VA and Defense Health Care: More Information Needed to Determine 
If VA Can Meet an Increase in Demand for Post-Traumatic Stress	 
Disorder Services (20-SEP-04, GAO-04-1069).			 
                                                                 
Post-traumatic stress disorder (PTSD) is caused by an extremely  
stressful event and can develop after the threat of death or	 
serious injury as in military combat. Experts predict that about 
15 percent of servicemembers serving in Iraq and Afghanistan will
develop PTSD. Efforts by VA to inform new veterans, including	 
Reserve and National Guard members, about the expanded		 
availability of VA health care services could result in an	 
increased demand for VA PTSD services. GAO identified the	 
approaches DOD uses to identify servicemembers at risk for PTSD  
and examined if VA has the information it needs to determine	 
whether it can meet an increase in demand for PTSD services. GAO 
visited military bases and VA facilities, reviewed relevant	 
documents, and interviewed DOD and VA officials to determine how 
DOD identifies servicemembers at risk for PTSD, and what	 
information VA has to estimate demand for VA PTSD services.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-1069					        
    ACCNO:   A12611						        
  TITLE:     VA and Defense Health Care: More Information Needed to   
Determine If VA Can Meet an Increase in Demand for Post-Traumatic
Stress Disorder Services					 
     DATE:   09/20/2004 
  SUBJECT:   Health care facilities				 
	     Health care programs				 
	     Health care services				 
	     Mental care facilities				 
	     Mental health care services			 
	     Mental illnesses					 
	     Rehabilitation counseling				 
	     Veterans						 
	     Warfare						 
	     Afghanistan					 
	     Iraq						 

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GAO-04-1069

United States Government Accountability Office

  GAO	Report to the Ranking Democratic Member, Committee on Veterans' Affairs,
                            House of Representatives

September 2004

VA AND DEFENSE HEALTH CARE

 More Information Needed to Determine If VA Can Meet an Increase in Demand for
                    Post-Traumatic Stress Disorder Services

                                       a

GAO-04-1069

[IMG]

September 2004

VA AND DEFENSE HEALTH CARE

More Information Needed to Determine If VA Can Meet an Increase in Demand for
Post-Traumatic Stress Disorder Services

                                 What GAO Found

DOD uses two approaches to identify servicemembers at risk for PTSD: the
combat stress control program and the post-deployment health assessment
questionnaire. The combat stress control program trains servicemembers to
recognize the early onset of combat stress, which can lead to PTSD.
Symptoms of combat stress and PTSD include insomnia, nightmares, and
difficulties coping with relationships. To assist servicemembers in the
combat theater, teams of DOD mental health professionals travel to units
to reinforce the servicemembers' knowledge of combat stress symptoms and
to help identify those who may be at risk for combat stress and PTSD. DOD
also uses the post-deployment health assessment questionnaire to identify
physical ailments and mental health issues commonly associated with
deployments, including PTSD. The questionnaire includes the following four
screening questions that VA and DOD mental health experts developed to
identify servicemembers at risk for PTSD:

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

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

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

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

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

VA lacks the information it needs to determine whether it can meet an
increase in demand for VA PTSD services. VA does not have a count of the
total number of veterans currently receiving PTSD services at its medical
facilities and Vet Centers-community-based VA facilities that offer trauma
and readjustment counseling. Without this information, VA cannot estimate
the number of new veterans its medical facilities and Vet Centers could
treat for PTSD. VA has two reports on the number of veterans it currently
treats, with each report counting different subsets of veterans receiving
PTSD services. Veterans who are receiving VA PTSD services may be counted
in both reports, one of the reports, or not included in either report. VA
does receive demographic information from DOD, which includes home
addresses of servicemembers that could help VA predict which medical
facilities or Vet Centers servicemembers may access for health care. By
assuming that 15 percent or more of servicemembers who have left active
duty status will develop PTSD, VA could use the home zip codes of
servicemembers to broadly estimate the number of servicemembers who may
need VA PTSD services and identify the VA facilities located closest to
their homes. However, predicting which veterans will seek VA care and at
which facilities is inherently uncertain, particularly given that the
symptoms of PTSD may not appear for years.

                 United States Government Accountability Office

Contents

  Letter

Results In Brief
Background
DOD Uses Two Approaches to Identify Servicemembers At Risk for

PTSD VA Lacks Information Needed to Determine Whether It Can Meet an

Increase in Demand for PTSD Services Conclusions Recommendation for
Executive Action Agency Comments

1 3 4

6

11 16 16 16

Appendixes

Appendix I:

Appendix II:

                                       Appendix III: Appendix IV: Appendix V:

Scope and Methodology

Department of Defense Post-Deployment Health Assessment Questionnaire
DD-2796

Comments from the Department of Veterans Affairs

Comments from the Department of Defense

GAO Contact and Staff Acknowledgments

GAO Contact Acknowledgments 18

20

24

27

28 28 28

Related GAO Products

Figures Figure 1: DOD's Process for "Yes" Responses to PTSD Questions on
DD 2796 10 Figure 2: Veterans Included in VA's Annual Reports 13

Abbreviations

DOD Department of Defense
NEPEC Northeast Program Evaluation Center
OIG Office of Inspector General
PTSD post-traumatic stress disorder
VA Department of Veterans Affairs

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
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copyright holder may be necessary if you wish to reproduce this material
separately.

