DEFENSE HEALTH

Coordinating 

Authority Needed for 

Psychological Health 

and Traumatic Brain 

Injury Activities 

Report to the Chairman and Ranking 

Member, Committee on Armed 

Services, House of Representatives

January 2012

GAO-12-154

United States Government Accountability Office

GAO

This report was revised on January 27, 2012, to change $52.5 

million to $52.5 billion, on page 4 (Background), line 4, and some 

references to annual reports on pages 9 and 26 were clarified. 
United States Government Accountability Office

Highlights of GAO-12-154, a report to the 

Chairman and Ranking Member, Committee 

on Armed Services, House of Representatives

January 2012

DEFENSE HEALTH

Coordinating Authority Needed for Psychological 

Health and Traumatic Brain Injury Activities 

Why GAO Did This Study

Post-traumatic stress disorder 

(PTSD), which falls into the broader 

field of psychological health (PH), and 

traumatic brain injury (TBI) are 

recognized as the signature wounds 

of the wars in Afghanistan and Iraq. In 

two reports issued in 2011 

(GAO-11-219 and GAO-11-611), 

GAO cited numerous management 

weaknesses at the Defense Center of 

Excellence for PH and TBI (DCOE). 

For the present report, GAO reviewed 

(1) funding for DOD's PH and TBI 

activities in fiscal years 2007 through 

2010 and the accuracy of its reporting 

on these activities to Congress and 

(2) DOD's ability to coordinate its PH 

and TBI activities to help ensure that 

funds are used to support programs 

of the most benefit to servicemembers. GAO interviewed DOD 

officials, reviewed legislation and 

DOD’s annual reports, and obtained 

relevant documentation.

What GAO Recommends

GAO recommends that DOD direct the 

Assistant Secretary of Defense for 

Health Affairs to (1) include expenditure 

data in annual reports to Congress, as 

required; (2) establish quality control 

mechanisms on PH and TBI data; (3) if 

patient care costs are provided in future 

annual reports, specify what they 

include; and (4) revisit DCOE’s role as 

DOD’s coordinating authority for issues 

concerning PH and TBI, as stated in 

DCOE’s campaign plan, and determine 

whether DCOE or another organization 

should perform this function. In written 

comments on a draft of this report, DOD 

concurred with all four 

recommendations.

What GAO Found

From fiscal year 2007 through fiscal year 2010, DOD activities for the 

treatment and research of PH and TBI received more than $2.7 billion. In fiscal 

year 2007, funding for these activities totaled $900 million; in fiscal year 2008, 

it was $573.8 million; in fiscal year 2009, $395 million; and in fiscal year 2010, 

$838.6 million. GAO found, however, that the reports DOD provided to 

Congress on these activities did not include expenditures, as required by law, 

and that the obligations data they contained were unreliable. Governmentwide 

policies call for agencies to have effective internal controls to assure accurate 

reporting of obligations and expenditures. However, the Office of the Assistant 

Secretary of Defense for Health Affairs has not developed quality control 

mechanisms to help ensure that data on PH and TBI activities are complete 

and accurate. Further, although DOD listed patient care among reported costs, 

it did not specify what those costs included, making it difficult for 

decisionmakers and Congress to fully understand the costs. 

No one organization coordinates DOD’s PH and TBI activities. The National 

Defense Authorization Act for Fiscal Year 2008 directed the Secretary of 

Defense to establish a Center for PTSD and a Center for TBI to, among other 

things, implement DOD’s comprehensive plans for these issues, disseminate 

best practices, provide guidance, and conduct research. Subsequently, a 

Senior Oversight Committee established by the Secretaries of Defense and 

Veterans Affairs reported in its plan to Congress that DOD had created a 

single Defense Center of Excellence for PH and TBI (DCOE) to lead efforts in 

practice standards, training, outreach, research, and direct care. The 

Committee tasked DCOE with acting as an information clearinghouse that 

would allow servicemembers and their families to navigate the system of 

care. In its own plan, DCOE stated that it would serve as a coordinating 

authority for DOD's PH and TBI issues and perform a gap analysis to identify 

needed programming. GAO found, however, as it had in prior reports, that 

DCOE’s strategic plan did not reflect a clear mission focusing the 

organization on its statutory responsibilities. Instead, those responsibilities 

are dispersed among the TRICARE Management Activity, the Army Medical 

Research and Materiel Command, and others. While the Office of the 

Assistant Secretary of Defense for Health Affairs has broad oversight for all 

of DOD’s medical missions, its global role prevents it from focusing on PH 

and TBI activities specifically. As a result, no single organization is devoted to 

ensuring that accurate and timely data are available on DOD’s PH and TBI 

activities or coordinating these activities. GAO, in conducting this review, had 

to obtain information from several different sources to compile a 

comprehensive list of DOD's PH and TBI activities. This finding was echoed 

in a recent RAND report that also noted that no single source in DOD tracked 

its PH and TBI programs or had appropriate resources to direct 

servicemembers to the full array of programs available. Without an entity to 

coordinate these activities, DOD will remain hampered in its efforts to ensure 

that resources are used effectively to meet goals, and Congress will be 

limited in its ability to obtain reliable information to guide decisionmaking. 

View GAO-12-154 or key components.

For more information, contact Brenda S. 

Farrell at (202) 512-3604 or farrellb@gao.gov. 
Page i GAO-12-154 Defense Health

Letter 1 

Background 4

More Than $2.7 Billion in Appropriated Funds Supported DOD 

Treatment and Research Activities Related to PH and TBI 8

Multiple Entities Play Roles in PH and TBI Activities, but None 

Serves as Coordinating Authority 15

Conclusions 23

Recommendations for Executive Action 23

Agency Comments and Our Evaluation 24

Appendix I Scope and Methodology 26

Appendix II Responsibilities for the Defense Centers of Excellence as Detailed 

in the National Defense Authorization Act for Fiscal Year 2008 29

Appendix III RDT&E-Funded Projects 32

Appendix IV Examples Provided by the Army Medical Research and Materiel 

Command of Ongoing Research That Was Representative of Positive 

Results Achieved to Date 44

Appendix V Comments from the Department of Defense 48

Appendix VI GAO Contact and Staff Acknowledgments 51

Related GAO Products 52

Contents
Page ii GAO-12-154 Defense Health

Tables

Table 1: Defense Components with Roles Addressing PH and TBI 22

Table 2: RDT&E-funded Projects Addressing PH and TBI 32

Figures

Figure 1: Defense Center of Excellence for Psychological Health 

and Traumatic Brain Injury Alignment within DOD 6

Figure 2: System Anticipated from the Army’s Biomarker 

Assessment 45

Figure 3: Brain Imagery Demonstrating the Impact of Treatment 

with NNZ-2256 46

Figure 4: Differences among CT, Routine MRI, and Advanced 

Protocol MRI Scans 47

Abbreviations

DCOE Defense Center of Excellence for Psychological Health and 

Traumatic Brain Injury 

DOD Department of Defense

O&M Operation and Maintenance

PH psychological health

PTSD Post-Traumatic Stress Disorder 

RDT&E Research, Development, Test and Evaluation 

TBI Traumatic Brain Injury 

TMA TRICARE Management Activity

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Page 1 GAO-12-154 Defense Health

United States Government Accountability Office

Washington, DC 20548

January 25, 2012

The Honorable Howard P. McKeon

Chairman

The Honorable Adam Smith

Ranking Member

Committee on Armed Services

House of Representatives

Public concern over health care issues confronting servicemembers 

returning from the wars in Afghanistan and Iraq has grown considerably 

over the past several years. Most recently, concerns have centered on 

two injuries—post-traumatic stress disorder (PTSD) and traumatic brain 

injury (TBI)—which are referred to as the “signature wounds” of these 

wars. TBI is defined as a traumatically induced structural injury or 

physiological disruption of brain function resulting from external force. TBI 

can vary greatly in terms of severity—from mild cases that might involve a 

brief change in mental status, such as being dazed or confused, to severe 

cases that may involve an extended period of unconsciousness or 

amnesia after the injury. Brain injuries are classified as mild, moderate, 

severe, or penetrating, based on factors associated with the initial injury, 

such as the length of time the patient spent in a coma, rather than on the 

symptoms or long-term effects.

In the wake of the February 2007 disclosure of deficiencies in outpatient 

services at the Walter Reed Army Medical Center following an 

investigation by the Washington Post,

1

 

1

Dana Priest and Anne Hull, “Soldiers Face Neglect, Frustration at Army’s Top Medical 

Facility,” Washington Post (Feb. 18, 2007).

various review groups, task 

forces, and presidential commissions investigated the care and benefits 

provided to servicemembers and veterans by the Department of Defense 

 
 

Page 2 GAO-12-154 Defense Health

(DOD) and the Department of Veterans Affairs.2 In May 2007, Congress 

passed a supplemental appropriation that included funding for the 

treatment of PTSD and TBI.3 In the National Defense Authorization Act 

for Fiscal Year 2008, Congress directed DOD to establish Defense 

Centers of Excellence for the prevention, diagnosis, mitigation, treatment, 

and rehabilitation of post-traumatic stress disorder and other mental 

health conditions, as well as traumatic brain injury.4

Consistent with your oversight responsibility, you requested GAO to 

determine how much funding had been used to support DOD PH and TBI 

activities in recent years and how those funds had been used.

Specifically, you requested that we review the following:

(1) DOD’s funding for PH and TBI activities in fiscal years 2007 through 

2010, as well as the accuracy of DOD’s reported obligations and 

expenditures for PH and TBI in its required annual reports to 

Congress; and

(2) DOD’s ability to coordinate its PH and TBI activities to help ensure 

that funds are used to support activities of the most benefit to 

servicemembers.

To determine the amount of appropriated funds that supported activities 

related to PH and TBI for fiscal years 2007 through 2010, we reviewed 

DOD appropriations acts and accompanying committee reports from 

fiscal years 2007 through 2010, and we interviewed and obtained 

documentation from officials with the Office of the Assistant Secretary of 

 

2

The reports include the Independent Review Group, Rebuilding the Trust: Report on 

Rehabilitative Care and Administrative Processes at Walter Reed Army Medical Center 

and National Naval Medical Center (April 2007); Task Force on Returning Global War on 

Terror Heroes, Report to the President (April 2007); Department of Defense Task Force 

on Mental Health, An Achievable Vision: Report of the Department of Defense Task Force 

on Mental Health (June 2007); President’s Commission on Care for America’s Returning 

Wounded Warriors, Serve, Support, Simplify (July 2007); Veterans’ Disability Benefits 

Commission, Honoring the Call to Duty: Veterans’ Disability Benefits in the 21st Century 

(October 2007); and Inspectors General, Department of Defense, Department of Veterans 

Affairs, DOD/VA Care Transition Process for Service Members Injured in OIF/OEF 

(Operation Iraqi Freedom/Operation Enduring Freedom) (June 2008).

