who were deployed from October 1, 2001 through September 30, 
2004 and answered positively to three or four of the four PTSD 
screening questions on the DD 2796.

[End of figure]

DOD Cannot Provide Reasonable Assurance That OEF/OIF Servicemembers Who 
Need Mental Health Referrals Receive Them:

During the post-deployment process, DOD relies on the clinical judgment 
of its health care providers to determine which servicemembers should 
receive referrals for further mental health or combat/operational 
stress reaction evaluations. Following a servicemember's completion of 
the DD 2796, DOD requires its health care providers to interview all 
servicemembers. For these interviews, DOD's guidance for health care 
providers using the DD 2796 advises the providers to "pay particular 
attention to" servicemembers who provide positive responses to three or 
four of the four PTSD screening questions on their DD 2796s. According 
to DOD officials, not all of the servicemembers with three or four 
positive responses to the PTSD screening questions need referrals for 
further evaluations. Instead, DOD instructs health care providers to 
interview the servicemembers, review their medical records for past 
medical history and, based on this information, determine which 
servicemembers need referrals.[Footnote 26]

DOD expects its health care providers to exercise their clinical 
judgment in determining which servicemembers need referrals. DOD's 
guidance suggests that its health care providers consider, when 
exercising their clinical judgment, factors such as servicemembers' 
behavior, reasons for positive responses to any of the four PTSD 
screening questions on the DD 2796, and answers to other questions on 
the DD 2796. However, DOD has not identified whether these factors or 
other factors are used by its health care providers in making referral 
decisions. As a result, DOD cannot provide reasonable assurance that 
all OEF/OIF servicemembers who need referrals for further mental health 
or combat/operational stress reaction evaluations receive such 
referrals.

DOD has a quality assurance program that, in part, monitors the 
completion of the DD 2796, but the program is not designed to evaluate 
health care providers' decisions to issue referrals for mental health 
and combat/operational stress reaction evaluations. As part of its 
review, the Deployment Health Quality Assurance Program requires DOD's 
military service branches to collect information from medical records 
on, among other things, the percentage of DD 2796s completed in each 
military service branch and whether referrals were made. However, the 
quality assurance program does not require the military service 
branches to link responses on the four PTSD screening questions to the 
likelihood of receiving a referral. Therefore, the program could not 
provide information on why some OEF/OIF servicemembers with three or 
more positive responses to the PTSD screening questions received 
referrals while others did not.

DOD is conducting a study that is intended to evaluate the outcomes and 
quality of care provided by DOD's health care system. This study is 
part of DOD's National Quality Management Program. The study is 
intended to track those who responded positively to three or four PTSD 
screening questions on the DD 2796 and used the form as well to 
indicate they had other mental health issues, such as feeling 
depressed.[Footnote 27] One of the objectives of the study is to 
determine the percentage of those who were referred for further mental 
health or combat/operational stress reaction evaluations, based on 
their responses on the DD 2796.

Conclusions:

Many OEF/OIF servicemembers have engaged in the type of intense and 
prolonged combat that research has shown to be highly correlated with 
the risk for developing PTSD. During DOD's post-deployment process, DOD 
relies on its health care providers to assess the likelihood of OEF/OIF 
servicemembers being at risk for developing PTSD. As part of this 
effort, providers use their clinical judgment to identify those 
servicemembers whose mental health needs further evaluation.

Because DOD entrusts its health care providers with screening OEF/OIF 
servicemembers to assess their risk for developing PTSD, the department 
should have confidence that these providers are issuing referrals to 
all servicemembers who need them. Variation among DOD's military 
service branches in the frequency with which their providers issued 
referrals to OEF/OIF servicemembers with identical results from the 
screening questionnaire suggests the need for more information about 
the decision to issue referrals. Knowing the factors upon which DOD 
health care providers based their clinical judgments in issuing 
referrals could help explain variation in the referral rates and allow 
DOD to provide reasonable assurance that such judgments are being 
exercised appropriately. However, DOD has not identified the factors 
its health care providers used in determining why some servicemembers 
received referrals while other servicemembers with the same number of 
positive responses to the four PTSD screening questions did not.