A

United States Government Accountability Office Washington, D.C. 20548

September 20, 2004

The Honorable Lane Evans Ranking Democratic Member Committee on Veterans'
Affairs House of Representatives

Dear Mr. Evans:

Mental health experts predict that because of the intensity of warfare in
Iraq and Afghanistan 15 percent or more of the servicemembers returning
from these conflicts will develop post-traumatic stress disorder (PTSD).1,
2 This rate approximates the PTSD rate for Vietnam War veterans.3 PTSD,
which is caused by an extremely stressful event, can develop after
military combat and exposure to the threat of death or serious injury.
Symptoms of PTSD, which may appear within months or be delayed for years
after the stressful event, include insomnia, intense anxiety, nightmares
about the event, and difficulties coping with work, family, and social
relationships. Although there is no cure for PTSD, experts believe that
early identification and treatment of PTSD symptoms may lessen the
severity of the condition and improve the overall quality of life for
servicemembers and veterans. If left untreated, PTSD can lead to substance
abuse, severe depression, and suicide.

The Department of Veterans Affairs (VA) has intensified its efforts to
inform new veterans from the Iraq and Afghanistan conflicts about the
health care services-including treatment for PTSD-it offers to eligible
veterans. These efforts, along with expanded availability of VA health
care services for Reserve and National Guard members, could result in an
increased percentage of veterans from Iraq and Afghanistan seeking PTSD
services through VA. Concerns have been raised about whether VA can
provide PTSD services for a new influx of veterans, while at the same time
continuing these services for veterans that VA currently treats for PTSD.

1Servicemembers include active duty members of the Army, Marines, Air
Force, and Navy and members of the Reserves and National Guard.

2Hoge, 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.

3Kulka, R., et.al. Trauma and the Vietnam War Generation: Report of
Findings from the National Vietnam Veterans Readjustment Study. (New York:
1990).

You asked that we review the Department of Defense's (DOD) efforts to
identify servicemembers who have served in Iraq and Afghanistan and are at
risk for PTSD, and VA's efforts to ensure that PTSD services are available
for all veterans. Specifically, we identified the approaches DOD uses to
identify servicemembers who are at risk for PTSD. We also examined if VA
has the information it needs to determine whether it can meet an increase
in demand for VA PTSD services.

To determine the approaches DOD uses to identify servicemembers who are at
risk for PTSD, we reviewed documents, interviewed DOD officials, and
visited a military installation for each of DOD's uniform services, some
of which had large numbers of servicemembers returning from Iraq and
Afghanistan. We have reviewed how well DOD's uniform services implemented
these approaches in previous work and did not address that issue in this
review.4 To determine whether VA has the information it needs to estimate
the future demand for VA PTSD services, we interviewed VA headquarters and
facility officials to discuss the number of veterans receiving treatment
for PTSD and future demand for these services in areas of the country
where large numbers of servicemembers were returning from Iraq and
Afghanistan. To obtain additional information on identifying and treating
veterans with PTSD, we interviewed VA's PTSD experts at the National
Center for PTSD.5 We reviewed VA's annual capacity reports, which include
information on the number of seriously mentally ill veterans receiving
PTSD services. We also reviewed the findings of the VA Office of Inspector
General (OIG) who is responsible for reporting to Congress on the accuracy
of VA's capacity reports. We did not include data from VA's annual
capacity reports because the OIG found that the data were not sufficiently
reliable. We also interviewed VA headquarters and facility officials and
DOD officials to determine what information they share about returning
servicemembers. For a complete description of our scope and

4Previous GAO reports have addressed DOD's compliance with screening
requirements for returning servicemembers deployed outside of the U.S.:
GAO, Defense Health Care: Quality Assurance Process Needed to Improve
Force Health Protection and Surveillance, GAO-031041 (Washington, D.C.:
Sept. 19, 2003) and Defense Health Care: DOD Needs to Improve Force Health
Protection and Surveillance Processes, GAO-04-158T (Washington, D.C.: Oct.
16, 2003).

5The Veterans' Health Care Act of 1984 required the establishment of the
National Center on PTSD (now known as National Center for PTSD) as a
research and education organization within VA. See Pub. L. No. 98-528, S:
110(c), 98 Stat. 2686, 2692 (codified at 38 U.S.C. S: 1712A note). The
Center advances the clinical care and social welfare of veterans through
research, education, and training clinicians in the causes, diagnosis, and
treatment of PTSD, but does not provide clinical care for veterans.

methodology, see appendix I. Our work was conducted from May through
September 2004 in accordance with generally accepted government auditing
standards.