3

U.S. Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability 

Appropriations Act, 2007, Pub. L. No. 110-28 (2007), 121 Stat. 134.

4

Pub. L. No. 110-181 §§ 1621, 1622 (2008). 
 

Page 3 GAO-12-154 Defense Health

Defense for Health Affairs; the TRICARE Management Activity’s5 Office 

of the Chief Financial Officer, which manages operation and maintenance 

(O&M) and procurement funds; and the Army Medical Research and 

Materiel Command, which manages research, development, test and 

evaluation (RDT&E) funds. To determine how accurately DOD has been 

reporting obligations and expenditures for PH and TBI in required annual 

reports to Congress, we reviewed and analyzed DOD’s annual reports to 

Congress on expenditures for these activities for calendar years 2008, 

2009, and 2010 and compared information contained in these reports to 

documentation we obtained from the TRICARE Management Activity, the 

Army Medical Research and Materiel Command, and the individual 

military services. Through our assessment of data provided by DOD, as 

well as the assessments of previous GAO reviews,6

To evaluate DOD’s ability to coordinate its PH and TBI activities to help 

ensure that funds are used to support activities of greatest benefit to 

servicemembers, we interviewed officials with the Office of the Assistant 

Secretary of Defense for Health Affairs, which oversees DOD’s medical 

and dental programs; the TRICARE Management Activity; the Defense 

Center of Excellence for Psychological Health and Traumatic Brain Injury 

(DCOE); and the Army Medical Research and Materiel Command. In 

we determined that 

data on reported PH and TBI obligations were unreliable. However, we 

also determined that, because these data are used by DOD and the 

military services to manage their operations, it was appropriate to use 

these data as a starting point for our analysis. Data reliability issues are 

discussed throughout the report, as applicable. Moreover, our findings 

and recommendations address the need for DOD to address data 

reliability weaknesses.

 

5

The TRICARE Management Activity oversees DOD’s medical and dental programs and 

manages and executes the Defense Health Program appropriation. The Director of the 

TRICARE Management Activity reports to the Assistant Secretary of Defense for Health 

Affairs. TRICARE Management Activity’s associated programs, resources, and functions 

include the Uniformed Services University of the Health Sciences, the Armed Forces 

Radiobiology Research Institute, and DCOE. 

6

In conducting prior work in this area, GAO compared Defense Center of Excellence for 

Psychological Health and Traumatic Brain Injury obligations recorded by TRICARE 

Management Activity to supporting documentation and found that, while the date and 

amount of obligations were properly recorded, there were problems at the subobject 

classification level for fiscal year 2009. See GAO, Defense Health: Management 

Weaknesses at Defense Centers of Excellence for Psychological Health and Traumatic 

Brain Injury Require Attention, GAO-11-219 (Washington, DC: Feb. 28, 2011).
 

Page 4 GAO-12-154 Defense Health

addition, we reviewed the legislation establishing different organizations 

with responsibilities for overseeing PH and TBI, i.e., DCOE; the DOD/VA 

Wounded, Ill, and Injured Senior Oversight Committee; the Joint 

Executive Committee; and the Armed Services Biomedical Research 

Evaluation and Management Committee. We analyzed the documents 

generated by these organizations to provide guidance and oversight of 

PH and TBI activities.

We conducted this performance audit from June 2010 through January 

2012 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives. For additional information 

on our scope and methodology, see appendix I.

Congress typically provides funding for the Defense Health Program 

appropriation, including funding for PH and TBI activities, in annual 

defense appropriations. For its fiscal year 2012 budget request, DOD 

requested $52.5 billion to provide health care to approximately 9.6 million 

active-duty servicemembers, reservists, retirees, and their dependents.

This funding includes O&M, RDT&E, and procurement.7 O&M generally 

covers the hiring and payment of civilian providers, along with operation 

costs for running hospitals and other facilities. RDT&E generally covers 

research and development efforts. Procurement covers acquisition 

expenses. The Defense Health Program’s O&M funds are generally 

available for obligation for 1 fiscal year, subject to certain exceptions.8

 

7

The salaries of military medical personnel are funded through the services’ Military 

Personnel appropriations and are therefore not included in the costs we have calculated in 

this report related to care for servicemembers with PH- and TBI-related conditions.

RDT&E funds are generally available for obligation for 2 fiscal years, 

while procurement funds are generally available for obligation for 3 fiscal 

years.

8

For example, certain O&M amounts appropriated for the Defense Health Program by the 

Department of Defense Appropriations Act of for fiscal year 2010 were made available for 

obligation for longer than one fiscal year. Pub. L. No. 111-118, 123 Stat. 3424 (2009).

Background 
 

Page 5 GAO-12-154 Defense Health

Within DOD, the Office of the Assistant Secretary of Defense for Health 

Affairs oversees the Military Health System, a global medical network that 

provides health care to all U.S. military personnel worldwide. The Military 

Health System comprises over 133,000 military and civilian doctors, 

nurses, medical educators, researchers, healthcare providers, allied 

health professionals, and health administration personnel. The Assistant 

Secretary of Defense for Health Affairs oversees the development of 

medical policies, analyses, and recommendations to the Secretary of 

Defense and the Undersecretary for Personnel and Readiness, and 

issues guidance to DOD components on medical matters. The Assistant 

Secretary also serves as the principal advisor to the Undersecretary for 

Personnel and Readiness on matters of chemical, biological, radiological, 

and nuclear medical defense programs and deployment matters 

pertaining to force health. Providing broad oversight for PH and TBI 

matters is only one element among the Assistant Secretary’s 

comprehensive responsibilities. Within the Office of the Assistant 

Secretary of Defense for Health Affairs, the Office of Force Health 

Protection and Readiness coordinates and transmits information on PH 

and TBI activities to Congress on behalf of DOD. The Office of the 

Assistant Secretary of Defense for Health Affairs also serves as director 

of the TRICARE Management Activity, which oversees DOD’s medical 

and dental programs and manages and executes the Defense Health 

Program appropriation. TRICARE Management Activity’s associated 

programs, resources, and functions include the Uniformed Services 

University of the Health Sciences, the Armed Forces Radiobiology 

Research Institute, and the Defense Center of Excellence for 

Psychological Health and Traumatic Brain Injury (DCOE).

Figure 1 presents an organizational chart that shows the current 

alignment of the organizations involved in managing DOD’s PH and TBI 

activities. The TRICARE Management Activity manages and executes 

Defense Health Program O&M and procurement funding for PH and TBI; 

the Army Medical Research and Materiel Command manages and 

executes the majority of Defense Health Program RDT&E funding for PH 

and TBI; and each military service also uses Defense Health Program 

O&M funds distributed to them for PH and TBI activities.
 

Page 6 GAO-12-154 Defense Health

Figure 1: Defense Center of Excellence for Psychological Health and Traumatic 

Brain Injury Alignment within DOD

In two reports that we issued in 2011, we cited numerous management 

weaknesses at DCOE, as well as unreliable reporting of how DOD was 

obligating Defense Health Program O&M funds for the treatment of and 

research on servicemembers experiencing PH- and TBI-related 

problems.9 The National Defense Authorization Act for Fiscal Year 2008 

required DOD to create centers of excellence for PTSD and other mental 

health conditions, and for TBI.10

In our February 2011 report, we discussed challenges facing DCOE as it 

was being developed. We found that DCOE’s lack of mission clarity 

hampered its ability to move forward and that its strategic plan had two 

Congress tasked these centers of 

excellence with numerous responsibilities, to include providing for the 

development, testing, and dissemination of best practices within DOD for 

the treatment of PTSD and TBI. In response, DOD established DCOE as 

the one entity intended to lead DOD’s effort to develop excellence in its 

prevention, outreach, and care for those with these conditions.

 

9

GAO, Defense Health: Management Weaknesses at Defense Centers of Excellence for 

Psychological Health and Traumatic Brain Injury Require Attention, GAO-11-219

(Washington, DC: Feb. 28, 2011) and GAO, Defense Centers of Excellence: Limited 

Budget and Performance Information on the Center for Psychological Health and 

Traumatic Brain Injury, GAO-11-611 (Washington, DC: June 30, 2011).

10Pub. L. No. 110-181, §§ 1621-1622 (2008). 
 

Page 7 GAO-12-154 Defense Health

areas of weakness that did not conform to best practices. Specifically, the 

plan’s management reviews—intended to align activities, resources, and 

goals—were insufficient to ensure that its daily activities were aligned with 

its mission and goals; and the plan did not fully describe how meeting its 

performance measures would help DCOE assess attainment of its goals.

We further found that the TRICARE Management Activity, which 

administered funds allocated to DCOE, had not developed written policies 

and procedures to ensure the proper recording of obligations and that it 

had not properly classified most of DCOE’s fiscal year 2009 contract 

obligations. We recommended that DCOE take steps to improve its 

strategic plan and that the TRICARE Management Activity develop, 

implement, and maintain written procedures for the proper classification 

and recording of DCOE obligations. DOD concurred with our 

recommendations.

In our June 2011 report we reviewed DCOE’s budget formulation process 

and the availability of information about DCOE to Congress. We found 

that DCOE’s role in the DOD budget formulation process was limited to 

consolidating component centers’ budget requests and providing them to 

the TRICARE Management Activity. Further, these budget requests did 

not include complete narrative justifications. Like the February report, this 

one found that DOD had not clearly defined DCOE’s mission. This report 

also found that because DCOE is a relatively small entity funded primarily 

through the larger Defense Health Program appropriation, it falls below 

the most detailed level that is presented in congressional budget 

presentation materials; additionally, DOD is not required to report 

separately on DCOE. We recommended that the TRICARE Management 

Activity work with DCOE to develop and use additional narrative in budget 

justifications and regularly collect and review data on funding and 

obligations. DOD concurred with these recommendations.
 

Page 8 GAO-12-154 Defense Health

From fiscal year 2007 through fiscal year 2010, DOD activities relating to 

the treatment and research of PH and TBI received more than $2.7 

billion. Funding for PH and TBI was derived from specific appropriations 

and congressionally directed amounts drawn from Defense Health 

Program O&M; procurement; and RDT&E appropriations.11 During this 

period, Congress appropriated $675 million specifically for PH and TBI, 

and more than $2 billion was drawn from Defense Health Program 

accounts for activities related to PH and TBI.12

 

11Congressionally directed DOD allocations for PH and TBI were included in explanatory 

statements and committee reports accompanying the respective public laws. In the case 

of large programs, funds are sometimes appropriated specifically for the program in 

question, either directly in the Appropriations Act or through incorporation by reference to 

sections of the relevant conference report. However, funds for a given program may also 

be included in a lump sum appropriation rather than being specifically appropriated for that 

program. Conference reports (and committee reports) often contain program-by-program 

funding information, but these congressional directions do not ordinarily create a legally 

binding subdivision of funds unless they have been incorporated by reference into the 

relevant Appropriation Act. Our totals represent funds specifically appropriated or 

otherwise designated by the DOD for PH and TBI activities out of lump sum 

appropriations.

