Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors
Its Providers Use to Make Mental Health Evaluation Referrals for 
Servicemembers (11-MAY-06, GAO-06-397). 			 
                                                                 
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.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-397 					        
    ACCNO:   A53743						        
  TITLE:     Post-Traumatic Stress Disorder: DOD Needs to Identify the
Factors Its Providers Use to Make Mental Health Evaluation	 
Referrals for Servicemembers					 
     DATE:   05/11/2006 
  SUBJECT:   Data collection					 
	     Eligibility determinations 			 
	     Health care planning				 
	     Health care services				 
	     Health policy					 
	     Health statistics					 
	     Health surveys					 
	     Mental health					 
	     Policy evaluation					 
	     DOD Operation Iraqi Freedom			 
	     Operation Enduring Freedom 			 
	     Post-Traumatic Stress Disorder			 

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GAO-06-397

     

     * Results in Brief
     * Background
          * DOD's Post-Deployment Process and Screening for PTSD
          * DOD and VA Health Care Systems
          * DOD's Quality Assurance Program
     * For Veterans, DOD Offers a Benefit for a Specific Period of
          * DOD Offers Mental Health Benefits to OEF/OIF Veterans for 18
          * VA Offers Health Services, Including Specialized PTSD Servic
     * Based on DOD Data, About 5 Percent of OEF/OIF Servicemembers
          * About 5 Percent of OEF/OIF Servicemembers May Have Been at R
          * Twenty-two Percent Who May Have Been at Risk for Developing
     * DOD Cannot Provide Reasonable Assurance That OEF/OIF Service
     * Conclusions
     * Recommendation for Executive Action
     * Agency Comments and Our Evaluation
     * GAO Contact
     * Acknowledgments
     * GAO's Mission
     * Obtaining Copies of GAO Reports and Testimony
          * Order by Mail or Phone
     * To Report Fraud, Waste, and Abuse in Federal Programs
     * Congressional Relations
     * Public Affairs

Report to Congressional Committees

United States Government Accountability Office

GAO

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

Contents

Letter 1

Results in Brief 4
Background 6
For Veterans, DOD Offers a Benefit for a Specific Period of Time and VA
Offers Various Health Care Services 11
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 16
DOD Cannot Provide Reasonable Assurance That OEF/OIF Servicemembers Who
Need Mental Health Referrals Receive Them 19
Conclusions 20
Recommendation for Executive Action 21
Agency Comments and Our Evaluation 21
Appendix I Scope and Methodology 26
Appendix II Comments from the Department of Defense 29
Appendix III GAO Contact and Staff Acknowledgments 34

Tables

Table 1: TRICARE Beneficiary Costs Through TAMP 12
Table 2: VA Specialized Outpatient and Inpatient PTSD Treatment Programs
15

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 9
Figure 2: OEF/OIF Servicemembers Who May Have Been at Risk for Developing
PTSD, by Military Service Branch 17
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 18

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

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separately.

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),1
respectively-have engaged in intense and prolonged combat, which research
has shown to be strongly associated with the risk for developing PTSD.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.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.4

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

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.

3Servicemembers 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.

4DOD'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.

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.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)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.

5In 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.

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

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;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 2796.8 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.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.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.

7We 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.

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

9Department 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).

10Prins, 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.

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.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.

11Because 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.

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.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

           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?

           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.

12The 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, S: 765(a)(1),
111 Stat. 1629, 1826, codified at 10 U.S.C. S: 1074f(b) (2000).

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

Source: DOD.

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.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.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.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.16

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

14We 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).

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

 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.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

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

17The Ronald W. Reagan National Defense Authorization Act for Fiscal Year
2005, Pub. L. No. 108-375, S: 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.

           o  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.
           o  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.
           o  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

           Source: DOD.

           In addition, OEF/OIF veterans may purchase DOD health care
           benefits through CHCBP for 18 months.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.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.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 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.21, 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.