Results In Brief	DOD uses two approaches to identify servicemembers at
risk for PTSD: the combat stress control program and the post-deployment
health assessment questionnaire. The combat stress control program trains
servicemembers to recognize the early symptoms of combat stress, which can
be a precursor to PTSD. To assist servicemembers in the combat theater,
teams of DOD mental health professionals travel to units to reinforce the
servicemembers' knowledge of combat stress symptoms and to help identify
those who may be at risk for combat stress or PTSD. DOD uses the
post-deployment health assessment questionnaire to identify physical
ailments and mental health issues commonly associated with deployments,
including PTSD. The questionnaire includes four screening questions that
VA and DOD mental health experts developed to identify servicemembers who
may be at risk of developing PTSD. DOD generally requires servicemembers
deployed outside of the United States to complete this questionnaire
within 30 days before leaving a deployment location or within 5 days after
returning to the United States. Completed questionnaires must be reviewed
by a DOD clinical provider, who interviews servicemembers to determine if
further medical evaluation is necessary.

VA lacks the information it needs to determine whether it can meet an
increase in demand for VA PTSD services. VA does not have a count of the
total number of veterans currently receiving PTSD services at its medical
facilities and Vet Centers-community-based VA facilities that offer trauma
and readjustment counseling. Without this information, VA cannot estimate
the number of additional veterans its medical facilities and Vet Centers
could treat for PTSD. A VA official told us that a count of the total
number of veterans with a diagnosis of PTSD who receive VA services at
medical facilities could be obtained from VA's existing database. However,
this database does not include Vet Centers' information because this
information is kept separate from the medical facilities' data. VA has two
reports on the number of veterans it currently treats, with each report
counting different subsets of veterans receiving PTSD services. Veterans
who are receiving VA PTSD services may be counted in both reports, one of
the reports, or not included in either report. For example, veterans
receiving PTSD services exclusively in Vet Centers may not be counted in
either report. On the other hand, VA does have information it can use to

broadly estimate the number of servicemembers who may access VA health
care, including PTSD services. In September 2003, DOD provided VA with
demographic information on servicemembers from the Iraq and Afghanistan
conflicts who have left active duty status and are eligible for VA health
care. The demographic information includes the names and home addresses of
servicemembers. In July 2004, VA provided this information to its
facilities for planning future services for additional veterans. By
assuming that 15 percent or more of returning servicemembers will develop
PTSD, based on the predictions of mental health experts, VA and its
facilities could use DOD's demographic information to broadly estimate
demand for PTSD services. However, predicting which veterans will seek VA
care and at which facilities is inherently uncertain, particularly given
that the symptoms of PTSD may not appear for years. Based on DOD's
demographic information, some VA medical facility officials expressed
concern about their ability to meet an increase in demand for VA PTSD
services from servicemembers returning from Iraq and Afghanistan.

To help VA better estimate the number of additional veterans it could
treat for PTSD and to plan for the future demand for VA PTSD services, we
recommend that VA determine the total number of veterans receiving VA PTSD
services and provide facility-specific information to VA medical
facilities and Vet Centers. VA and DOD commented on a draft of this
report. In its comments VA concurred with our recommendation and
acknowledged that more coordinated efforts are needed to improve its
existing PTSD data. VA stated that it plans to aggregate at the national
level the number of veterans receiving PTSD services at VA medical
facilities and Vet Centers. DOD concurred with the findings and
conclusions in this report and provided technical comments on the report,
which we incorporated as appropriate.

Background	PTSD can develop following exposure to life-threatening events,
natural disasters, terrorist incidents, serious accidents, or violent
personal assaults like rape. PTSD is the most prevalent mental disorder
arising from combat. 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. Symptoms that appear within the first 4 days after
exposure to a stressful event are generally diagnosed as acute stress
reaction or combat stress. If

the symptoms of acute stress reaction or combat stress continue for more
than 1 month, PTSD is diagnosed.

PTSD services are provided in VA medical facilities and VA community
settings. VA medical facilities offer PTSD services as well as other
services, which range from complex specialty care, such as cardiac or
spinal cord injury, to primary care. VA's community settings include more
than 800 community-based outpatient clinics and 206 Vet Centers.
Communitybased outpatient clinics are an extension of VA's medical
facilities and mainly provide primary care services.6 Vet Centers offer
PTSD and family counseling, employment services, and a range of social
services to assist veterans in readjusting from wartime military service
to civilian life. Vet Centers also function as community points of access
for many returning veterans, providing them with information and referrals
to VA medical facilities. Vet Centers were established as entities
separate from VA medical facilities to serve Vietnam veterans, who were
reluctant to access health care provided in a federal building. As a
result, Vet Centers are not located on the campuses of VA medical
facilities.

VA has specialized PTSD programs that are staffed by clinicians who have
concentrated their clinical work in the area of PTSD treatment. VA
specialized PTSD programs are located in 97 VA medical facilities and
provide services on an inpatient and outpatient basis. VA PTSD services
include individual counseling, support groups, and drug therapy and can be
provided in non-specialized clinics, such as general mental health
clinics.