In fiscal year 2007, total 

appropriations of $900 million supported PH and TBI activities. In fiscal 

year 2008, total funding was $573.8 million. In fiscal year 2009, total 

12Although the National Defense Authorization Act for Fiscal Year 2008 directed DOD to 

establish a center of excellence for TBI and a center of excellence for PTSD and other 

mental health conditions, DOD established one center covering TBI and psychological 

health, which includes post-traumatic stress disorder. Congress, in fiscal year 2008 

expanded the use of funding for post-traumatic stress disorder to include psychological 

health. 

More Than $2.7 

Billion in 

Appropriated Funds 

Supported DOD 

Treatment and 

Research Activities 

Related to PH and TBI

Funding Totaled More 

Than $2.7 Billion
 

Page 9 GAO-12-154 Defense Health

funding was $395 million. In fiscal year 2010, appropriations totaled 

$838.6 million.

Annual reports submitted to Congress by DOD on amounts expended on 

PH and TBI have been incomplete; data on reported obligations are 

unreliable; and, in calculating the cost of medical care for patients with PH 

and TBI, DOD has not clearly stated what is and is not included in these 

figures, making it difficult to arrive at a comprehensive cost for DOD’s PH 

and TBI activities. Section 1634 of the National Defense Authorization Act 

for Fiscal Year 2008 requires the Secretary of Defense to submit an 

annual report setting forth the amounts DOD expended during the 

preceding calendar year on activities relating to the diagnosis, treatment, 

and rehabilitation of servicemembers with PH (to include PTSD) or TBI 

concerns.13

Our analysis of all four reports showed that, while the reports included 

information about reported obligations, they did not include expenditure 

data—as required by the law. Officials in the Office of the Assistant 

Secretary of Defense for Health Affairs, who are responsible for compiling 

and transmitting the reports, said that they had intentionally reported 

amounts obligated instead of amounts expended for two reasons: first, 

expenditures are recorded later, and second, obligation figures are more

representative of current costs, which they interpreted to be Congress’s 

primary interest. In response to the issues raised by our review, these 

officials said that in future reports they would provide an explanation of 

why the only figures reported are amounts obligated. While we recognize 

DOD’s position on this matter, we note that reporting only amounts 

Section 1634 further directs DOD to submit reports annually 

through 2013, with the first report being due no later than March 1, 2008. 

The Office of Force Health Protection and Readiness within the Office of 

the Assistant Secretary of Defense for Health Affairs coordinates and 

transmits this report to Congress on behalf of DOD and works in 

conjunction with the Office of the Chief Financial Officer, TRICARE 

Management Activity, to obtain the requested amounts. DOD has 

submitted four of these annual reports thus far. The first report was 

submitted on May 1, 2008; two reports for calendar year 2009 were 

submitted, one on June 30, 2009, and one on June 29, 2010; and the 

report for calendar year 2010 was submitted on May 10, 2011.

 

13Pub. L. No. 110-181 § 1634 (2008).

DOD-Provided Data in 

Annual Reports to 

Congress on PH and TBI 

Are Incomplete and 

Unreliable
 

Page 10 GAO-12-154 Defense Health

obligated is not fully consistent with the statute. Furthermore, in the 

absence of expenditure data, Congress will not have a complete 

accounting of the cost of PH or TBI activities.

In all four reports, DOD presented general information on activities and 

associated amounts reported as having been obligated for PH and TBI.

DOD also included the estimated number of patients served and the 

estimated costs for PH and TBI patient diagnosis and care. Beyond that, 

in responding to its annual reporting requirement, DOD pursued different 

approaches in its four annual reports. Accordingly, the types of 

information DOD presented varied each year. In its initial report, DOD 

identified spending plans and reported obligations for fiscal year 2008 

O&M and RDT&E funds as of February 29, 2008. The first report provided 

general information on reported monthly O&M obligations across the six 

categories of civilian pay, travel, contracts, supplies, equipment, and 

other. The report also contained reported monthly obligations of RDT&E 

funds divided between PH and TBI. In contrast, the second, third, and 

fourth reports displayed funding data for reported O&M obligations 

according to the strategic initiatives of access to care, quality of care, 

resilience, transition, screening and surveillance, and leadership and 

advocacy. All reported RDT&E obligations were listed under the strategic 

initiative of research. The second, third, and fourth reports also described 

progress achieved to date and planned activities in the upcoming year for 

each strategic initiative. Absent from the third report was any discussion 

of procurement dollars, even though the summary table showed that $20 

million had been appropriated for Defense Health Program procurement 

in fiscal year 2009.

We found, however, that the O&M funding data that DOD provided for all 

four reports on PH and TBI activities are not reliable. As noted earlier, we 

reported in 2011 that we could not confirm the accuracy of O&M figures 

for DCOE and that we had unresolved concerns about the reliability of 

funding and obligations data provided by TRICARE Management 

Activity.14

 

14GAO, Defense Centers of Excellence: Limited Budget and Performance Information on 

the Center for Psychological Health and Traumatic Brain Injury, 

In the present study, we have again found that O&M figures for 

GAO-11-611

(Washington, DC: June 30, 2011). 
 

Page 11 GAO-12-154 Defense Health

DCOE and funding and obligations data provided by TRICARE 

Management Activity are unreliable.15

This lack of reliability is attributable to DOD’s not having a coordinated 

mechanism enabling it to confirm the reliability of data maintained by the 

different databases used in reporting PH- and TBI-related funding. The 

Assistant Secretary of Defense for Health Affairs does not obtain needed 

data from one source; rather, in order to comprehensively identify DOD 

PH and TBI funding and projects, that office must assemble and integrate 

data obtained from several entities. Officials from the Office of the 

Secretary of Defense for Health Affairs obtain funding data from various 

information systems that are maintained by the TRICARE Management 

Activity, the services, and the Defense Finance and Accounting Service.

To track PH and TBI activities funded with O&M dollars, TRICARE 

Management Activity officials use an internal, Web-based information 

system that extracts and aggregates funding data from the internal 

TRICARE Management Activity system as well as the individual service 

components’ systems. TRICARE Management Activity officials said that 

they could confirm the reliability only of information extracted from their 

own internal TRICARE Management Activity system and that they rely on 

the services’ PH/TBI program management offices to ensure the 

completeness and accuracy of the services’ data. The TRICARE officials 

directed us to communicate directly with the respective services’ PH/TBI 

program management offices regarding the completeness and accuracy 

of the services’ data. Service program management and information 

system management officials in turn told us that their internal data 

systems were subcomponents of multiple military departmentwide 

financial management systems. For example, Army officials explained 

that to track Defense Health Program RDT&E funds, the Army Medical 

Research and Materiel Command, must rely on three separate 

servicewide systems—the Standard Army Finance Information System, 

the Standard Operation and Maintenance Army Research and 

 

15To determine data reliability, we drafted and distributed a data reliability assessment 

questionnaire to DOD entities that provided us financial and project information. For 

additional information, see appendix I.
 

Page 12 GAO-12-154 Defense Health

Development System, and the General Fund Enterprise Business 

System—to maintain visibility over relevant funding.16

We have identified internal control17

TRICARE Management Activity officials acknowledged having a 

shortcoming in meeting the internal control standard for confirming 

completeness and accuracy in data and indicated that the Activity is 

moving to integrate its financial management systems. Until the Office of 

the Assistant Secretary of Defense for Health Affairs establishes quality 

control mechanisms coordinated specifically to address the collection and 

reporting of data related to PH and TBI activities maintained on DOD’s 

and the services’ various financial information management systems, 

Congress and others cannot be assured when using DOD’s annually 

reported obligation and expenditure data that they are complete and 

accurate.

as a major part of managing an 

organization and providing reasonable assurance that an agency will 

produce reliable financial reporting, such as reports on budget execution, 

financial statements, and other reports for internal and external use. One 

of the standards for internal control entails the proper execution of 

transactions and events, accurate and timely recording of transactions 

and events, and controls over information processing. This standard 

includes a process for confirming completeness, accuracy, authorization, 

and validity of all transactions during processing.

In addition, DOD includes in its annual reports the estimated costs of caring 

for patients with PH and TBI, but it does not clearly inform readers which 

costs they can expect to find included in these reports. For example, the 

first report states that the full costs of caring for PH and TBI are contained 

in multiple appropriations, yet the report includes only the costs from the 

Defense Health Program’s appropriation. As another example, the report 

states that the scope of psychological health is very broad and includes 

programs ranging from preclinical to transitional health programs and 

services, as well as family, leadership, and community education and 

 

16The Under Secretary of Defense (Comptroller)/Chief Financial Officer has acknowledged 

that DOD financial management systems do not substantially comply with federal financial 

management system requirements, U.S. generally accepted accounting principles, and 

the U.S. Government Standard General Ledger at the transaction level.

17GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, DC: November 1999).
 

Page 13 GAO-12-154 Defense Health

training. However, DOD does not include the costs for these programs, and 

DOD’s calculation of patient care includes only care for servicemembers 

who deployed to Afghanistan or Iraq. Also, although DOD states that 

patient care costs include “direct care and purchased care,” it does not 

define these terms. In particular, it is not clear whether “direct care” 

includes the salaries of military medical personnel. As a result, it is not clear 

which patient care costs should be added to reported O&M, RDT&E, and 

procurement obligations to arrive at a comprehensive cost for DOD’s PH 

and TBI activities. If DOD continues to provide a calculation of patient care 

costs in its annual reports without a clear explanation of what is and is not 

included in its calculation, DOD decisionmakers and Congress will not have 

information needed to enable them to make a complete assessment of how 

much it costs to provide PH and TBI-related activities.

In light of the shortcomings of the reported O&M obligation data that 

TRICARE Management Activity provided to us, we requested obligation 

information on DOD’s O&M- and procurement-related PH and TBI 

projects directly from the military services’ PH/TBI program management 

offices for the 2 years for which data were available— fiscal years 2009 

and 2010.18 We determined that it was appropriate to use this project 

information for the purposes of this review because these are the data 

that DOD and the services use to manage their operations.19 According to 

the service program management offices’ databases, 177 separate PH 

and TBI projects were funded with O&M funds in fiscal years 2009 and 

2010: 152 in fiscal year 2009 and 133 in fiscal year 2010.20

 

18 We were unable to obtain data for fiscal years 2007 and 2008. TRICARE Management 

Activity distributed supplemental funds appropriated in 2007 as a 2-year appropriation for 

fiscal years 2007 and 2008. According to service officials, obligations and distributions 

were thus recorded and tracked as combined fiscal year 2007/2008 transactions, rather 

than separate fiscal years 2007 and 2008 transactions.