Recommendation for Executive Action:

We recommend that the Secretary of Defense direct the Assistant 
Secretary of Defense for Health Affairs to identify the factors that 
DOD health care providers use in issuing referrals for further mental 
health or combat/operational stress reaction evaluations to explain 
provider variation in issuing referrals.

Agency Comments and Our Evaluation:

In commenting on a draft of this report, DOD concurred with our 
conclusions and recommendation. DOD's comments are reprinted in 
appendix II. DOD noted that it plans a systematic evaluation of 
referral patterns for the post-deployment health assessment through the 
National Quality Management Program and that an ongoing validation 
study of the post-deployment health assessment and the post-deployment 
health reassessment is projected for completion in October 2006. 
Despite its planned implementation of our recommendation to identify 
the factors that its health care providers use to make referrals, DOD 
disagreed with our finding that it has not provided reasonable 
assurance that OEF/OIF servicemembers receive referrals for further 
mental health evaluations when needed.

To support its position, DOD identified several factors in its comments 
that it stated may explain why some OEF/OIF servicemembers with the 
same number of positive responses to the four PTSD screening questions 
are referred while others are not. For example, DOD health care 
providers may employ watchful waiting instead of a referral for a 
further evaluation for servicemembers with three or four positive 
responses to the PTSD screening questions. Additionally, DOD stated in 
its technical comments that providers may use the referral category of 
"other" rather than place a mental health label on a referral by 
checking the further evaluation categories of mental health or combat/ 
operational stress reaction. DOD also stated in its technical comments 
that health care providers may not place equal value on the four PTSD 
screening questions and may only refer servicemembers who indicate 
positive responses to certain questions. Although DOD identified 
several factors that may explain why some servicemembers are referred 
while others are not, DOD did not provide data on the extent to which 
these factors affect health care providers' clinical judgments on 
whether to refer OEF/OIF servicemembers with three or four positive 
responses to the four PTSD screening questions. Until DOD has better 
information on how its health care providers use these factors when 
applying their clinical judgment, DOD cannot reasonably assure that 
servicemembers who need referrals receive them. DOD's plans to develop 
this information should lead to reasonable assurance that 
servicemembers who need referrals receive them.

DOD also described in its written comments its philosophy of clinical 
intervention for combat and operational stress reactions that could 
lead to PTSD. Central to its approach is the belief that attempting to 
diagnose normal reactions to combat and assigning too much significance 
to symptoms when not warranted may do more harm to a servicemember than 
good. While we agree that PTSD is a complex disorder that requires DOD 
health care providers to make difficult clinical decisions, issues 
relating to diagnosis and treatment are not germane to the referral 
issues we reviewed and were beyond the scope of our work. Instead, our 
work focused on the referral of servicemembers who may be at risk for 
PTSD because they answered three or four of the four PTSD screening 
questions positively, not whether they should be diagnosed and treated.

Further, DOD implied that our position is that servicemembers must have 
a referral to access mental health care, but there are other avenues of 
care for servicemembers where a referral is not needed. We do not 
assume that servicemembers must have a referral in order to access 
these health care services. Rather, in this report we identify the 
health care services available to OEF/OIF servicemembers who have been 
discharged or released from active duty and focus on how decisions are 
made by DOD providers regarding referrals for servicemembers who may be 
at risk for PTSD. DOD also provided technical comments, which we 
incorporated as appropriate.

VA provided comments on a draft of this report by e-mail. VA concurred 
with the facts in the draft report that related to VA.

We are sending copies of this report to the Secretary of Veterans 
Affairs; the Secretary of Defense; the Secretaries of the Army, the Air 
Force, and the Navy; the Commandant of the Marine Corps; and 
appropriate congressional committees. We will also provide copies to 
others upon request. In addition, the report is available at no charge 
on the GAO Web site at [Hyperlink, http://www.gao.gov].

If you or your staff members have any questions regarding this report, 
please contact me at (202) 512-7101 or bascettac@gao.gov. Contact 
points for our Offices of Congressional Relations and Public Affairs 
may be found on the last page of this report. GAO staff members who 
made major contributions to this report are listed in appendix III. 