Veterans who served in any conflict after November 11, 1998 are eligible
for VA health care services for any illness, including PTSD services, for
2 years from the date of separation from military service, even if the
condition is not determined to be attributable to military service.7 This
2-year eligibility includes those Reserve and National Guard members who
have left active

6Veterans treated at community-based outpatient clinics are included in
the medical facility's count of veterans treated for PTSD.

7See 38 U.S.C. S: 1710(e)(1)(D); VHA Directive 2004-017, Establishing
Combat Veteran Eligibility. Conflicts are situations in which the
servicemembers are subjected to danger comparable to the danger
encountered in combat with enemy armed forces during a period of war, as
determined by the Secretary of VA. Veterans who served on active duty in
combat operations during a period of war after the Persian Gulf War will
also be eligible for care under section 1710(e)(1)(D). Eligibility under
38 U.S.C. S: 1710(e)(1)(D) does not extend, however, to veterans whose
disabilities are found to have resulted from a cause other than the
service described in the statute.

duty and returned to their units. After 2 years, these veterans will be
subject to the same eligibility rules as other veterans, who generally
have to prove that a medical problem is connected to their military
service or have relatively low incomes. In July 2004, VA reported that so
far 32,684 or 15 percent of veterans who have returned from service in
Iraq or Afghanistan, including Reserve and National Guard members, have
accessed VA for various health care needs.

DOD and VA have formed a Seamless Transition Task Force with the goal of
meeting the needs of servicemembers returning from Iraq and Afghanistan
who will eventually become veterans and may seek health care from VA. To
achieve this goal, DOD and VA plan to improve the sharing of information,
including individual health information, between the two departments in
order to enhance VA's outreach efforts to identify and serve returning
servicemembers, including Reserve and National Guard members, in need of
VA health care services. Since April 2003, VA requires that every
returning servicemember from the Iraq and Afghanistan conflicts who needs
health care services receive priority consideration for VA health care
appointments.8

DOD Uses Two Approaches to Identify Servicemembers At Risk for PTSD

DOD uses two approaches to identify servicemembers who may be at risk of
developing PTSD: the combat stress control program and the postdeployment
health assessment questionnaire. DOD's combat stress control program
identifies servicemembers at risk for PTSD by training all servicemembers
to identify the early onset of combat stress, which if left untreated,
could lead to PTSD. DOD uses the post-deployment health assessment
questionnaire to screen servicemembers for physical ailments and mental
health issues commonly associated with deployments, including PTSD. The
questionnaire contains four screening questions that were developed
jointly by DOD and VA mental health experts to identify servicemembers at
risk for PTSD.

8Servicemembers who served in the Iraq and Afghanistan conflicts do not
have priority over veterans with service-connected disabilities.

DOD Trains Servicemembers to Identify Symptoms That Could Lead to PTSD

DOD's combat stress control program identifies servicemembers at risk for
PTSD by training all servicemembers to identify the early onset of combat
stress symptoms, which if left untreated, could lead to PTSD. The program
is based on the principle of promptly identifying servicemembers with
symptoms of combat stress in a combat theater, with the goal of treating
and returning them to duty.9 This principle is consistent with the views
of PTSD experts, who believe that early identification and treatment of
combat stress symptoms may reduce the risk of PTSD. To assist
servicemembers in the combat theater, teams of DOD mental health
professionals travel to units to reinforce the servicemembers' knowledge
of combat stress symptoms and to help identify those who may be at risk
for combat stress or PTSD. The teams may include psychiatrists,
psychologists, social workers, nurses, mental health technicians, and
chaplains. DOD requires that the effectiveness of the combat stress
control program be monitored on an annual basis.

DOD Uses the Post-Deployment Questionnaire to Identify Servicemembers At
Risk for PTSD

DOD generally uses the post-deployment health assessment questionnaire, DD
2796, to identify servicemembers at risk for PTSD following deployment
outside of the United States.10 (See app. II for a copy of the DD 2796.)
DOD requires certain servicemembers deployed to locations outside of the
United States to complete a DD 2796 within 30 days before leaving a
deployment location or within 5 days after returning to the United
States.11 This applies to all servicemembers returning from a combat
theater, including Reserve and National Guard members.

The DD 2796 is a questionnaire used to determine the presence of any
physical ailments and mental health issues commonly associated with
deployments, any special medications taken during deployment, and

9If a servicemember's symptoms persist, the servicemember is transferred
to a medical facility where specialty care is available.

10The questionnaire is used to satisfy the requirement for post-deployment
mental health assessments established by the National Defense
Authorization Act for Fiscal Year 1998. See Pub. L. No. 105-85, S:
765(a)(1), 111 Stat. 1629, 1826 (adding new section 1074f(b) to title 10,
United States Code).