For both 

years, a small percentage of these projects accounted for the 

preponderance of reported obligation funds. For example, according to 

Army data, the Army undertook 71 and 52 projects in fiscal years 2009 

and 2010, respectively. Of those projects, four accounted for more than 

half of its O&M-funded projects in both fiscal years. The four projects 

19 We note, however, that both the DOD Inspector General and GAO have identified 

weaknesses in these reported obligation data.

20Of the 177 separate PH and TBI projects, 102 projects spanned both fiscal years 2009 

and 2010.

Small Percentage of PH 

and TBI Projects 

Accounted for 

Preponderance of O&M 

Funding 
 

Page 14 GAO-12-154 Defense Health

were designed to increase TBI care capabilities at six regional medical 

centers; to supplement rehabilitation capabilities at 16 facilities with large 

troop populations; and to hire additional behavioral health practitioners.

According to Army data, prior to fiscal year 2007, each mental health 

practitioner had approximately 6.5 sessions per patient; by fiscal year 

2010, each practitioner had an average of 8 sessions per patient.

Similarly, 4 of the Navy’s 63 projects accounted for more than 50 percent 

of its reported Defense Health Program O&M-funded obligations in fiscal 

years 2009 and 2010.21 The four projects focused on hiring staff and 

purchasing equipment and supplies to support timely access to PH and 

TBI health care; on a family support program to promote family unit 

cohesion following a servicemember’s high-risk deployments; and on 

developing curriculums for service primary care providers to expand their 

knowledge of mental health services. Lastly, Air Force data indicate that 3 

of its 18 projects accounted for less than 80 percent of its reported 

obligations for Defense Health Program O&M funding in fiscal years 2009 

and 2010. That service’s projects entailed the recruitment, qualification, 

and retention of health care workers at service medical treatment facilities 

both inside and outside the United States. We could not complete a 

similar analysis of O&M obligations for fiscal years 2007 and 2008, as the 

data for those years were unavailable. The services have used 

procurement funds to purchase computed tomography scanning22 and 

magnetic resonance imaging equipment to aid in the diagnosis and 

treatment of servicemembers with traumatic brain injuries.

The Army Medical Research and Materiel Command, which has visibility 

over Army and Defense Health Program RDT&E-funded work for PH and 

TBI, identified 397 projects that were underway during fiscal years 2007 

through 2009; data for all of fiscal year 2010 were unavailable at the time 

of our data request. Sixty-six percent of the 397 projects were Research 

and Technology Development (nonclinical) projects. These types of 

studies form the knowledge- and technology-based foundation necessary 

to establish the initial feasibility and practicality of proposed solutions to 

problems. The remaining 34 percent of the 397 projects were Clinical 

 

21The Department of the Navy includes the Navy and the Marine Corps.

22Computed tomography scanning is the imaging of anatomical information from a crosssectional plane of the body, each image generated by a computer synthesis of x-ray 

transmission data obtained in many different directions in a given plane.

Army and Defense Health 

Program RDT&E Funding 

Evenly Divided Between 

Clinical and Non-Clinical 

Projects
 

Page 15 GAO-12-154 Defense Health

Research and Development—projects that are typically conducted in a 

clinical setting using human research volunteers (including patients) and 

are directed at amassing the definitive level of evidence required to inform 

changes in medical practice or required for licensure of a product 

regulated by the Food and Drug Administration. Although there were 

twice as many nonclinical as there were clinical projects, dollars awarded 

were distributed fairly evenly between these two types. See appendix III

for a listing of the 397 RDT&E projects, and see appendix IV for 

descriptions of three examples the Army highlighted as representative of 

positive results achieved to date.

No one organization coordinates DOD’s PH and TBI activities. The 

National Defense Authorization Act of Fiscal Year 2008 directed the 

Secretary of Defense to establish a Center of Excellence for PTSD and 

other mental health conditions and a second Center of Excellence for TBI 

and directed those Centers to, among other things, implement DOD’s 

comprehensive plans for these issues, disseminate best practices, provide 

guidance, and conduct research. (For a complete listing of the 

responsibilities assigned to the Centers in this legislation, see app. II.) 

Subsequently, a Senior Oversight Committee established by the 

Secretaries of Defense and Veterans Affairs reported in its comprehensive 

plan to Congress that DOD had combined these two Centers into one 

DCOE for PH and TBI to lead efforts in practice standards, training, 

outreach, research, and direct care. We found, however, as we had in prior 

reports, that DCOE’s strategic plan did not reflect a clear mission that 

focused the organization on its statutory responsibilities. Instead, 

responsibilities are dispersed among the TRICARE Management Activity, 

the Army Medical Research and Materiel Command, and others. While the 

Office of the Assistant Secretary of Defense for Health Affairs has broad 

oversight for all of DOD’s missions, its global role prevents it from focusing 

on PH and TBI activities specifically.

Multiple Entities Play 

Roles in PH and TBI 

Activities, but None 

Serves as 

Coordinating 

Authority
 

Page 16 GAO-12-154 Defense Health

The National Defense Authorization Act for Fiscal Year 2008 directed the 

establishment of Defense Centers of Excellence to address the 

prevention, diagnosis, mitigation, treatment, and rehabilitation of PTSD 

and TBI and other mental health conditions.23 In the legislation, Congress 

enumerated 10 responsibilities for the Center dedicated to PTSD and 

other mental health conditions and 13 responsibilities for the Center 

dedicated to TBI. Among other things, Congress directed the Centers to 

implement DOD’s comprehensive plans for these issues, disseminate 

best practices, provide guidance, and conduct research. The 

comprehensive plan24 that was issued by the DOD/VA Wounded, Ill, and 

Injured Senior Oversight Committee25 combined the two Centers into one 

and reported that DOD had created this Center—DCOE—to lead efforts 

in PH and TBI practice standards, training, outreach, research, and direct 

care. The Committee assigned to DCOE the responsibility for acting as 

an information clearinghouse that would allow any servicemember or 

family member to navigate the system of care “with a single phone call.” It 

also assigned DCOE the responsibility for coordinating an overarching 

program of research that is relevant to the needs of the field, in 

coordination with other DOD organizations, the Department of Veterans 

Affairs, the National Institutes of Health, and other partners. In its own 

plan, DCOE further defined its anticipated mission. DCOE said that it 

would serve as a coordinating authority for DOD’s PH and TBI issues and 

perform a DOD-wide gap analysis to identify needed programming.

DCOE said that it would also provide teams for site visits to evaluate 

facilities and innovative practices and coordinate initiatives to address 

research gaps.

 

23Pub. L. No. 110-181 §§ 1621-1622 (2008). PTSD was later incorporated into the 

category of psychological health.

24Report to Congress in Response to the National Defense Authorization Act for Fiscal 

Year 2008, Section 1618, Comprehensive Plan on Prevention, Diagnosis, Mitigation, 

Treatment, and Rehabilitation of, and Research on, Traumatic Brain Injury, PostTraumatic Stress Disorder, and Other Mental Health Conditions in Members of the Armed 

Forces (Oct. 31, 2008).

25 This Committee was established by the Secretaries of Defense and Veterans Affairs in 

2007 to make recommendations for existing policies on the coordination and sharing of 

resources between DOD and the Department of Veterans Affairs.

Defense Center of 

Excellence for PH and TBI 

Was Directed to Implement 

DOD’s Comprehensive 

Plans for PH and TBI
 

Page 17 GAO-12-154 Defense Health

As stated previously, DCOE, in defining its mission, reported that it would 

serve as DOD’s coordinating authority on PH and TBI matters. However, 

as also stated earlier, we found, as we had in our previous 2011 reports, 

that DCOE’s strategic plan did not reflect a clear mission that focused the 

organization on its statutory responsibilities. Instead, responsibilities are 

dispersed among the TRICARE Management Activity, the Army Medical 

Research and Materiel Command, and others. While the Office of the 

Assistant Secretary of Defense for Health Affairs has broad oversight for 

all of DOD’s missions, including DCOE, its global role prevents it from 

focusing on PH and TBI activities specifically.26

Within the Office of the Assistant Secretary of Defense for Health Affairs, 

the TRICARE Management Activity Program, Budget, and Execution 

Division manages O&M and procurement funds for PH and TBI. The 

Office of the Chief Financial Officer is responsible for an internal, Webbased information system used to record and track Defense Health 

Program-related data on O&M-funded PH and TBI initiatives. The Office 

of Force Health Protection and Readiness operates and maintains a data 

management system called ProSight, which contains descriptions of the 

O&M-funded projects.

At present, to report on 

DOD Defense Health Program-funded PH and TBI activities, the Office of 

the Assistant Secretary of Defense for Health Affairs must collect 

information on activities funded with O&M and procurement funds from 

the TRICARE Management Activity, while for activities funded with 

RDT&E funds, it collects the information from the Army Medical Research 

and Materiel Command and other DOD research activities. It must 

additionally obtain information directly from the military services, which 

have been given funds for these purposes. More importantly, no single 

organization is devoted to ensuring that accurate and timely data are 

available on DOD’s PH and TBI activities, which would help to ensure that 

DOD-wide efforts are coordinated and do not involve duplication of effort.

Separately, the Army Medical Research and Materiel Command manages 

the majority of the Defense Health Program’s RDT&E funds for PH and TBI. 

In 2006, Congress directed the Secretary of Defense to designate an 

 

26According to DOD Directive 5136.01, the Office of the Assistant Secretary of Defense for 

Health Affairs is responsible for ensuring the effective execution of DOD’s medical 

mission, and, in carrying out that responsibility, is required to exercise authority, direction, 

and control over funding and other resources, which would include funds used for PH and 

TBI. 

Multiple Organizations 

Have Purview over PH and 

TBI Initiatives
 

Page 18 GAO-12-154 Defense Health

executive agent for coordinating and managing DOD’s medical research 

efforts and programs relating to the prevention, mitigation, and treatment of 

blast injuries.27 In response, DOD issued a directive in July 2006 designating 

the Secretary of the Army as the executive agent28

To identify DOD’s PH and TBI funding and projects, the Office of the 

Assistant Secretary of Defense for Health Affairs must reach out to 

several entities, acquire the discrete sets of data needed, and assemble 

them into a single integrated list. In conducting our review, we, too, had to 

obtain the information from several different sources, including the 

TRICARE Management Activity, the Medical Research and Materiel 

Command, and the individual military services, in order to compile a 

comprehensive, up-to-date, and reliable list of its PH and TBI activities.