                                    TRICARE Extra                  
                    TRICARE Prime   (preferred         TRICARE Standard
                    (managed care)  provider)          (fee-for-service)
Annual           None            $50-$150           $50-$150 (individual)
deductible                       (individual) and   and $100-$300 maximum
                                    $100-$300 maximum  (family), depending on
                                    (family),          military rank
                                    depending on       
                                    military rank      
Cost share after Outpatient:     Outpatient: 15% of Outpatient: 20% of
deductibles for  None            the fee negotiated allowable charges for
mental health                    by TRICARE         covered services after
visits                           contractor after   the deductible is met
                                    the deductible is  
                                    met                
                    Inpatient: None Inpatient: greater Inpatient: greater of
                                    of $20/day or $25  $20/day or $25 minimum
                                    minimum charge per charge per admission
                                    admission          

18OEF/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.

19The National Defense Authorization Act for Fiscal Year 2005, Pub. L. No.
108-375, S: 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.

20Active 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.

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

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

22OEF/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).

Table 2: VA Specialized Outpatient and Inpatient PTSD Treatment Programs

                                                                    Number of 
                                                              facilities with 
Outpatient treatment                                      specialized PTSD 
program                Description of service            treatment program 
PTSD Clinical Team        o  Group and one-on-one                      152 
                             evaluation, education,         
                             counseling and psychotherapy   
Substance Use and PTSD    o  Education, evaluation, and                 10 
Team                      counseling with a focus on     
                             veterans with both substance   
                             abuse and PTSD                 
Women's Stress            o  Individual evaluation,                     17 
Disorder Treatment        counseling, and psychotherapy  
Team/Military Sexual      for women                      
Trauma Team               o  Group counseling and        
                             psychotherapy for women        
                             o  Mostly women, may include   
                             small number of men separate   
                             from women                     
PTSD Day Hospital         o  Social, recreational, and                  11 
                             vocational activities and      
                             counseling                     
Inpatient treatment    
program                
Evaluation and Brief      o  Evaluation, education, and                  4 
Treatment Unit            psychotherapy for PTSD         
                             o  Duration of service: 14 to  
                             28 days                        
Specialized Inpatient     o  Evaluation, education, and                  5 
PTSD Unit                 counseling for substance use   
                             and PTSD psychotherapy         
                             o  Duration of service: 28 to  
                             90 days                        
PTSD Residential          o  Residential service                        14 
Rehabilitation Program    providing evaluation,          
                             education, and counseling to   
                             help veterans resume a         
                             productive involvement in      
                             community life                 
                             o  Duration of service: 28 to  
                             90 days                        
Women's Trauma            o  Residential service with an                 2 
Recovery Program          emphasis on interpersonal      
                             skills for veterans with PTSD  
                             o  Duration of service: up to  
                             60 days                        
PTSD Domiciliary          o  Residential program                         8 
                             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                       
                             o  Duration of service: about  
                             85 days                        

Source: VA, March 2006.

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.23

23Hoge, 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.

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

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.

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.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.25

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

25DOD 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.

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

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.

  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.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.

26The 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.

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.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.

27In 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?"

                      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 http://www.gao.gov .

If you or your staff members have any questions regarding this report,
please contact me at (202) 512-7101 or [email protected] . 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.

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

Appendix I: Scope and Methodology 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

           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?

           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.1 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.2 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.3

           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.

           Cynthia A. Bascetta at (202) 512-7101 or [email protected]

           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.

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1VA and DOD, Veterans Health Administration/DOD Clinical Practice
Guideline for Management of Post-Traumatic Stress Disorders.

2Prins, Annabel et al. "The Primary Care PTSD Screen (PC-PTSD):
Development and Operating Characteristics."

3 GAO-03-1041 .

Appendix II: Comments from the Department of Defense Appendix II: Comments
from the Department of Defense

Appendix III: GAOA Appendix III: GAO Contact and Staff Acknowledgments

                                  GAO Contact

                                Acknowledgments

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Highlights of GAO-06-397 , a 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

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 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.

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.
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