11Servicemembers who are deployed for 30 or more continuous days to
locations without permanent treatment facilities are required to complete
DD 2796. Servicemembers who are deployed to locations with permanent
treatment facilities are not required to complete the questionnaire
because these locations are not high risk for environmental or
occupational exposures.

possible environmental or occupational exposures. The DD 2796 includes the
following four screening questions that VA and DOD mental health experts
developed to identify servicemembers at risk for PTSD:

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

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

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

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

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

Once completed, the DD 2796 must be initially reviewed by a DOD health
care provider, which could range from a physician to a medic or
corpsman.12 Figure 1 illustrates DOD's process for completion and review
of the DD 2796. The form is then reviewed, completed, and signed by a
health care provider, who can be a physician, physician assistant, nurse
practitioner, or an independent duty medical technician or corpsman. This
health care provider reviews the completed DD 2796 to identify any "yes"
responses to the screening questions-including questions related to
PTSD-that may indicate a need for further medical evaluation. The review
is to take place in a face-to-face interview with the servicemember and be
conducted either on an individual basis, as we observed at the Army's Fort
Lewis in Washington, or in a group setting, as we found at the Marine
Corps' Camp Lejeune in North Carolina. If a servicemember answers "yes" to
a PTSD question, the health care provider is instructed to gather
additional information from the servicemember and use clinical judgment to
determine if the servicemember should be referred for further medical
evaluation to a physician, physician's assistant, nurse, or an independent

12Medics and corpsmen are enlisted personnel who have been trained to give
first aid and basic medical treatment, especially in combat situations.

duty medical technician.13,14 To document completion of the DD 2796, DOD
requires that the questionnaire be placed in the servicemember's permanent
medical record and a copy sent to the Army Medical Surveillance Activity,
which maintains a database of all servicemembers' completed health
assessment questionnaires.15

13Independent duty medical technicians are enlisted personnel who receive
advanced training and are certified to provide treatment and prescribe
medications within defined parameters.

14Reserve and National Guard members who are referred for further medical
evaluation may remain on active duty status until the medical problem is
treated and resolved or the condition becomes stable.

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

Figure 1: DOD's Process for "Yes" Responses to PTSD Questions on DD 2796

Source: GAO analysis based on the Department of Defense, Enhanced
Post-Deployment Health Assessments, April 2003, and interviews with DOD
officials.

The National Defense Authorization Act for Fiscal Year 1998 required DOD
to establish a quality assurance program to ensure, among other things,
that post-deployment mental health assessments are completed16 for
servicemembers who are deployed outside of the United States. Completion
of the DD 2796 is tracked as part of this quality assurance program.17 DOD
delegated responsibility for developing procedures for the required
quality assurance program to each of its uniform services. The uniform
services have given unit commanders the responsibility to ensure
completion of the DD 2796 by all servicemembers under their command. To
ensure the DD 2796 is completed, one DOD official we interviewed told us
that servicemembers would not be granted leave to go home until the DD
2796 was completed. Another official told us that Reserve and National
Guard members would not be given their active duty discharge paperwork
until the DD 2796 was completed.

VA Lacks Information Needed to Determine Whether It Can Meet an Increase
in Demand for PTSD Services

VA does not have all the information it needs to determine whether it can
meet an increase in demand for VA PTSD services. VA does not have a count
of the total number of veterans currently receiving PTSD services at its
medical facilities and Vet Centers. Without this information, VA cannot
estimate the number of veterans its medical facilities and Vet Centers
could treat for PTSD. VA could use demographic information it receives
from DOD to broadly estimate the number of servicemembers who may access
VA health care, including PTSD services. By assuming that 15 percent or
more of returning servicemembers will develop PTSD, VA could use the
demographic information to broadly estimate demand for PTSD services.
However, predicting which veterans will seek VA care and at which
facilities is inherently uncertain, particularly given that the symptoms
of PTSD may not appear for years.

16See Section 765(a)(1), 111 Stat. at 1826 (codified at 10 U.S.C. S:
1074f(d)).

17In September 2003, we found that DOD had not established an effective
quality assurance program and recommended that this be done. See
GAO-03-1041.

VA Does Not Have Information on the Total Number of Veterans Currently
Receiving PTSD Services

VA does not have a count of the total number of veterans currently
receiving PTSD services at its medical facilities and Vet Centers. Without
this information, VA cannot estimate the number of additional veterans its
facilities could treat for PTSD. On August 27, 2004, a Northeast Program
Evaluation Center (NEPEC) official told us that a count of the total
number of veterans with a diagnosis of PTSD who receive VA services at
medical facilities could be obtained from VA's existing database. However,
this database does not include Vet Centers' information because this
information is kept separate from the medical facilities' data.

VA publishes two reports that contain information on some of the veterans
receiving PTSD services at its medical facilities. Neither report includes
all veterans receiving PTSD services at VA medical facilities and Vet
Centers. VA's annual capacity report, which is required by law,18 provides
data on VA's most vulnerable populations, such as veterans with spinal
cord injuries, blind veterans, and seriously mentally ill veterans with
PTSD.19 The NEPEC annual report mainly provides data on veterans with a
primary diagnosis of PTSD.20 VA has not developed a methodology that would
allow it to count the number of veterans receiving PTSD services at its
medical facilities and Vet Centers.