The office that provided us with data on obligations and expenditures 

related to O&M-funded PH and TBI was the TRICARE Management 

Activity Office of the Chief Financial Officer. The office that provided us 

descriptions of O&M-funded PH and TBI projects was the Assistant 

Secretary of Defense for Health Affairs’ Force Health Protection and 

Readiness office. Officials in this office, which maintains the ProSight 

database, told us this database is solely a tool for monitoring the quantity 

for the purpose specified 

by Congress. The Secretary of the Army delegated the authority and 

assigned executive responsibility to the Assistant Secretary of the Army 

(Acquisition, Logistics, and Technology), who delegated authority and 

assigned program responsibility to the U.S. Army Medical Command. The 

Blast Injury Coordinating Office was established within and is managed by 

the Medical Research and Materiel Command, a subcomponent of the Army 

Medical Command, to assist in coordinating and managing relevant DOD 

medical research efforts and programs related to the prevention, mitigation, 

and treatment of blast injuries. According to the directive, a blast injury is 

defined as an injury that occurs as a result of the detonation of high 

explosives, including vehicle-borne and person-borne explosive devices, 

rocket-propelled grenades, and improvised explosive devices. According to a 

Medical Research and Materiel Command official, medical research on blast 

injuries is very often applicable to the prevention, mitigation, and treatment of 

PTSD, PH, and TBI.

 

27National Defense Authorization Act for Fiscal Year 2006, Pub. L. No. 109-163, § 256 

(2006). 

28Department of Defense Directive 6025.21E, Medical Research for Prevention, Mitigation, 

and Treatment of Blast Injuries (July 5, 2006).
 

Page 19 GAO-12-154 Defense Health

and type of projects—emphasizing that it is not an authoritative source of 

information on associated obligations or expenditures. In light of this 

limitation, as well as our assessment that the reported O&M obligation 

data TRICARE Management Activity provided us were unreliable, we 

requested obligation information on DOD’s O&M- and procurementrelated PH and TBI projects directly from the military services, as 

discussed above. To obtain information on RDT&E projects, we 

requested data from the Army Medical Research and Materiel Command, 

which has visibility over the majority of Defense Health Program RDT&E 

appropriations. In a recently issued report, the RAND Corporation 

similarly found the identification of PH and TBI programs to be “a complex 

task.” RAND also found that no single source in DOD or any of the 

branches of service maintains a complete listing of programs, tracks the 

development of new programs, or has appropriate resources in place to 

direct servicemembers and their families to the full array of programs that 

best meet their needs.29

By the time DCOE was established in 2007, review groups, task forces, 

and presidential commissions had already developed more than 400 

recommendations on how to improve the care and treatment of wounded 

warriors. These groups agreed that the Military Health System lacked the 

fiscal resources and fully trained personnel needed to fulfill its mission to 

support PH and TBI in peacetime, as well as the enhanced requirements 

imposed during times of conflict.

For example, to address rising concerns over the care and treatment of 

wounded warriors from Operations Enduring Freedom and Iraqi Freedom, 

in May 2007 the Secretaries of Defense and Veterans Affairs created a 

Senior Oversight Committee composed of officials and service chiefs from 

DOD, the Department of Veterans Affairs, and the military services. Tasked 

with initiating the process of reforming the system of care for wounded 

warriors, the committee dedicated one of its eight lines of action to 

addressing the issues of PH and TBI. In June 2007, the Office of Force 

Health Protection and Readiness, in the Office of the Assistant Secretary of 

Defense for Health Affairs, brought in subject matter experts from each of 

the services and the Department of Veterans Affairs’ healthcare system to 

 

29RAND, Programs Addressing Psychological Health and Traumatic Brain Injury Among 

U.S. Military Servicemembers and Their Families (Arlington, VA: 2011).

Other Entities Also Play 

Roles in PH and TBI 

Matters
 

Page 20 GAO-12-154 Defense Health

establish the “Red Cell”—a group meant to cut across routine channels to 

quickly implement changes. The Red Cell was tasked with reviewing the 

400 recommendations for improving the care and treatment of wounded 

warriors and with formulating an action plan, developing proposals for 

policy changes needed to implement the plan, and serving as liaison with 

DOD and the Department of Veterans Affairs. DOD officials told us that the 

Committee remains in existence, although it was originally intended to be 

temporary. Section 1624 of the National Defense Authorization Act for 

Fiscal Year 2008 required that a report be submitted to Congress on the 

establishment of the centers of excellence for PH and TBI, among other 

things, and the Committee addressed that requirement.30 Section 1618 of 

the 2008 National Defense Authorization Act also required that the 

Secretary of Defense, in consultation with the Secretary of Veterans Affairs, 

submit a comprehensive plan for programs and activities of the Department 

of Defense to prevent, diagnose, mitigate, treat, research, and otherwise 

respond to traumatic brain injury, PTSD, and other mental health conditions 

in members of the armed forces. A report was issued in response to that 

requirement in October 2008.31

When the Senior Oversight Committee was established in 2007, other 

committees already existed whose responsibilities included oversight of 

activities for PH and TBI. For example, in 2003 Congress established the 

Department of Defense-Department of Veterans Affairs Joint Executive 

Committee, to comprise the Deputy Secretary of Veterans Affairs and 

DOD’s Under Secretary of Defense for Personnel and Readiness, as well 

as others designated by the Secretary of Veterans Affairs and the 

Secretary of Defense.32

 

30Report on Establishment of Centers of Excellence: Report to Congress, DoD/VA 

Wounded, Ill, and Injured Senior Oversight Committee (Nov. 19, 2008). 

This committee was tasked, among other things, 

with reviewing and making recommendations for existing policies, 

procedures, and practices relating to the coordination and sharing of 

resources between DOD and the Department of Veterans Affairs and with 

identifying changes that would promote mutually beneficial coordination, 

31Report to Congress in Response to the National Defense Authorization Act for Fiscal 

Year 2008, Section 1618, Comprehensive Plan on Prevention, Diagnosis, Mitigation, 

Treatment, and Rehabilitation of, and Research on, Traumatic Brain Injury, PostTraumatic Stress Disorder, and other Mental Health Conditions in Members of the Armed 

Forces (Oct. 31, 2008).

32National Defense Authorization Act for Fiscal Year 2004, Pub. L. No. 108-136 § 583 

(Nov. 24, 2003), codified at 38 U.S.C. § 320.
 

Page 21 GAO-12-154 Defense Health

use, or exchange of services and resources of the two Departments. 

Additionally, the law requires the committee to submit an annual report to 

the Secretaries, recommending strategic direction for joint coordination and 

sharing efforts between and within the two Departments, under 38 U.S.C.§ 

8111, and to oversee implementation of those efforts. The Joint Executive 

Committee subsequently issued a Joint Strategic Plan for 2010-2012 to 

provide direction on DOD’s and the Department of Veterans Affairs’ joint 

efforts to coordinate and share resources. Under Goal 2, High Quality 

Health Care, this plan included various initiatives involving PH, TBI, and the 

Centers of Excellence. The Committee also created a subgroup to oversee 

these issues: the Health Executive Council’s Psychological 

Health/Traumatic Brain Injury Working Group.

In 2002, a committee was established by DOD to provide guidance and 

oversight of all military health system programs: the Senior Military 

Medical Advisory Council, chaired by the Assistant Secretary of Defense 

for Health Affairs and made up of the services’ surgeons general. The 

task of this council is to make recommendations concerning the military 

health system. In 2011, one of this council’s initiatives was to create a 

Center of Excellence Advisory Board, which will have responsibility for 

reviewing all centers of excellence, including DCOE, with a view toward 

eliminating any duplication of efforts or unnecessary services.

As early as 1980, DOD had also established a committee to coordinate 

the efforts undertaken by the offices of the Under Secretary of Defense 

for Acquisition, Technology, and Logistics and the Assistant Secretary of 

Defense for Health Affairs. In that year, DOD created the Armed Services 

Biomedical Research Evaluation and Management Committee to be cochaired by the Director of Defense Research and Engineering under the 

Under Secretary of Defense for Acquisition, Technology, and Logistics 

and the Assistant Secretary of Defense for Health Affairs. The purpose of 

this committee was to facilitate coordination within DOD biomedical 

research and development. (See table 1 for a listing of the organizations 

that play roles in addressing PH and TBI matters.)
 

Page 22 GAO-12-154 Defense Health

Table 1: Defense Components with Roles Addressing PH and TBI 

Number Defense component Duties

1 Office of the Assistant Secretary of Defense for 

Health Affairs

Oversees the Military Health System, a global medical network that 

provides health care to all U.S. military personnel worldwide

TRICARE Management Activity Manages and executes O&M and procurement funding for PH and 

TBI, including funding for the Defense Center of Excellence

Office of Force Health Protection and 

Readiness

Coordinates and transmits the annual report required by section 1634 

of the National Defense Authorization Act for Fiscal Year 2008 to 

Congress on behalf of DOD and works in conjunction with the Office 

of the Chief Financial Officer, TRICARE Management Activity, to 

obtain the requested amounts

Operates and maintains a data management system called ProSight, 

which contains descriptions of the O&M-funded projects.

Defense Center of Excellence for PH and TBI Established in 2007 to lead DOD’s effort to develop excellence in its 

prevention of, outreach to, and care for those suffering from these 

conditions

2 Army Medical Research and Materiel 

Command

Manages and executes the majority of Defense Health Program 

RDT&E funding for PH and TBI

3 Joint DOD/Veterans Affairs Wounded, Ill, and 

Injured Senior Oversight Committee

Established in 2007 and tasked with initiating reform of the system of 

care for wounded warriors; one of its eight lines of action addresses 

the issues of PH and TBI

4 Joint Executive Committee

(Undersecretary of Defense for Personnel and 

Readiness and Deputy Secretary for Veterans 

Affairs) 

Established in 2003 and tasked with reviewing and making 

recommendations regarding policies, procedures, and practices 

relating to the coordination and sharing of resources between DOD 

and the Department of Veterans Affairs

Health Executive Council’s Psychological 

Health / Traumatic Brain Injury Working Group

Subgroup created by the Joint Executive Committee to oversee PH 

and TBI issues

5 Senior Military Medical Advisory Council Established in 2002 and tasked with making recommendations 

concerning the military health system; recently created the Center of 

Excellence Advisory Board

Center of Excellence Advisory Board Established in 2011 and tasked with reviewing all centers of 

excellence, including DCOE, so as to avert any duplication of efforts 

or unnecessary services

6 Armed Services Biomedical Research 

Evaluation and Management Committee

Established in 1980 and tasked with facilitating coordination within 

DOD for biomedical research and development

Source: Compiled by GAO based on DOD information.

While these DOD and Veterans Affairs’ organizations may each serve a 

unique purpose, the organization responsible for addressing reform 

efforts needed for PH and TBI (the DOD/VA Wounded, Ill, and Injured 

Senior Oversight Committee) intended DCOE to be the information 

clearinghouse and coordinator of an overarching program of research for 

PH and TBI matters. DCOE did not ultimately grow into that role. Also, 

though the Office of the Assistant Secretary of Defense for Health Affairs 

provides broad oversight for all of DOD’s missions, its global role 
 

Page 23 GAO-12-154 Defense Health

prevents it from focusing on PH and TBI activities specifically. Until a 

single organization is tasked with coordinating DOD’s PH and TBI 

activities, DOD’s ability to manage these activities will remain fragmented, 

and duplication of effort remains a possibility.