Signed By:

Cynthia A. Bascetta: 
Director: 
Health Care:

List of Committees:

The Honorable John Warner: 
Chairman: 
The Honorable Carl Levin: 
Ranking Minority Member: 
Committee on Armed Services: 
United States Senate:

The Honorable Larry E. Craig: 
Chairman: 
The Honorable Daniel K. Akaka: 
Ranking Minority Member: 
Committee on Veterans' Affairs: 
United States Senate:

The Honorable Kay Bailey Hutchison: 
Chairman: 
The Honorable Dianne Feinstein: 
Ranking Minority Member: 
Subcommittee on Military Construction, Veterans' Affairs, and Related 
Agencies: 
Committee on Appropriations: 
United States Senate:

The Honorable Ted Stevens: 
Chairman: 
The Honorable Daniel K. Inouye: 
Ranking Minority Member: 
Subcommittee on Defense: 
Committee on Appropriations: 
United States Senate:

The Honorable Duncan L. Hunter: 
Chairman: 
The Honorable Ike Skelton: 
Ranking Minority Member: 
Committee on Armed Services: 
House of Representatives:

The Honorable Steve Buyer: 
Chairman: 
The Honorable Lane Evans: 
Ranking Minority Member: 
Committee on Veterans' Affairs: 
House of Representatives:

The Honorable James T. Walsh: 
Chairman: 
The Honorable Chet Edwards: 
Ranking Minority Member: 
Subcommittee on Military Quality of Life and Veterans Affairs and 
Related Agencies: 
Committee on Appropriations: 
House of Representatives:

The Honorable C. W. Bill Young: 
Chairman: 
The Honorable John P. Murtha: 
Ranking Minority Member: 
Subcommittee on Defense: 
Committee on Appropriations: 
House of Representatives:

[End of section]

Appendix I: Scope and Methodology:

To describe the mental health benefits available to veterans who served 
in military conflicts in Afghanistan and Iraq--Operation Enduring 
Freedom (OEF) and Operation Iraqi Freedom (OIF), we reviewed the 
Department of Defense (DOD) health care benefits and Department of 
Veterans Affairs (VA) mental health services available for these 
veterans. We reviewed the policies, procedures, and guidance issued by 
DOD's TRICARE and VA's health care systems and interviewed DOD and VA 
officials about the benefits and services available for post-traumatic 
stress disorder (PTSD). We defined an OEF/OIF veteran as a 
servicemember who was deployed in support of OEF or OIF from October 1, 
2001, through September 30, 2004, and had since been discharged or 
released from active duty status. We classified National Guard and 
Reserve members as veterans if they had been released from active duty 
status after their deployment in support of OEF/OIF.

We interviewed officials in DOD's Office of Health Affairs about health 
care benefits, including length of coverage, offered to OEF/OIF 
veterans who are members of the National Guard and Reserves and have 
left active duty status. We attended an Air Force Reserve and National 
Guard training seminar in Atlanta, Georgia, for mental health 
providers, social workers, and clergy to obtain information on PTSD 
mental health services offered to National Guard and Reserve members 
returning from deployment. To obtain information on DOD's Military 
OneSource, we interviewed DOD officials and the manager of the Military 
OneSource contract about the services available and the procedures for 
referring OEF/OIF veterans for mental health services. We interviewed 
representatives from the Army, Air Force, Marines, and Navy about their 
use of Military OneSource.

We interviewed VA headquarters officials, including mental health 
experts, to obtain information about VA's specialized PTSD services. We 
reviewed applicable statutes and policies and interviewed officials to 
identify the services offered by VA's Vet Centers for OEF/OIF veterans. 
In addition, to inform our understanding of the issues related to DOD's 
post-deployment process, we interviewed veterans' service organization 
representatives from The American Legion, Disabled American Veterans, 
and Vietnam Veterans of America.

