United States Government Accountability Office

GAO Report to Congressional Committees

POST-TRAUMATIC 

STRESS DISORDER 

DOD Needs to Identify 

the Factors Its 

Providers Use to Make 

Mental Health 

Evaluation Referrals 

for Servicemembers 

May 2006 

 

GAO-06-397 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

May 2006

POST-TRAUMATIC STRESS DISORDER

DOD Needs to Identify the Factors Its 

Providers Use to Make Mental Health 

Evaluation Referrals for Servicemembers 

Highlights of GAO-06-397, a report to 

congressional committees 

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. 

www.gao.gov/cgi-bin/getrpt?GAO-06-397.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Cynthia A. 

Bascetta at (202) 512-7101 or 

bascettac@gao.gov. 
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 

Page i GAO-06-397 DOD Referrals for Mental Health Evaluations
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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Page ii GAO-06-397 DOD Referrals for Mental Health Evaluations
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 lifethreatening 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 deploymentrelated 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

 1

OEF/OIF servicemembers include National Guard and Reserve members. 

2

Hoge, Charles W., MD et al., “Combat Duty in Iraq and Afghanistan, Mental Health 

Problems, and Barriers to Care,” The New England Journal of Medicine, 351 (2004): 13-22. 

3

Servicemembers who are deployed for 30 or more continuous days to locations without

permanent DOD treatment facilities are required to complete a post-deployment screening

questionnaire. 

4

DOD’s referrals are used to document DOD’s assessment that servicemembers are in need

of further mental health evaluations, including those for PTSD. In this report, we refer to

such referrals as issued to or received by servicemembers. 

Page 1 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

 5

In this report, we use the term discharged to describe servicemembers who have 

completed their active duty service commitment and have not made a future service 

commitment. We use the term released to describe Reserve and National Guard 

servicemembers who have completed their active duty service commitment, made a future

commitment to active duty, and therefore can be recalled to active duty. 

6

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

Page 2 GAO-06-397 DOD Referrals for Mental Health Evaluations
We also interviewed DOD officials and the military service branches about 

these benefits. In addition, we reviewed VA’s policies, directives, and 

educational information on its health care services, including the mental 

health services that VA has available for OEF/OIF veterans. We reviewed

the types of mental health services available through VA’s health care 

system for OEF/OIF veterans. We also interviewed VA headquarters 

officials about these services. 

To determine the number of OEF/OIF servicemembers who may be at risk

for developing PTSD and the number of these servicemembers referred for 

further mental health evaluations, we analyzed DOD computerized data. 

We obtained from DOD a list of OEF/OIF servicemembers who (1) were 

deployed in support of OEF/OIF from October 1, 2001, through 

September 30, 2004; (2) had since been discharged or released from active 

duty;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 

 7

We did not include military retirees in our analysis because the mandate specifies that we 

include servicemembers who have been discharged or released from active duty, not 

retired servicemembers. According to a DOD official, DOD does not include retirees in its 

definition of discharged servicemembers or servicemembers who have been released from 

active duty status. 

8

Department of Defense, Department of Defense Post-Deployment Health Assessment 

DD-2796 (Washington, D.C.: April 2003).

9

Department of Veterans Affairs and Department of Defense, Veterans Health

Administration/DOD Clinical Practice Guideline for Management of Post-Traumatic 

Stress (Washington, D.C.: January 2004). 

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. 

Page 3 GAO-06-397 DOD Referrals for Mental Health Evaluations
servicemembers who received referrals from a DOD health care provider, 

we used information from the post-deployment questionnaires of the 

178,664 OEF/OIF servicemembers in our review. The questionnaires 

indicate whether a DOD health care provider issued a referral for a mental 

health or combat/operational stress reaction evaluation. We determined 

that DOD’s data were sufficiently reliable for the purposes of the report. 

To examine whether DOD can provide reasonable assurance that OEF/OIF 

servicemembers who need further mental health evaluations receive

referrals, we reviewed DOD’s policies and guidance, including guidance 

for DOD health care providers who use the DD 2796. We reviewed DOD’s 

quality assurance program and spoke to a researcher about a DOD study 

on PTSD referrals to examine the extent to which DOD studies its 

providers’ decisions to issue referrals. We interviewed DOD officials, 

including mental health clinicians involved with the DD 2796 and asked 

them about DOD’s criteria for issuing referrals to those who may be at risk 

for developing PTSD. 