The PTSD data used in VA's annual capacity report and the data used in
NEPEC's annual report are drawn from different-though not mutually
exclusive-subgroups of veterans receiving PTSD services at VA's medical
facilities. VA developed criteria that allow it to determine which
veterans should be included in each subgroup. VA's criteria, which differ
in each report, are based on the type and frequency of mental health
services provided to veterans with PTSD at its medical facilities. (See
Figure 2 for the veterans included in each of VA's annual reports.)

18See 38 U.S. C. S: 1706(b)(5).

19Seriously mentally ill veterans are those diagnosed with a mental,
behavioral or emotional disorder of sufficient duration to substantially
interfere with one or more life activities, including basic daily living
skills such as eating, bathing, or dressing.

20Department of Veterans Affairs, The Long Journey Home XII Treatment of
Posttraumatic Stress Disorder in the Department of Veterans Affairs:
Fiscal Year 2003 Service Delivery and Performance, Northeast Program
Evaluation Center, VA Connecticut Healthcare System (Connecticut: April
2004). The Northeast Program Evaluation Center, a division of the National
Center for PTSD, monitors and evaluates the implementation and performance
of VA's specialized PTSD programs.

               Figure 2: Veterans Included in VA's Annual Reports

                  Veterans who are seriously mentally ill with PTSD, which is
                                                               equivalent to:
                          or or 6 or more                                     
                  outpatient visits to VA                      or received    
                       specialized mental     or 2 visits      care in a PTSD 
         Capacity         health services     to a VA PTSD     outpatient     
         report              hospitalized     outpatient       clinic         
                  psychiatric service for and clinic       and received care  
                          a mental health     primary          in a PTSD      
                  disorder inpatient in a     diagnosis of     inpatient      
                      VA residential care     PTSD             service
                     program for a mental                      
                          health disorder                      
         NEPEC            Veterans who have a primary diagnosis of PTSD in an
         reporta                                           outpatient setting

Source: GAO analysis

Note: Analysis of VA's Fiscal Year 2002 "Maintaining Capacity to Provide
for the Specialized Treatment and Rehabilitative Needs of Disabled
Veterans" and NEPEC's "Long Journey Home XII Treatment of Posttraumatic
Stress Disorder in the Department of Veterans Affairs: Fiscal Year 2003
Service Delivery and Performance." Examples of VA specialized mental
health services include PTSD and substance abuse.

aThis refers to Table E1 in Appendix E of The Long Journey Home XII
Treatment of Posttraumatic Stress Disorder in the Department of Veterans
Affairs: Fiscal Year 2003 Service Delivery and Performance Northeast
Program Evaluation Center, VA Connecticut Healthcare System (Connecticut:
April 2004).

Veterans who are receiving VA PTSD services may be counted in both
reports, only counted in the NEPEC report, or not included in either
report. For example, a veteran who is seriously mentally ill and has a
primary diagnosis of PTSD is counted in both reports. On the other hand, a
veteran who has a primary diagnosis of PTSD but is not defined as
seriously mentally ill is counted in the NEPEC report but not in the
capacity report. Finally, a veteran who is receiving PTSD services only at
a Vet Center is not counted in either report.

Furthermore, both the VA OIG and VA's Committee on Care of Veterans with
Serious Mental Illness have found inaccuracies in the data used in VA's
annual capacity report.21 For example, OIG found inconsistencies in the
PTSD program data reported by some VA medical facilities. OIG found that
some medical facilities reported having active PTSD programs, although the
facilities reported having no staff assigned to these programs.
Additionally, the Committee on Care of Veterans with Serious Mental
Illness, commenting on VA's fiscal year 2002 capacity report, stated the
data VA continues to use for reporting information on specialized programs
are inaccurate and recommended changes in future reporting.22, 23 VA
agreed with OIG that the data were inaccurate and is continuing to make
changes to improve the accuracy of the data in its annual capacity report.
VA's fiscal year 2003 capacity report to Congress is currently undergoing
review by OIG, which informed us that VA has not incorporated all of the
changes necessary for OIG to certify that the report is accurate. OIG
further stated that it will continue to oversee this process.

VA Has Information to Broadly Estimate Future Demand for PTSD Services

VA has information it can use to broadly estimate what the increase in
demand for VA PTSD services may be from returning servicemembers. In
September 2003, DOD began providing VA with demographic information on
servicemembers returning from the Iraq and Afghanistan conflicts who have
left active duty status and are eligible for VA health care.24 The
information includes name, home address including zip code, branch of
service, and gender.25 Using servicemembers' home zip codes could help VA

21The VA OIG is required to examine each of VA's annual reports on its
specialized services, including PTSD, and submit to Congress a
certification as to its accuracy. See 38 U.S.C. S: 1706(b)(5)(C).