To determine the number of OEF/OIF servicemembers who may be at risk 
for developing PTSD and the number of these servicemembers who were 
referred for further mental health evaluations, we analyzed 
computerized DOD data. We worked with officials at DOD's Defense 
Manpower Data Center to identify the population of OEF/OIF 
servicemembers from the Contingency Tracking System deployment and 
activation data files. We then worked with officials from DOD's Army 
Medical Surveillance Activity (AMSA) to identify which OEF/OIF 
servicemembers had responded positively to one, two, three, or four of 
the four PTSD screening questions on the DD 2796 questionnaire. AMSA 
maintains a database of all servicemembers' completed DD 2796s. The DD 
2796 is a questionnaire that DOD uses to identify servicemembers who 
may be at risk for developing PTSD after their deployment and contains 
the four PTSD screening questions that may identify these 
servicemembers. The four questions are:

Have you ever had any experience that was so frightening, horrible, or 
upsetting that, in the past month, you:

* have had any nightmares about it or thought about it when you did not 
want to?

* tried hard not to think about it or went out of your way to avoid 
situations that remind you of it?

* were constantly on guard, watchful, or easily startled?

* felt numb or detached from others, activities, or your surroundings?

Because a servicemember may have been deployed more than once, some 
servicemembers' records at AMSA included more than one completed DD 
2796. We obtained information from the DD 2796 that was completed 
following the servicemembers' most recent deployment in support of OEF/ 
OIF. We removed from our review servicemembers who either did not have 
a DD 2796 on file at AMSA or completed a DD 2796 prior to DOD adding 
the four PTSD screening questions to the questionnaire in April 2003. 
In all, we reviewed DD 2796's completed by 178,664 OEF/OIF 
servicemembers. To determine the criteria we would use to identify OEF/ 
OIF servicemembers who may have been at risk for developing PTSD, we 
reviewed the clinical practice guideline for PTSD developed jointly by 
VA and DOD, which states that three or more positive responses to the 
four questions indicate a risk for developing PTSD.[Footnote 28] 
Further, we reviewed a retrospective study that found that those 
individuals who provided three or four positive responses to the four 
PTSD screening questions were highly likely to have been previously 
given a diagnosis of PTSD prior to the screening.[Footnote 29] To 
determine the number of OEF/OIF servicemembers who may be at risk for 
developing PTSD and were referred for further mental health 
evaluations, we asked AMSA to identify OEF/OIF servicemembers whose DD 
2796 forms indicated that they were referred for further mental health 
or combat/operational stress reaction evaluations by a DOD health care 
provider.

To examine whether DOD has reasonable assurance that OEF/OIF veterans 
who needed further mental health evaluations received referrals, we 
reviewed DOD's policies and guidance, as well as policies and guidance 
for each of the military service branches (Army, Navy, Air Force, and 
Marines). Based on electronic testing of logical elements and our 
previous work on the completeness and accuracy of AMSA's centralized 
database, we concluded that the data were sufficiently reliable for the 
purposes of this report.[Footnote 30]

NDAA also directed us to determine the number of OEF/OIF veterans who, 
because of their referrals, accessed DOD or VA health care services to 
obtain a further mental health or combat/operational stress reaction 
evaluation. However, as discussed with the committees of jurisdiction, 
we could not use data from OEF/OIF veterans' DD 2796 forms to determine 
if veterans accessed DOD or VA health care services because of their 
mental health referrals. DOD officials explained that the referral 
checked on the DD 2796 cannot be linked to a subsequent health care 
visit using DOD computerized data. Therefore, we could not determine 
how many OEF/OIF veterans accessed DOD or VA health care services for 
further mental health evaluations because of their referrals. We 
conducted our work from December 2004 through April 2006 in accordance 
with generally accepted government auditing standards.

[End of section]

Appendix II: Comments from the Department of Defense:

[End of section]

Appendix III: GAO Contact and Staff Acknowledgments: 

The Assistant Secretary Of Defense:
1200 Defense Pentagon: 
Washington, DC 20301-1200: 

Health Affairs:

Ms. Cynthia Bascetta:
Director: 
Health Care - Veterans' Health and Benefits Issues:
U.S. Government Accountability Office: 
Washington, DC 20548:

Dear Ms. Bascetta:

This is the Department of Defense (DoD) response to the Government 
Accountability Office (GAO) Draft Report, "Post-Traumatic Stress 
Disorder: DoD Needs to identify the Factors Its Providers Use to Make 
Mental Health Evaluation Referrals for Servicemembers," dated March 20, 
2006, GAO Code 290437/GAO-06-397.