NDAA also directed us to determine the number of OEF/OIF veterans who, 

because of their DOD provider-issued referrals, accessed DOD or VA 

health care services to obtain a further mental health or 

combat/operational stress reaction evaluation. However, as discussed with 

the committees of jurisdiction, we could not use data from OEF/OIF 

veterans’ DD 2796 forms to determine if veterans accessed DOD or VA 

health care services because of their mental health referrals. DOD officials 

explained that the referral checked on the DD 2796 cannot be linked to a 

subsequent health care visit using DOD computerized data. Therefore, we 

could not determine how many OEF/OIF veterans accessed DOD or VA 

health care services for further mental health evaluations because of their

referrals. 

For a complete discussion of our scope and methodology, see appendix I.

We conducted our work from December 2004 through April 2006 in 

accordance with generally accepted government auditing standards. 

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 

Results in Brief 

Page 4 GAO-06-397 DOD Referrals for Mental Health Evaluations
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, 

Page 5 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

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. 

Background 

 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. 

Page 6 GAO-06-397 DOD Referrals for Mental Health Evaluations
Symptoms that persist longer than 4 days are diagnosed as acute stress 

disorder. If the symptoms continue for more than 30 days and significantly 

disrupt an individual’s daily activities, PTSD is diagnosed. PTSD may 

occur with other mental health conditions, such as depression and 

substance abuse. Clinicians offer a range of treatments to individuals 

diagnosed with PTSD, including individual and group therapy and 

medication to manage symptoms. These treatments are usually delivered 

in an outpatient setting, but they can include inpatient services if, for 

example, individuals are at risk of causing harm to themselves. 

DOD’s Post-Deployment 

Process and Screening for 

PTSD 

DOD’s screening for PTSD occurs during its post-deployment process. 

During this process, DOD evaluates servicemembers’ current physical and 

mental health and identifies any psychosocial issues commonly associated 

with deployments, special medications taken during the deployment, and

possible deployment-related occupational/environmental exposures. The 

post-deployment process also includes completion by the servicemember 

of the post-deployment screening questionnaire, the DD 2796. DOD uses 

the DD 2796 to assess health status, including identifying servicemembers 

who may be at risk for developing PTSD following deployment.12 In 

addition to questions about demographics and general health, including 

questions about general mental health, the DD 2796 includes four 

questions used to screen servicemembers for PTSD. The four questions 

are: 

Have you ever had any experience that was so frightening, horrible, or 

upsetting that, in the past month, you 

• have had any nightmares about it or thought about it when you did not 

want to? 

• tried hard not to think about it or went out of your way to avoid situations 

that remind you of it? 

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

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

The completed DD 2796 is reviewed by a DOD health care provider who 

conducts a face-to-face interview to discuss any deployment-related health

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

Page 7 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

Page 8 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

Page 9 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

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 

DOD and VA Health Care 

Systems 

DOD’s Quality Assurance 

Program 

 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. 

Page 10 GAO-06-397 DOD Referrals for Mental Health Evaluations
from the military service branches, site visits, and AMSA to develop an

annual report on its Deployment Health Quality Assurance Program.16

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. 

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 

For Veterans, DOD 

Offers a Benefit for a 

Specific Period of 

Time and VA Offers 

Various Health Care 

Services 

DOD Offers Mental Health 

Benefits to OEF/OIF 

Veterans for 180 Days or 

More 

 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, § 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. 

Page 11 GAO-06-397 DOD Referrals for Mental Health Evaluations
• TRICARE Prime—a managed care option that allows OEF/OIF veterans to 

obtain, without a referral, mental health services directly from a mental 

health provider in the TRICARE network of providers with no cost for 

services. 

• TRICARE Extra—a preferred provider option that allows OEF/OIF 

veterans to obtain, without a referral, mental health services directly from

a mental health provider in the TRICARE network of providers. 

Beneficiaries pay a deductible and a share of the cost of services. 

• TRICARE Standard—a fee-for-service option that allows OEF/OIF 

veterans to obtain, without a referral, mental health services directly from

any mental health provider, including those outside the TRICARE network 

of providers. Beneficiaries pay a deductible and a larger share of the costs 

of services than under the TRICARE Extra option. 

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

TRICARE option. 