Despite the heightened significance of PH and TBI matters, the attention 

drawn to them by numerous studies, and the more than $2.7 billion of 

appropriated funds that supported related programs, DOD is not currently 

in a position to readily report in a reliable manner on how funds are being 

used to provide benefits to servicemembers. While DOD has undertaken 

a number of initiatives, the information that it has been reporting has been 

incomplete and based on data that are unreliable. Further, DOD’s visibility 

of PH and TBI activities remains limited because it must collect 

information from many entities—the TRICARE Management Activity, the 

Assistant Secretary of Defense for Health Affairs’ Force Health Protection 

and Readiness Office, the Army Medical Research and Materiel 

Command, and the individual military services. At present, there is no 

entity tasked with maintaining up-to-date and comprehensive information 

on DOD’s PH and TBI activities and, more importantly, no entity 

coordinates DOD’s PH and TBI activities. As a result, DOD is hampered 

in its efforts to ensure that resources are used effectively to meet goals; 

and Congress and entities with oversight responsibility will be limited in 

their ability to obtain reliable information to guide their decisionmaking.

To increase visibility over how DOD is spending appropriated funds to 

address PH and TBI conditions, we recommend that the Secretary of 

Defense direct the Assistant Secretary of Defense for Health Affairs to 

take the following four actions:

(1) include expenditures for PH and TBI activities in annual reports to 

Congress as directed by Section 1634 of the National Defense 

Authorization Act for Fiscal Year 2008;

(2) develop, maintain, and coordinate quality control mechanisms that 

help ensure that the obligation and expenditure data they report on 

PH and TBI projects and research are complete and accurate;

(3) if patient costs are provided in future annual reports, clearly show 

what is included and not included for all patient costs; and

Conclusions 

Recommendations for 

Executive Action
 

Page 24 GAO-12-154 Defense Health

(4) revisit DCOE’s role as DOD’s coordinating authority for issues 

concerning PH and TBI, as stated in its own plan, and determine 

whether it or another organization should perform this function.

In written comments on a draft of this report, DOD concurred with all four 

of our recommendations (see app. V). In concurring with our first 

recommendation, which addresses the need to include expenditures in 

DOD’s annual reports, DOD stated that it will include available 

expenditure data in the next annual report but noted that expenditure data 

often lag behind the end of the fiscal year by several months. We agree, 

but since the upcoming annual report is the fifth report, expenditure data 

would be available for the preceding years.

In commenting on our second recommendation, which concerns quality 

control mechanisms to help ensure the completeness and accuracy of 

data, DOD stated that the DOD accounting structure does not allow for a 

single system of assembling and reporting fiscal data but that the Office 

of the Assistant Secretary of Defense for Health Affairs and TRICARE 

Management Activity will take steps to improve the accuracy and 

reliability of the data. While we commend DOD’s efforts to improve the 

accuracy of its data, we did not recommend that it maintain a single data 

system; we believe that multiple systems can be coordinated to provide 

accurate and reliable data if appropriate internal controls are in place.

In concurring with our third recommendation—to clearly show in annual 

reports what is included and what is not included in the calculation of 

patient costs, if such costs are to be provided in future annual reports—

DOD stated it will omit this information in future reports, as it is confusing.

While DOD’s report is not explicitly required to include the cost of patient 

care, we believe that DOD’s inclusion of the cost of patient care in its 

annual reports, if clearly presented, would provide a more complete 

picture of overall TBI and PH costs.

Lastly, in concurring with our fourth recommendation, to revisit DCOE’s 

role as DOD’s coordinating authority for issues concerning PH and TBI 

and determine whether DCOE or another organization should perform 

this function, DOD stated that a “revisit” of DCOE’s role is currently 

underway. DOD stated that the Center of Excellence Advisory Board, part 

of the Military Health System’s governance structure, is overseeing the 

development of a revised and detailed concept of operations for DCOE. 

DOD also stated that its Cost Assessment and Program Evaluation Office 

has requested that DCOE assume a larger role in the evaluation of 

Agency Comments 

and Our Evaluation
 

Page 25 GAO-12-154 Defense Health

psychological health and traumatic brain injury programs. We commend 

DOD for undertaking a revisit of DCOE’s role, especially in having DCOE 

evaluate current programs. Such evaluations should provide DOD with 

valuable information that will help decisionmakers determine how to 

maximize resources to ensure that funds are spent as efficiently as 

possible.

The Office of the Assistant Secretary of Defense for Health Affairs and 

the Department of the Army provided technical comments as well, which 

we have addressed in the report text, where applicable.

We are sending copies of this report to the Secretary of Defense, the 

Assistant Secretary of Defense for Health Affairs, appropriate 

congressional committees, and other interested parties. This report will 

also be available at no charge on GAO’s Web site at http://www.gao.gov. 

If you or your staff have questions about this report, please contact me at 

(202) 512-3604 or farrellb@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. Key contributors to this report are listed in appendix VI.

Brenda S. Farrell

Director, Defense Capabilities 

 and Management
Appendix I: Scope and Methodology

Page 26 GAO-12-154 Defense Health

In the course of our review, we obtained information from or interviewed 

officials with the Office of the Secretary of Defense, in Falls Church, 

Virginia; TRICARE Management Activity, in Falls Church, Virginia; Army 

Medical Command, in Joint Base San Antonio, Texas; Army Medical 

Research and Materiel Command, in Fort Detrick, Maryland; Navy 

Bureau of Medicine, in Washington, D.C.; and Air Force Medical Service, 

in Joint Base San Antonio, Texas.

To determine how much funding was received by activities related to PH 

and TBI for fiscal years 2007 through 2010, we reviewed DOD 

appropriations acts and accompanying committee reports from fiscal 

years 2007 through 2010, and we interviewed and obtained 

documentation from officials with the TRICARE Management Activity. To 

assess how accurately DOD has been in reporting obligations and 

expenditures for PH and TBI in its required annual reports to Congress, 

we reviewed section 1634 of the 2008 National Defense Authorization Act 

mandating the annual reports and analyzed DOD’s annual reports to 

Congress on expenditures for activities on PH and TBI for calendar years 

2008, 2009, and 2010. In addition, we interviewed officials with the Office 

of the Assistant Secretary of Defense for Health Affairs and the TRICARE 

Management Activity regarding the methodology used to develop each of 

the four annual reports. To determine the PH and TBI activities for which 

O&M and procurement funds had been obligated, we obtained 

documentation from and conducted interviews with officials at the 

TRICARE Management Activity. To determine activities for which RDT&E 

funds had been obligated, we obtained documentation from and 

conducted interviews with officials from the Army Medical Research and 

Materiel Command. To assess and verify the reliability of the obligation 

data received from these DOD entities, we drafted and distributed a data 

reliability assessment questionnaire to DOD entities that provided us 

financial and project information. From the officials’ responses, we 

received information on the purpose of, the collection processes, and the 

internal quality controls used by the respective entity’s financial 

information system. In addition, we interviewed officials with the 

TRICARE Management Activity and the military departments about their 

policies and internal control procedures used to ensure the accuracy and 

reliability of information entered into DOD’s information and financial 

management systems. We and the DOD Inspector General have reported 

on the unreliability of DOD’s financial transactions data, including 

Appendix I: Scope and Methodology
Appendix I: Scope and Methodology

Page 27 GAO-12-154 Defense Health

accounting for obligations.1

To evaluate DOD’s ability to coordinate all PH and TBI activities to help 

ensure that funds are used to support programs of the most benefit to 

servicemembers, we interviewed officials with the Office of the Assistant 

Secretary of Defense for Health Affairs, TRICARE Management Activity, 

Defense Center of Excellence for Psychological Health and Traumatic 

Brain Injury, and Army Medical Research and Materiel Command.

However, because these data are the only 

data available describing how PH/TBI funds are used and they are the 

data used by DOD and the military services to manage their operations, 

we determined that it is appropriate to use these data for the purpose of 

our report. Although we requested and received expenditure data from 

DOD, we identified several inconsistencies and determined the data were 

unreliable. As a result, we excluded that information and reported only on 

those PH and TBI activities for which funds had been obligated.

In addition, we reviewed the legislation establishing the Defense Centers 

of Excellence. We also reviewed the Senior Oversight Committee’s 2008 

report to Congress outlining its strategy for transforming and expanding 

PH and TBI services and providing protection, prevention, diagnosis, 

treatment, recovery, and care transition to military members. We also 

reviewed section 583 of the National Defense Authorization Act for 2004 

that established the Joint Executive Committee, which was tasked with, 

among other things, reviewing policies, procedures, and practices relating 

to the coordination and sharing of resources between the Department of 

Veterans Affairs and DOD and making related recommendations. We 

reviewed the Joint Executive Council’s Joint Strategic Plan for 2010-2012, 

which provided direction on DOD’s and the Department of Veterans 

Affairs’ joint efforts to coordinate and share resources and described a 

 

1

In conducting prior work in this area, the GAO team tested DCOE obligations recorded by 

TMA for DCOE to supporting documentation and found that while the date and amount of 

obligations were properly recorded, there were problems at the subobject classification 

level for fiscal year 2009. See Defense Health: Management Weaknesses at Defense 

Centers of Excellence for Psychological Health and Traumatic Brain Injury Require 

Attention, GAO-11-219 (Washington, DC: Feb. 28, 2011). See also GAO, DOD Financial 

Management: Weaknesses in Controls over the Use of Public Funds and Related 

Improper Payments, GAO-11-950T (Washington, DC: Sept. 22, 2011) and DOD Financial 

Management: Improvements Are Needed in Antideficiency Act Controls and 

Investigations, GAO-08-1063 (Washington, DC: Sept. 26, 2008) and Department of 

Defense Office of Inspector General, Independent Auditor’s Report on the DOD Agency 

wide FY 2010 and 2009 Basic Financial Statements, Report D-2011-013 (Arlington, VA:

Nov. 15, 2010).
Appendix I: Scope and Methodology

Page 28 GAO-12-154 Defense Health

subgroup formed to oversee PH and TBI issues, the Health Executive 

Council’s Psychological Health/Traumatic Brain Injury Working Group. In 

addition, we reviewed documents describing the role of a committee 

established by DOD in 2002 to provide guidance and oversight of all 

military health system programs: the Senior Military Medical Advisory 

Committee, chaired by the Assistant Secretary of Defense for Health 

Affairs and made up of the services’ surgeons general. Finally, we 

reviewed DOD’s guidance on the Armed Services Biomedical Research 

Evaluation and Management Committee to coordinate efforts undertaken 

by the offices of the Under Secretary of Defense for Acquisition, 

Technology and Logistics and the Assistant Secretary of Defense for 

Health Affairs.