Thank you for the opportunity to review your draft report. We commend 
the GAO team for their diligence in addressing a complex issue and the 
associated implications in two complex healthcare systems. We also wish 
to thank the Congressional Committees for their ongoing interest in the 
mental health of our military personnel.

Overall, I concur with the draft report's conclusions and 
recommendations. However, I nonconcur with GAO's premise that 
reasonable assurance is not available to support that Operation Iraqi 
Freedom/Operation Enduring Freedom servicemembers receive referrals 
when needed.

Specific comments are provided addressing various aspects of the 
report. A response to the recommendations is provided with technical 
comments for your consideration to help strengthen the report and make 
it more valuable to the Department.

Please direct any questions to my points of contact on this matter, Dr. 
Michael Kilpatrick (functional) at (703) 578-8510 and Mr. Gunther J. 
Zimmerman (Audit Liaison) at (703) 681-3492, extension 4065. 

Signed By:

William Winkenwerder, Jr., MD:

Enclosures: As stated:

Gao Draft Report - Dated March 20, 2006 (GAO CODE - 290437/GAO-06-397):

"Post-Traumatic Stress Disorder: DoD Needs to Identify the Factors Its 
Providers Use to Make Mental Health Evaluation Referrals for 
Servicemembers"

Department Of Defense Comments:

Overall Comments:

While DoD concurs with the recommendation to clearly identify the 
factors actually used by clinicians in making a referral decision, DoD 
non-concurs with the premise that reasonable assurance is not available 
to support the position that OIF/OEF servicemembers receive referrals 
when needed. DoD recommends that this statement be eliminated from the 
report, based on information in the specific comments above and in 
addition to the general comments that follow. Occupationally related 
health decisions are made by clinicians who are familiar with the 
occupational demands. Military deployments represent occupationally 
unique situations. Decisions are made based on knowledge of clinical 
concerns as well as occupational environment. All relevant factors need 
to be considered in the assessment and referral process.

Combat and Operational Stress Reactions (COSR), philosophy of 
intervention. Decades of experience have resulted in the currently 
accepted practice of rest and restoration as a method of intervention 
for COSR. In past conflicts, providers and line personnel discovered 
that it is very common to have a negative reaction to the stress and 
trauma of combat; it is just a part of human nature. If these normal 
reactions to an abnormal situation are immediately medicalized, the 
individual takes on a patient role and the symptoms that may normally 
dissipate with rest and restoration tend to persist. Therefore, the 
recommended action is to expect the symptoms to remit naturally and to 
offer social support through unit cohesion along with a few nights of 
restful sleep and restorative nutrition in a safe environment. This 
philosophy of treatment has served the military well in the more recent 
conflicts. Symptoms associated with COSR, adjustment difficulties or 
bereavement may spontaneously remit once the individual assimilates or 
processes the event, reduces fatigue and replenishes natural defensive 
processes. Over-pathologizing symptoms in the interim may do more harm 
than good. Clearly, if the symptoms impair an individual's ability to 
function in this demanding environment or if they do not remit after a 
period of rest, clinical intervention is certainly warranted. There is 
no reason to expose an individual to pain and suffering when medical 
care could remediate the problem. However, it is also not prudent to 
assume that a medical treatment is immediately warranted.

Timing of assessment. The PDHA is conducted immediately at the end of 
the deployment; most often before the servicemember leaves the theater 
of operation. At this point in time, servicemembers still feel as if 
they are in the combat environment, even if the threat is reduced. 
Symptoms associated with PTSD, such as hyperarousal, emotional numbing, 
trouble sleeping, compartmentalizing or trying to avoid thinking about 
the combat experience, nightmares and similar thoughts and feelings are 
not uncommon and may even be adaptive in the high-threat combat 
environment. To label those symptoms as denoting a disorder may not be 
appropriate at this time.