Table 1: TRICARE Beneficiary Costs Through TAMP 

TRICARE Prime 

(managed care) 

TRICARE Extra 

(preferred provider) 

TRICARE Standard 

(fee-for-service) 

Annual 

deductible

None $50-$150 (individual) and 

$100-$300 maximum 

(family), depending on 

military rank 

$50-$150 (individual) 

and $100-$300

maximum (family), 

depending on military 

rank 

Outpatient: None Outpatient: 15% of the 

fee negotiated by 

TRICARE contractor 

after the deductible is 

met 

Outpatient: 20% of 

allowable charges for 

covered services after 

the deductible is met 

Cost share 

after 

deductibles for

mental health

visits 

Inpatient: None Inpatient: greater of 

$20/day or $25 minimum 

charge per admission 

Inpatient: greater of 

$20/day or $25

minimum charge per 

admission 

Source: DOD. 

Page 12 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

 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, § 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. 

Page 13 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

VA Offers Health Services, 

Including Specialized 

PTSD Services, to 

OEF/OIF Veterans 

 21See 38 U.S.C. § 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 serviceconnected 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). 

Page 14 GAO-06-397 DOD Referrals for Mental Health Evaluations
Table 2: VA Specialized Outpatient and Inpatient PTSD Treatment Programs 

Outpatient treatment program Description of service

Number of facilities with

specialized PTSD 

treatment program 

PTSD Clinical Team • Group and one-on-one evaluation, education, 

counseling and psychotherapy

152

Substance Use and PTSD Team • Education, evaluation, and counseling with a focus on 

veterans with both substance abuse and PTSD 

10

Women’s Stress Disorder Treatment 

Team/Military Sexual Trauma Team 

• Individual evaluation, counseling, and psychotherapy 

for women 

• Group counseling and psychotherapy for women 

• Mostly women, may include small number of men 

separate from women 

17

PTSD Day Hospital • Social, recreational, and vocational activities and 

counseling 

11

Inpatient treatment program 

Evaluation and Brief Treatment Unit • Evaluation, education, and psychotherapy for PTSD 

• Duration of service: 14 to 28 days 

4

Specialized Inpatient PTSD Unit • Evaluation, education, and counseling for substance 

use and PTSD psychotherapy

• Duration of service: 28 to 90 days 

5

PTSD Residential Rehabilitation Program • Residential service providing evaluation, education, 

and counseling to help veterans resume a productive

involvement in community life

• Duration of service: 28 to 90 days 

14

Women’s Trauma Recovery Program • Residential service with an emphasis on interpersonal 

skills for veterans with PTSD 

• Duration of service: up to 60 days 

2

PTSD Domiciliary • Residential program providing integrated rehabilitative 

and restorative care with the goal of helping veterans 

with PTSD achieve and maintain the highest level of 

functioning and independence possible 

• Duration of service: about 85 days 

8

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. 

Page 15 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

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

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 

About 5 Percent of 

OEF/OIF Servicemembers 

May Have Been at Risk for 

Developing PTSD 

 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. 

Page 16 GAO-06-397 DOD Referrals for Mental Health Evaluations
Figure 2: OEF/OIF Servicemembers Who May Have Been at Risk for Developing

PTSD, by Military Service Branch

0

1

2

3

4

5

6

7

Army Marines Navy Air Force 

Percent

Military service branch

Source: GAO analysis of DOD data.

6.4%

(7,935)

3.8%

(706)

2.6%

(327)

0.8%

(177)

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. 

Page 17 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

Twenty-two Percent Who 

May Have Been at Risk for 

Developing PTSD 

Received Referrals

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

0

5

10

15

20

25

Army Marines Navy Air Force 

Percent referred

Military service branch

Source: GAO analysis of DOD data.

23.0%

(1,822)

15.3%

(108)

18.0%

(59)

22.6%

(40)

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. 

Page 18 GAO-06-397 DOD Referrals for Mental Health Evaluations
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 Cannot Provide 

Reasonable

Assurance That 

OEF/OIF 

Servicemembers Who 

Need Mental Health 

Referrals Receive 

Them 

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 

 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.

Page 19 GAO-06-397 DOD Referrals for Mental Health Evaluations
responses on the four PTSD screening questions to the likelihood of 

receiving a referral. Therefore, the program could not provide information 

on why some OEF/OIF servicemembers with three or more positive 

responses to the PTSD screening questions received referrals while others 

did not. 