We conducted this performance audit from July 2010 through January 

2012 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.
Appendix II: Responsibilities for the Defense 

Centers of Excellence as Detailed in the 

National Defense Authorization Act for Fiscal 

Year 2008

Page 29 GAO-12-154 Defense Health

In sections 1621 and 1622 of the National Defense Authorization Act 

for Fiscal Year 2008, Pub. L. No. 110-181 (2008), Congress directed 

the Department of Defense to establish Defense Centers of 

Excellence for Traumatic Brain Injury (TBI) and for Post-Traumatic 

Stress Disorder (PTSD) and other mental health conditions.

Section 1621 states that the Center of Excellence for TBI shall have 

the following responsibilities:

1. To implement the comprehensive plan and strategy for the 

Department of Defense, required by section 1618 of this Act, for the 

prevention, diagnosis, mitigation, treatment, and rehabilitation of 

traumatic brain injury, including research on gender and ethnic groupspecific health needs related to traumatic brain injury.

2. To provide for the development, testing, and dissemination within the 

Department of best practices for the treatment of traumatic brain injury.

3. To provide guidance for the mental health system of the Department 

in determining the mental health and neurological health personnel 

required to provide quality mental health care for members of the 

Armed Forces with traumatic brain injury.

4. To establish, implement, and oversee a comprehensive program to 

train mental health and neurological health professionals of the 

Department in the treatment of traumatic brain injury.

5. To facilitate advancements in the study of the short-term and longterm psychological effects of traumatic brain injury.

6. To disseminate within the military medical treatment facilities of the 

Department best practices for training mental health professionals, 

including neurological health professionals, with respect to traumatic 

brain injury.

7. To conduct basic science and translational research on traumatic 

brain injury for the purposes of understanding the etiology of traumatic 

brain injury and developing preventive interventions and new 

treatments.

8. To develop programs and outreach strategies for families of members 

of the Armed Forces with traumatic brain injury in order to mitigate the 

negative impacts of traumatic brain injury on such family members and 

to support the recovery of such members from traumatic brain injury.

Appendix II: Responsibilities for the Defense 

Centers of Excellence as Detailed in the National 

Defense Authorization Act for Fiscal Year 2008 
Appendix II: Responsibilities for the Defense 

Centers of Excellence as Detailed in the 

National Defense Authorization Act for Fiscal 

Year 2008

Page 30 GAO-12-154 Defense Health

9. To conduct research on the mental health needs of families of 

members of the Armed Forces with traumatic brain injury and develop 

protocols to address any needs identified through such research.

10. To conduct longitudinal studies (using imaging technology and other 

proven research methods) on members of the Armed Forces with 

traumatic brain injury to identify early signs of Alzheimer’s disease, 

Parkinson’s disease, or other manifestations of neurodegeneration, as 

well as epilepsy, in such members, in coordination with the studies 

authorized by section 721 of the John Warner National Defense 

Authorization Act for Fiscal Year 2007 (Public Law 109-364; 120 Stat. 

2294) and other studies of the Department of Defense and the 

Department of Veterans Affairs that address the connection between 

exposure to combat and the development of Alzheimer’s disease, 

Parkinson’s disease, and other neurodegenerative disorders, as well 

as epilepsy.

11. To develop and oversee a long-term plan to increase the number of 

mental health and neurological health professionals within the 

Department in order to facilitate the meeting by the Department of the 

needs of members of the Armed Forces with traumatic brain injury 

until their transition to care and treatment from the Department of 

Veterans Affairs.

12. To develop a program on comprehensive pain management, including 

management of acute and chronic pain, to utilize current and develop 

new treatments for pain, and to identify and disseminate best 

practices on pain management related to traumatic brain injury.

13. Such other responsibilities as the Secretary shall specify.

Section 1622 states that the Center of Excellence for PTSD and Other 

Mental Health Conditions shall have the following responsibilities:

1. To implement the comprehensive plan and strategy for the 

Department of Defense, required by section 1618 of this Act, for the 

prevention, diagnosis, mitigation, treatment, and rehabilitation of posttraumatic stress disorder and other mental health conditions, including 

research on gender and ethnic group-specific health needs related to 

post-traumatic stress disorder and other mental health conditions.

2. To provide for the development, testing, and dissemination within the 

Department of best practices for the treatment of post-traumatic stress 

disorder and other mental health conditions.
Appendix II: Responsibilities for the Defense 

Centers of Excellence as Detailed in the 

National Defense Authorization Act for Fiscal 

Year 2008

Page 31 GAO-12-154 Defense Health

3. To provide guidance for the mental health system of the Department 

in determining the mental health and neurological health personnel 

required to provide quality mental health care for members of the 

Armed Forces with post-traumatic stress disorder and other mental 

health conditions.

4. To establish, implement, and oversee a comprehensive program to 

train mental health and neurological health professionals of the 

Department in the treatment of post-traumatic stress disorder and 

other mental health conditions.

5. To facilitate advancements in the study of the short-term and longterm psychological effects of post-traumatic stress disorder and other 

mental health conditions.

6. To disseminate within the military medical treatment facilities of the 

Department best practices for training mental health professionals, 

including neurological health professionals, with respect to posttraumatic stress disorder and other mental health conditions.

7. To conduct basic science and translational research on post-traumatic 

stress disorder and other mental health conditions for the purposes of 

understanding the etiology of post-traumatic stress disorder, and 

developing preventive interventions and new treatments.

8. To develop programs and outreach strategies for families of members 

of the Armed Forces with post-traumatic stress disorder and other 

mental health conditions in order to mitigate the negative impacts of 

post-traumatic stress disorder and other mental health conditions on 

such family members and to support the recovery of such members 

from post-traumatic stress disorder and other mental health 

conditions.

9. To conduct research on the mental health needs of families of 

members of the Armed Forces with post-traumatic stress disorder and 

other mental health conditions and develop protocols to address any 

needs identified through such research.

10. To develop and oversee a long-term plan to increase the number of 

mental health and neurological health professionals within the 

Department in order to facilitate the meeting by the Department of the 

needs of members of the Armed Forces with post-traumatic stress 

disorder and other mental health conditions until their transition to 

care and treatment from the Department of Veterans Affairs.
Appendix III: RDT&E-Funded Projects

Page 32 GAO-12-154 Defense Health

The Army Medical Research and Materiel Command, which has visibility 

over RDT&E-funded work for PH and TBI, identified 397 projects that 

were underway during fiscal years 2007 through 2009; data for all of fiscal 

year 2010 were unavailable at the time of our data request. Sixty-six 

percent of the 397 projects were Research and Technology Development 

(nonclinical) projects. These types of studies form the knowledge- and 

technology-based foundation necessary to establish the initial feasibility 

and practicality of proposed solutions to problems. The remaining 34 

percent of the 397 projects were Clinical Research and Development—

projects that are typically conducted in a clinical setting using human 

research volunteers (including patients) and are directed at amassing the 

definitive level of evidence required to inform changes in medical practice 

or required for licensure of a product regulated by the Food and Drug 

Administration. Although there were twice as many nonclinical as there 

were clinical projects, dollars awarded were distributed fairly evenly 

between these two types.

Table 2: RDT&E-funded Projects Addressing PH and TBI

Clinical Research and Development (award titles)

Number of projects

funded under title

A Comprehensive Approach in Dissemination of Evidence-Based Care for Post-Traumatic Stress Disorder 

(PTSD) 

1 

A Double Blind Trial of Divalproex Sodium for Affective Liability and Alcohol Use Following Traumatic Brain 

Injury (TBI)

1 

A Placebo-Controlled Augmentation Trial of Prazosin for Combat Trauma PTSD 1 

A Randomized Clinical Trial of Ganaxolone for the Treatment of Severe Traumatic Brain Injury 2 

A Randomized Controlled Study of Mind-Body Skills Groups for Treatment of War-Zone Stress in Military and 

Veteran Populations

1 

A Randomized Controlled Trial of Medical Therapies for Chronic Post-Traumatic Headaches 1 

A Randomized Effectiveness Trial of a Systems-Level Approach to Stepped Care for War-Related PTSD 3 

A Randomized, Placebo-Controlled Trial of the Dopamine Beta Hydroxylase (DBH) Inhibitor, Nepicastat, for the 

Treatment of PTSD in Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) Veterans

1 

A Randomized, Placebo-Controlled Trial of the Dopamine-?-Hydroxylase (DBH) Inhibitor, Nepicastat for the 

Treatment of PTSD in OIF/OEF Veterans

1 

Acupuncture as a Novel Technique for Treating Insomnia in the Outpatient Traumatic Brain Injury Population: A 

Randomized Controlled Trial

1 

Acupuncture for Combat-Related Post-Traumatic Stress Disorder 1 

Acupuncture for the Treatment of Trauma-Induced Spectrum Disorder: A Three-Armed Randomized Pilot Study 1 

Adaptive Disclosure: A Combat-Specific PTSD Treatment 3 

Addressing the Needs of Children and Families of Combat Injured 1 

Advanced Restoration Therapies in Spinal Cord Injury 2 

Appendix III: RDT&E-Funded Projects
Appendix III: RDT&E-Funded Projects

Page 33 GAO-12-154 Defense Health

Clinical Research and Development (award titles)

Number of projects

funded under title

An Evaluation of Cognitive Processing Therapy to Treat Veterans in a PTSD Residential Rehabilitation Program 1 

Biomarker Assessment for Neurotrauma Diagnosis and Improved Triage System (BANDITS) with Modificationassessment of biomarkers of concussion and acute TBI2 

Biomarkers for PTSD 1 

Building Infrastructure to Accelerate Transfer of Basic Research in Spinal Cord Injury (SCI) to Clinical Practice: 

North American Clinical Trials Network (NACTN) for Treatment of Spinal Cord Injury

1 

Building Neurocognitive Resilience with Attention Training in a Military Cohort 1 

Burr Hole Creation Simulation-Based Training System 1 

Cognitive Behavioral Therapy (CBT) for TRICARE Management Activities in OEF/OIF Veterans 1 

Clinical Phase II B Trial of Oxycyte Perfluorocarbon in Severe Human Traumatic Brain Injury 1 

Clinical Phase II- B Trial of Oxycyte Perfluorocarbon in Severe Human Traumatic Brain Injury 1 

Cognitive Behavioral Social Rhythm Therapy (CBSRT) for Sleep and Mood Disturbances in Veterans with 

PTSD 

1 

Combat Stress Casualty Reduction: Predeployment Stress Inoculation Training 1 

Combat, Sexual Assault, and Post-Traumatic Stress in OIF/OEF Military Women 1 

Comparing Internet and In-Person Brief Cognitive Behavioral Therapy of Insomnia 1 

Comparing Virtual Reality Exposure Therapy to Prolonged Exposure in the Treatment of Soldiers with PTSD 1 

Computer-Guided Prolonged Exposure Therapy for PTSD 1 

Day-to-Day Mindfulness Skills for Improving Veterans’ Quality of Life and Wellness in Health Care Mental 

Health Settings

1 

Development and Pilot of an Intervention for Military Personnel and Their Families 1 

Development and Validation of a PTSD-Related Impairment Scale 1 

Discovery and Validation of Peripheral Biomarkers of Traumatic Brain Injury 1 

Dissemination of Evidence-Based CBT Intervention Components: Online Self-Administered Training for 

Providers Treating Military Deployment-Related PTSD

2 

Does Integrating Primary Care and Mental Health Services Improve Mental Health Services Utilization, 

Symptoms, and Functioning Among OEF/OIF Veterans?