Symptoms that present clinically significant distress or functional 
impairment in the first few days after a traumatic event are generally 
diagnosed as Acute Stress Disorder. Only when symptoms persist for more 
than 30 days would PTSD be considered. While it is conceivable that a 
highly traumatic event could occur early in the deployment that 
generated symptoms, it is less likely that the nature of the symptoms 
could be discerned until after the individual left the environment. The 
timing of the assessment prior to arrival home does not lend itself to 
clinical diagnosis of PTSD.

Potential risks associated with false positives. No medical 
intervention is without risks. The general premise of medical practice 
is that the benefits should outweigh the risks. In terms of PTSD, the 
risks are associated with potentially issuing a diagnosis of PTSD for 
an individual who has no diagnosable mental health disorder. 
Individuals who experience a diagnosable mental health disorder are 
generally relieved to have a name to put to their symptoms. However, 
those without a disorder often respond with some anxiety and a sense of 
foreboding about what this diagnosis will mean to their lives and their 
military careers. While, for the most part, it is a false perception 
that mental health treatment will in itself ruin a military career, it 
is still a widely held perception that generates distress in itself, in 
addition to the distress associated with any symptoms the individual 
may have. In making a clinical determination associated with a mental 
health referral, the risks of false positive must always be weighed 
against the accuracy of clinical judgment. Watchful waiting may be more 
appropriate in situations in which the clinician is not sure about a 
diagnosis or the severity of the symptoms.

Watchful waiting. The concept of watchful waiting is common in medical 
practice. Symptoms may present for any number of reasons that do not 
reach clinical significance or cannot be readily diagnosed. Frequently, 
individuals are provided the advice that they should pay attention to 
the symptoms and return if they do not dissipate or if they get worse. 
Watchful waiting is a clinically relevant position to take in the case 
of PTSD-related symptoms at the point in time at which the PDHA 
assessment is conducted.

PDHA is not the only avenue to care. The position espoused by GAO in 
their report hinges on the concern that individuals who need mental 
health care may not get a referral, and therefore, may not get access 
to care they need to treat their condition. However, the PDHA is not 
the only avenue to care available to the veteran or servicemember. As 
the report indicates, numerous avenues to care are offered to active 
duty, Reserve, and separated servicemembers both from DoD and from the 
VA. The absence of a referral does not preclude access to care.

Education and Clinical Health Risk Communication. PDHRA is a process 
that includes a mandatory medical threat debrief and benefits briefing 
and handouts. The medical threat debriefing includes signs and symptoms 
that may be associated with PTSD or other common deployment-related 
mental health conditions. It is not the case that PTSD is the primary 
or the only deployment-related mental health concern. Depression is 
equally common, equally distressing and clinically treatable. The 
educational process includes information on how to recognize mental 
health problems and where to go for help if these concerns arise at any 
time post-deployment. Since signs and symptoms may not immediately 
present, and given the fact that servicemembers may be reluctant to 
recognize or report these symptoms during the PDHA period, education is 
essential to alert them to things to watch for and what to do when they 
get back home. Based on recent research (Hoge, et al, JAMA, 2006), a 
high percentage of land combat troops, both soldiers and Marines, self- 
refer to mental health care during the first two months after they 
return home. This information provides a sense of assurance that our 
servicemembers are listening to the education our clinicians provide 
and are seeking care through the many avenues available to them rather 
than relying solely on a referral during the PDHA process.

Recommendation: The GAO recommended that the Secretary of Defense 
direct the Assistant Secretary of Defense for Health Affairs to 
identify the factors that DoD health care providers use in issuing 
referrals for further mental health or combat/operational stress 
evaluations in order to explain provider variation in issuing 
referrals. (Page 24/GAO Draft Report):

Dod Response: Concur. The Department generally concurs with this 
recommendation, but notes that a systematic evaluation of referral 
patterns is planned for the Post Deployment Health Assessment (PDHA) 
through the National Quality Management Program (NQMP). In addition, a 
thorough program evaluation, including a validation of the PDHA and 
PDHRA (Post-Deployment Health Reassessment) procedures, is already in 
progress, which will include all the mental health scales and provider 
referrals arising from use of the information in those scales in their 
clinical decision-making. The validation study is projected for 
completion in October 2006.