22The Committee on Care of Severely Chronically Mentally Ill Veterans
assesses VA's capability to meet the rehabilitation and treatment needs of
such veterans. See 38 U.S.C. S: 7321. The Committee, established within
VA, is generally referred to as the Committee on Care of Veterans with
Serious Mental Illness.

23Department of Veterans Affairs, Capacity Report Fiscal Year 2002
(Washington, D.C.: May 2003).

24Not all such servicemembers are eligible for VA health care. For
example, a servicemember who has been dishonorably discharged would not be
eligible for VA services.

25VA has used this information to send letters to servicemembers who have
left active duty status, informing them of their eligibility for VA's
health care services.

predict the facilities or Vet Centers that could experience an increase in
demand for care. By assuming that 15 percent or more of returning
servicemembers will eventually develop PTSD, based on the predictions of
mental health experts, VA could use the demographic information to broadly
estimate the number of returning servicemembers who may need VA PTSD
services and the VA facilities located closest to servicemembers' homes.
However, predicting which veterans will seek VA care and at which
facilities is inherently uncertain, particularly given that the symptoms
of PTSD may not appear for years.

VA headquarters received demographic information from DOD in September
2003; however, during our review we found that VA had not shared this
information with its facilities. On July 21, 2004, VA provided this
information to its medical facilities for planning future services for
veterans returning from the Iraq and Afghanistan conflicts. However, VA
did not provide the demographic information to Vet Centers. Officials at
seven VA medical facilities told us that while the demographic information
VA receives from DOD has limitations, it is the best national data
currently available and would help them plan for new veterans seeking VA
PTSD services.

Officials at six of the seven VA medical facilities we visited explained
that while they are now able to keep up with the current number of
veterans seeking PTSD services, they may not be able to meet an increase
in demand for these services.26 In addition, some of the officials
expressed concern about their ability to meet an increase in demand for VA
PTSD services from servicemembers returning from Iraq and Afghanistan
based on DOD's demographic information. Officials are concerned because
facilities have been directed by VA to give veterans of the Iraq and
Afghanistan conflicts priority appointments for health care services,
including PTSD service. As a result, VA medical facility officials
estimate that follow-up appointments for veterans currently receiving care
for PTSD may be delayed. VA officials estimate the delay may be up to 90
days. Veterans of the Iraq and Afghanistan conflicts will not be given
priority appointments over veterans who have a service-connected
disability and are currently receiving services.27

26One medical facility believed it could accommodate, with the facility's
current staffing levels, a one to two percent increase in additional
veterans seeking PTSD services. However, it would have to restructure its
PTSD services provided to current veterans.

Conclusions	While the VA OIG continues to oversee VA's efforts to improve
the accuracy of data in the capacity reports, VA does not have a report
that counts all veterans receiving VA PTSD services. Although VA can use
DOD's demographic information to broadly estimate demand for VA PTSD
services, VA does not know the number of veterans it now treats for PTSD
at its medical facilities and Vet Centers. As a result, VA will be unable
to estimate its capacity for treating additional veterans who choose to
seek VA's PTSD services, and therefore, unable to plan for an increase in
demand for these services.

Recommendation for 	To help VA estimate the number of additional veterans
it could treat for PTSD and to plan for the future demand for VA PTSD
services from

Executive Action	additional veterans seeking these services, we recommend
that the Secretary of Veterans Affairs direct the Under Secretary for
Health to determine the total number of veterans receiving VA PTSD
services and provide facility-specific information to VA medical
facilities and Vet Centers.

Agency Comments	In commenting on a draft of this report, VA concurred with
our recommendation and acknowledged that more coordinated efforts are
needed to improve its existing PTSD data. VA stated that it plans to
aggregate, at the national level, the number of veterans receiving PTSD
services at VA medical facilities and Vet Centers. We believe VA should
provide these data to both its medical facilities and Vet Centers so they
have the information needed to plan for future demand for PTSD services.
In addition, VA provided two points of clarification. First, VA stated
that it is in the process of developing a mental health strategic plan
that will project demand by major diagnoses and identify where projected
demand may exceed resource availability. VA stated that future revisions
to the mental health strategic plan would include Vet Center data. Second,
VA stated that it would seek additional information from DOD on
servicemembers who have served in Iraq and Afghanistan to improve its
provision of health care services to these new veterans. VA's written
comments are reprinted in appendix III. DOD concurred with the findings

27A service-connected disability is an injury or disease that was incurred
or aggravated while on active military duty.

and conclusions in this report and provided technical comments, which we
incorporated as appropriate. DOD's written comments are reprinted in
appendix IV.

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its date. We will then send copies of this report to the Secretary
of Veterans Affairs and other interested parties. We also will make copies
available to others upon request. In addition, the report will be
available at no charge at the GAO Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please call me
at (202) 512-7101. Another contact and key contributors are listed in
appendix V.