DOD is conducting a study that is intended to evaluate the outcomes and 

quality of care provided by DOD’s health care system. This study is part of 

DOD’s National Quality Management Program. The study is intended to 

track those who responded positively to three or four PTSD screening 

questions on the DD 2796 and used the form as well to indicate they had

other mental health issues, such as feeling depressed.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. 

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. 

Conclusions 

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 

 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?” 

Page 20 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

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. 

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. 

Recommendation for 

Executive Action 

Agency Comments 

and Our Evaluation 

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. 

Page 21 GAO-06-397 DOD Referrals for Mental Health Evaluations
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. 

Page 22 GAO-06-397 DOD Referrals for Mental Health Evaluations
If you or your staff members have any questions regarding this report, 

please contact me at (202) 512-7101 or bascettac@gao.gov. Contact points 

for our Offices of Congressional Relations and Public Affairs may be found 

on the last page of this report. GAO staff members who made major 

contributions to this report are listed in appendix III. 

Cynthia A. Bascetta 

Director, Health Care 

Page 23 GAO-06-397 DOD Referrals for Mental Health Evaluations
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 

Page 24 GAO-06-397 DOD Referrals for Mental Health Evaluations
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 

Page 25 GAO-06-397 DOD Referrals for Mental Health Evaluations
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 

Page 26 GAO-06-397 DOD Referrals for Mental Health Evaluations
Appendix I: Scope and Methodology 

then worked with officials from DOD’s Army Medical Surveillance Activity

(AMSA) to identify which OEF/OIF servicemembers had responded 

positively to one, two, three, or four of the four PTSD screening questions

on the DD 2796 questionnaire. AMSA maintains a database of all 

servicemembers’ completed DD 2796s. The DD 2796 is a questionnaire that 

DOD uses to identify servicemembers who may be at risk for developing

PTSD after their deployment and contains the four PTSD screening 

questions that may identify these servicemembers. The four questions are: 

Have you ever had any experience that was so frightening, horrible, or 

upsetting that, in the past month, you 

• have had any nightmares about it or thought about it when you did not 

want to? 

• tried hard not to think about it or went out of your way to avoid situations 

that remind you of it? 

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

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

Because a servicemember may have been deployed more than once, some 

servicemembers’ records at AMSA included more than one completed 

DD 2796. We obtained information from the DD 2796 that was completed 

following the servicemembers’ most recent deployment in support of 

OEF/OIF. We removed from our review servicemembers who either did 

not have a DD 2796 on file at AMSA or completed a DD 2796 prior to DOD 

adding the four PTSD screening questions to the questionnaire in 

April 2003. In all, we reviewed DD 2796’s completed by 178,664 OEF/OIF 

servicemembers. To determine the criteria we would use to identify 

OEF/OIF servicemembers who may have been at risk for developing 

PTSD, we reviewed the clinical practice guideline for PTSD developed 

jointly by VA and DOD, which states that three or more positive responses 

to the four questions indicate a risk for developing PTSD.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 

 1

VA and DOD, Veterans Health Administration/DOD Clinical Practice Guideline for 

Management of Post-Traumatic Stress Disorders.

2

Prins, Annabel et al. “The Primary Care PTSD Screen (PC-PTSD): Development and 

Operating Characteristics.” 

Page 27 GAO-06-397 DOD Referrals for Mental Health Evaluations
Appendix I: Scope and Methodology 

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. 

 3

GAO-03-1041. 

Page 28 GAO-06-397 DOD Referrals for Mental Health Evaluations
Appendix II: Comments from the Department Appendix II: Comments from the Department of Defense 

of Defense 

Page 29 GAO-06-397 DOD Referrals for Mental Health Evaluations
Appendix II: Comments from the Department 

of Defense 

Page 30 GAO-06-397 DOD Referrals for Mental Health Evaluations
Appendix II: Comments from the Department 

of Defense 

Page 31 GAO-06-397 DOD Referrals for Mental Health Evaluations
Appendix II: Comments from the Department 

of Defense 

Page 32 GAO-06-397 DOD Referrals for Mental Health Evaluations
Appendix II: Comments from the Department 

of Defense 

Page 33 GAO-06-397 DOD Referrals for Mental Health Evaluations
Appendix III: GAO

A

 Contact and Staff 

cknowledgments 

Page 34 GAO-06-397

Appendix III: GAO Contact and Staff 

Acknowledgments 

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

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. 

DOD Referrals for Mental Health Evaluations

Acknowledgments 

(290437) 
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