GAO Contact:

Cynthia A. Bascetta at (202) 512-7101 or bascettac@gao.gov:

Acknowledgments:

In addition to the contact named above, key contributors to this report 
were Marcia A. Mann, Assistant Director; Mary Ann Curran, Martha A. 
Fisher, Krister Friday, Lori Fritz, and Martha Kelly.

FOOTNOTES

[1] OEF/OIF servicemembers include National Guard and Reserve members. 

[2] Hoge, Charles W., MD et al., "Combat Duty in Iraq and Afghanistan, 
Mental Health Problems, and Barriers to Care," The New England Journal 
of Medicine, 351 (2004): 13-22.

[3] Servicemembers who are deployed for 30 or more continuous days to 
locations without permanent DOD treatment facilities are required to 
complete a post-deployment screening questionnaire.

[4] DOD's referrals are used to document DOD's assessment that 
servicemembers are in need of further mental health evaluations, 
including those for PTSD. In this report, we refer to such referrals as 
issued to or received by servicemembers.

[5] In this report, we use the term discharged to describe 
servicemembers who have completed their active duty service commitment 
and have not made a future service commitment. We use the term released 
to describe Reserve and National Guard servicemembers who have 
completed their active duty service commitment, made a future 
commitment to active duty, and therefore can be recalled to active 
duty. 

[6] Pub. L. No. 108-375, § 598(b)(8), (9), 118 Stat. 1811, 1939-41 
(2004).

[7] We did not include military retirees in our analysis because the 
mandate specifies that we include servicemembers who have been 
discharged or released from active duty, not retired servicemembers. 
According to a DOD official, DOD does not include retirees in its 
definition of discharged servicemembers or servicemembers who have been 
released from active duty status. 

[8] Department of Defense, Department of Defense Post-Deployment Health 
Assessment DD-2796 (Washington, D.C.: April 2003).

[9] Department of Veterans Affairs and Department of Defense, Veterans 
Health Administration/DOD Clinical Practice Guideline for Management of 
Post-Traumatic Stress (Washington, D.C.: January 2004). 

[10] Prins, Annabel et al. "The Primary Care PTSD Screen (PC-PTSD): 
Development and Operating Characteristics," Primary Care Psychiatry, 9 
(2004): 9-14. This study was conducted using VA primary care patients.

[11] Because the symptoms of PTSD may be delayed, in October 2005, DOD 
began offering a post-deployment health reassessment for individuals 90 
to 180 days after returning from deployment as part of OEF/OIF. These 
individuals could be servicemembers or veterans. The reassessment 
includes the same four PTSD screening questions that are found on the 
DD 2796.

[12] The questionnaire is used to satisfy the requirement for post- 
deployment mental health assessments established by the National 
Defense Authorization Act for Fiscal Year 1998. Pub. L. No. 105-85, § 
765(a)(1), 111 Stat. 1629, 1826, codified at 10 U.S.C. § 1074f(b) 
(2000).

[13] Readjustment counseling is intended to help veterans resolve war- 
related psychological difficulties and achieve a successful postwar 
readjustment to civilian life. 

[14] We recommended in 2003 that DOD establish a quality assurance 
program. See GAO, Defense Health Care: Quality Assurance Process Needed 
to Improve Force Health Protection and Surveillance, GAO-03-
1041(Washington, D.C.: Sept. 19, 2003).

[15] The Army has lead responsibility for DOD's medical surveillance 
and operates a centralized data repository.

[16] Office of the Assistant Secretary of Defense, DOD Deployment 
Health Quality Assurance Program 2004 Annual Report, (Washington, D.C.: 
2005).

[17] The Ronald W. Reagan National Defense Authorization Act for Fiscal 
Year 2005, Pub. L. No. 108-375, § 706(a)(1), 118 Stat. 1811, 1983 
(2004), signed into law on October 28, 2004, extended the health care 
benefits offered under TAMP from 120 days to 180 days to help 
servicemembers with the transition from military service to civilian 
status. Dependents may also be included in these benefits. OEF/OIF 
veterans who are eligible for TAMP benefits are those who have 
involuntarily separated from active duty; separated from active duty 
after being involuntarily retained in support of a contingency 
operation; separated from active duty following a voluntary agreement 
to stay on active duty for less than 1 year in support of a contingency 
operation; and National Guard and Reserve members who have separated 
from active duty after being called up or ordered in support of a 
contingency operation and served for more than 30 days. 