Sincerely yours,

Cynthia A. Bascetta Director, Health Care-Veterans' Health and Benefits
Issues

Appendix I

Scope and Methodology

To determine the approaches DOD uses to identify servicemembers who are at
risk for PTSD, we reviewed directives on screening servicemembers deployed
to locations outside of the United States, interviewed DOD officials, and
visited a military installation for each of DOD's uniformed services. At
each of the military installations, we discussed with officials the steps
taken by each of the uniformed services to implement DOD's approaches,
particularly the steps involved in completing the postdeployment health
assessment questionnaire, DD 2796, as it relates to PTSD. How well the
uniformed services implemented DOD's approaches were reported in other GAO
reports. The uniformed services included in our review were Army, Marines,
Air Force, and Navy. We did not include the Coast Guard in this review
because few Coast Guard servicemembers are involved in the Iraq and
Afghanistan conflicts. The military installations visited were: Fort Lewis
Army Base and Madigan Army Medical Center in Washington, Seymour Johnson
Air Force Base in North Carolina, Camp Lejeune Marine Base and the Naval
Hospital Camp Lejeune in North Carolina, and the Naval Medical Center San
Diego in California. We also asked DOD officials whether they provide
information to VA that could help VA plan how to meet the demand for VA
PTSD services from servicemembers returning from the Iraq and Afghanistan
conflicts.

To determine whether VA has the information it needs to determine whether
it can meet an increase in demand for PTSD services, we interviewed PTSD
experts from the National Center for PTSD established within VA and
members of the Under Secretary for Health's Special Committee on PTSD.1 We
also visited three divisions of the National Center for PTSD: the
Executive Division in White River Junction, Vermont; the Education
Division in Palo Alto, California; and NEPEC in West Haven, Connecticut to
review the Center's reports on specialized PTSD programs.

We also reviewed VA's fiscal year 2001 and 2002 annual reports on VA's
capacity to provide services to special populations, including veterans
with PTSD, and NEPEC's annual reports on specialized PTSD programs to
determine the criteria VA uses to count the number of veterans receiving
VA PTSD services. We reviewed the findings of VA's Committee on Care of
Veterans with Serious Mental Illness and the VA OIG, who have reported on

1VA was required to establish a Special Committee on PTSD by the Veterans'
Health Care Act of 1984. See Section 110(b), 98 Stat. at 2691 (codified at
38 U.S.C. S: 1712A note). Among other things, the committee assesses VA's
care of veterans who require specialized treatment for PTSD.

Appendix I Scope and Methodology

the accuracy of VA's annual capacity report to Congress on the number of
veterans receiving specialized services, including PTSD services. We
interviewed officials from each of these groups to clarify their findings.
We did not include data from the annual capacity reports because the OIG
reported that the data were not sufficiently reliable. We also interviewed
the director of NEPEC to discuss the information included in NEPEC's
annual reports.

To determine whether VA facilities have the information needed to
determine whether they can meet an increase in demand for PTSD services,
we interviewed officials at 7 VA medical facilities, and 15 Vet Centers
located near the medical facilities to discuss the number of veterans
currently receiving VA PTSD services and the impact that an increase in
demand would have on these services. We also discussed DOD's demographic
information with four of the seven medical facilities we visited. We
contacted VA medical facilities located in Palo Alto and San Diego in
California; Durham and Fayetteville in North Carolina; White River
Junction, Vermont; West Haven, Connecticut; and Seattle, Washington. We
also contacted Vet Centers located in Vista, San Diego, and San Jose in
California; Raleigh, Charlotte, Greenville, Greensboro, and Fayetteville
in North Carolina; South Burlington and White River Junction in Vermont;
Hartford, Norwich, and New Haven in Connecticut; and Seattle and Tacoma in
Washington.

Our work was conducted from May through September 2004 in accordance with
generally accepted government auditing standards.

Appendix II

Department of Defense Post-Deployment
Health Assessment Questionnaire DD-2796

Appendix II
Department of Defense Post-Deployment
Health Assessment Questionnaire DD-2796

Appendix II
Department of Defense Post-Deployment
Health Assessment Questionnaire DD-2796

Appendix II
Department of Defense Post-Deployment
Health Assessment Questionnaire DD-2796

Appendix III

Comments from the Department of Veterans Affairs

Appendix III
Comments from the Department of Veterans
Affairs

Appendix III
Comments from the Department of Veterans
Affairs

                                  Appendix IV

                   Comments from the Department of Defense 	

Appendix V

                    GAO Contact and Staff Acknowledgments 	

                    GAO Contact Marcia A. Mann, 202-512-9526

Acknowledgments
In addition to the contact named above Mary Ann Curran, Linda Diggs,
Martha Fisher, Krister Friday, and Marion Slachta made key contributions
to this report.

Related GAO Products	

Defense Health Care: DOD Needs to Improve Force Health Protection and
Surveillance Processes. GAO-04-158T, Washington, D.C.: October 16, 2003.

Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance. GAO-03-1041, Washington, D.C.:
September 19, 2003.

Disabled Veterans' Care: Better Data and More Accountability Needed to
Adequately Assess Care. GAO/HEHS-00-57, Washington, D.C.: April 21, 2000.

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