[18] OEF/OIF veterans who have ended TAMP coverage or who are not 
eligible for TAMP benefits may be eligible to enroll in CHCBP if they 
are no longer eligible for TRICARE benefits or other benefits under the 
military health care system. To be eligible, OEF/OIF veterans must have 
been discharged or released from active duty, either voluntarily or 
involuntarily, under other than adverse conditions and have been 
entitled to coverage under a military health care plan immediately 
prior to discharge or release. OEF/OIF veterans must enroll in CHCBP 
within 60 days after separation from active duty or loss of eligibility 
for military health care benefits.

[19] The National Defense Authorization Act for Fiscal Year 2005, Pub. 
L. No. 108-375, § 701, 118 Stat. 1980. Under TRS, these veterans must 
have been called or ordered to active duty for more than 30 consecutive 
days and have served continuously in active duty for 90 or more days 
under those orders. OEF/OIF Reserve and National Guard veterans can 
purchase TRICARE coverage for themselves and their dependents for a 
period of either 1 year for each consecutive period of 90 days of 
active duty they served, or the number of full years for which the 
individual agrees to continue service, whichever is less. 

[20] Active duty servicemembers and their dependents are also eligible, 
as well as members of the National Guard and Reserves who have been 
released from active duty. These groups can access Military OneSource 
beyond 180 days. 

[21] See 38 U.S.C. § 1710(e)(1)(D), 1712A(a)(2)(B) (2000), and VHA 
Directive 2004-017, Establishing Combat Veteran Eligibility. 

[22] OEF/OIF veterans can receive VA health care services, including 
mental health services, without being subject to copayments or other 
cost for 2 years after discharge or release from active duty. After the 
2-year benefit ends, some OEF/OIF veterans without a service-connected 
disability or with higher incomes may be subject to a copayment to 
obtain VA health care services. VA assigns veterans who apply for 
hospital and medical services to one of eight priority groups. Priority 
is generally determined by a veteran's degree of service-connected or 
other disability or on financial need. VA gives veterans in Priority 
Group 1 (50 percent or higher service-connected disabled) the highest 
preference for services and gives lowest preference to those in 
Priority Group 8 (no disability and with income exceeding VA 
guidelines). 

[23] Hoge, Charles W., MD et al. "Mental Health Problems, Use of Mental 
Health Services, and Attrition From Military Service After Returning 
From Deployment to Iraq or Afghanistan," Journal of the American 
Medical Association, 295 (2006): 1023-1032. While this study reviewed 
screening for PTSD and referrals in addition to other mental health 
conditions, the results cannot be compared to ours because this study 
covered active duty servicemembers. 

[24] Friedman, Mathew J., "Veterans' Mental Health in the Wake of War," 
The New England Journal of Medicine, 352 (2005): 1287-1290. 

[25] DOD officials have stated that some OEF/OIF servicemembers may be 
reluctant to accurately report symptoms of PTSD because they could be 
delayed in returning home after deployment. 

[26] The DD 2796 is to be placed in the servicemember's medical record 
and a copy sent to AMSA. AMSA is DOD's centralized repository for DD 
2796 information from all of the military service branches. It provides 
ongoing and special analyses and reports for policy makers, medical 
planners, and researchers.

[27] In addition to the four PTSD screening questions, the DD 2796 
contains other questions related to mental health, such as asking "Over 
the last 2 weeks how often have you been bothered by any of the 
following problems--feeling depressed or having thoughts of harming 
yourself?" 

[28] VA and DOD, Veterans Health Administration/DOD Clinical Practice 
Guideline for Management of Post-Traumatic Stress Disorders.

[29] Prins, Annabel et al. "The Primary Care PTSD Screen (PC-PTSD): 
Development and Operating Characteristics."

[30] GAO-03-1041.

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