1 

Effectiveness of Cognitive Exposure and Skills Group Manualized Treatments in OIF/OEF Female Veterans 2 

Enhancing Emotion Regulation during Driving in OEF/OIF Veterans 1 

Enhancing Exposure Therapy for PTSD: Virtual Reality and Imaginal Exposure with Cognitive Enhancer 1 

Evaluating PTSD on Reproductive Outcomes: Women Deployed in Iraq and Afghanistan 1 

Evaluation and Impact of mCare, a Cell Phone Based Bi-Directional Messaging System, on the Case 

Management Care of Traumatic Brain Injury Patients Assigned to Community Based Warrior in Transition Units

1 

Evaluation of a Yoga Intervention for PTSD 2 

Evaluation of an Acute Ribonucleic Acid (RNA)-Mediated Therapeutic for Visual Dysfunction Associated with 

Traumatic Brain Injury

1 

Evaluation of the Tripler Army Medical Center (TAMC) Integrative Pain Management Center (IPMC) 2 

Evidence Based Multimodal Neurodiagnostic Imaging of Traumatic Brain Injury and PTSD at SANIC 1 
Appendix III: RDT&E-Funded Projects

Page 34 GAO-12-154 Defense Health

Clinical Research and Development (award titles)

Number of projects

funded under title

Evidence-Based Multimodal Neurodiagnostic Imaging of Traumatic Brain Injury and Post-Traumatic Stress 

Disorder at SANIC

2 

Family Functioning and Soldier PTSD: Correlates of Treatment Engagement and Military Job Satisfaction 1 

Family-Based Intervention With Traumatized Service Members and Their Young Children 1 

Families Overcoming and Coping With Stress – Combat Injured (FOCUS-CI): A Preventive Intervention With 

Children and Families of the Combat Injured

1 

Fiscal Year 2008 Deployment Related Medical Research Program (DRMRP) Clinical Trial: Strengthening 

Pathways to PTSD Recovery Using Systems-Level Intervention

1 

Homecoming Line: Telephone Support for Veterans 1 

Hyperbaric Oxygen Therapy in the Treatment of Chronic Mild-Moderate Blast-Induced Traumatic Brain Injury 

Post-Concussion Syndrome (PCS) and Post-Traumatic Stress Disorder 

1 

Identification of and At-Risk Interventions for Predeployment Psychophysiologic Predictors of Postdeployment 

Mental Health Outcomes

1 

Importance of Virtual Reality in the Treatment of PTSD: Comparison of Virtual Reality to a Controlled Stimulus 1 

Improving PTSD Outcomes in OIF/OEF Returnees: A Randomized Clinical Trial of Hydrocortisone 

Augmentation of Prolonged Exposure Therapy

1 

Initial Randomized Controlled Trial of Acceptance and Commitment Therapy (ACT) for Distress and Impairment 

in OEF/OIF Veterans

2 

Innovative Service Delivery for Secondary Prevention of PTSD in At-Risk OIF-OEF Service Men and Women 1 

Integrating Mental Health and Primary Care Services for OEF/OIF Combat Veterans With PTSD and Comorbid 

Disorders: Assessing the Evidence

1 

Interhemispheric Information Transfer: A New Diagnostic Method for Mild Traumatic Brain Injury 1 

Military to Civilian: Randomized Controlled Trial (RCT) of an intervention to promote post-deployment 

reintegration.

1 

Military, Family, and Community Networks Helping with Reintegration 1 

Mindfulness and Self-Compassion Meditation for Combat Post-Traumatic Stress Disorder: Randomized 

Controlled Trial and Mechanistic Study

1 

Mission Connect Mild TBI Translational Research Consortium 3 

Mortuary Affairs Soldiers: Early Intervention and Altering Barriers to Care for Traumatic Stress and PTSD 1 

Motivating Treatment Seeking and Behavior Change by Untreated Military Personnel Abusing Alcohol or Drugs 1 

Non-invasive Monitoring of Cerebral Venous Saturation in Patients with Traumatic Brain Injury 1 

Objective Methods to Test Visual Dysfunction in the Presence of Cognitive Impairment 1 

Oculomotor reflexes as a test of visual dysfunctions in cognitively impaired observers 1 

Operation Brain Trauma Therapy (OBTT) 1 

Optimizing Delivery of Mindfulness-Based Military Training Interventions in Army Infantry Platoons 1 

Phase II Clinical Trial of NNZ-2566 in Traumatic Brain Injury 3 

Pilot Trial of Inpatient Cognitive Therapy for the Prevention of Suicide in Military Personnel With Acute Stress 

Disorder or Posttraumatic Stress Disorder

1 

Prazosin for Treatment of Patients With PTSD and Comorbid Alcohol Dependence 1 

PTSD and Substance Abuse 1 
Appendix III: RDT&E-Funded Projects

Page 35 GAO-12-154 Defense Health

Clinical Research and Development (award titles)

Number of projects

funded under title

PTSD Biomarker Studies (Army Research Office) 1 

PTSD, Comorbid Disorders, and Service Utilization in Women Veterans 1 

PTSD/TBI Clinical Consortium Coordinating Center 2 

Randomized Controlled Equivalence Trial Comparing Videoconference and Face-to-Face Delivery of Cognitive 

Processing Therapy for PTSD

1 

Real-Time EEG Monitoring System (R-TEEMS) for Acute Traumatic Brain Injury 1 

Reintegration: The Role of Spouse Telephone Battlemind 2 

Reintegration: The Role of Spouse Telephone BATTLEMIND and Developing a Family/Community 

BATTLEMIND Curriculum

2 

Restoration of Life Role Participation Through Integrated Cognitive and Motor Training for Individuals with TBI 1 

Seeking Safety Therapy for PTSD, TBI, and Substance Use Disorder 1 

Special Warrior Wellness Action Team (SWWAT) Program at Camp LeJeune 1 

Strength at Home: Veteran’s Program 1 

Suicide Research Alliance 2 

Systems Biology Efforts in PTSD 1 

Telemedicine for Improved Delivery of Psychosocial Treatments for Post-Traumatic Stress Disorder 1 

Telemental Health and Cognitive Processing Therapy for Female Combat Veterans with Military-Related PTSD 1 

Telemental Health and Cognitive Processing Therapy for Rural Combat Veterans with PTSD 2 

Telerehabilitation for OIF/OEF Returnees with Combat Related Traumatic Brain Injury 1 

Telerehabilitation for OIF/OEF Returnees with Combat-Related Traumatic Brain Injury 1 

The Impact of Meditation on Veterans with Post-Traumatic Stress Disorder 1 

The Impact of Supported Employment Versus Standard Vocational Rehabilitation in Veterans With PTSD 1 

The STRONG STAR Multidisciplinary PTSD Research Consortium 9 

The Use of Psychiatric Service Dogs in the Treatment of Veterans with PTSD 1 

To Support Institute of Creative Technologies (ICT) contract W911NF-04-D-0005 1 

Treatment of Traumatic Brain Injury Using NNZ-2566: Clinical Trials 1 

Using Functional Magnetic Resonance Imaging (fMRI) to Measure Brain Response to Exposure-Based 

Psychotherapy in Individuals with Combat-Related PTSD

1 

Using Propranolol to Block Memory Reconsolidation in Female Veterans with PTSD 1 

Validation of the Military Acute Concussion Evaluation (MACE) for In-Theater Evaluation of Combat-Related 

Traumatic Brain Injury

1 

Validation of the Peritraumatic Behavior Questionnaire-Observer Rated (PBQ-OR), an Instrument for 

Embedded Medical Personnel to Assess In-Theater Risk for PTSD

1 

Virtual Reality and Cellular Phones as a Complementary Intervention for Veterans with PTSD and Substance 

Use Disorders

1 
Appendix III: RDT&E-Funded Projects

Page 36 GAO-12-154 Defense Health

Research and Technology Development (award titles)

Number of projects 

funded under 

award title

A Behavioral Treatment for Traumatic Brain Injury–Associated Visual Dysfunction Based on Adult Cortical 

Plasticity

1 

A Blast Model of Traumatic Brain Injury in Swine 1 

A Brain-Machine-Brain Interface for Rewiring of Cortical Circuitry after Traumatic Brain Injury 2 

A Brief Intervention to Reduce Suicide Risk in Military Service Members and Veterans 1 

A Longitudinal Study of the Impact of Combat Deployments on Military Personnel and Their Families 1 

A Multifunctional Blood Substitute (MBS) for Field Resuscitation of Polytrauma Combat Casualties with Brain 

Injury and Concomitant Hemorrhagic Shock

1 

A Novel Application of Ceftriaxone to Enhance Glutamate Transport after Traumatic Brain Injury 1 

A Pilot Study to Identify Barriers to Treatment in OIF/OEF Veterans with PTSD and Low Back Pain in 

Establishing Transdisciplinary Complementary Interventions

1 

A randomized control trial of a community mental health intervention for military personnel 3 

Advanced Magnetic Resonance Imaging (MRI) in Acute Military TBI 1 

Advanced MRI in Blast-Related TBI 1 

Advanced Sensors for TBI 2 

American Institute for Medical and Biological Engineering (AIMBE) - Military Collaboration: Bioengineering 

Challenges of Brain Trauma Conference

1 

An fMRI Study of TBI Associated with Blast Injury 1 

Antidepressants and the Risk of Self-Harm and Unintentional Injury Among Younger Veterans 1 

Application of Repetitive Transcranial Magnetic Stimulation (rTMS) to Reverse the Molecular Epileptogenic 

Changes Following Post-Traumatic Brain Injury

1 

Are Blast Brain Injuries Fundamentally Different than Traditional Experimental Models of TBI? 1 

Assessment of Acute Concussion in a Combat Environment: Concurrent Validity, Sensitivity, and Specificity of 

the Automated Neuropsychological Assessment Metrics (ANAM) 

2 

Adenosine Triphosphate (ATP)-Sensitive Potassium Channels for Neuroprotection from Blast-Induced TBI 1 

Auditory, Vestibular, and Cognitive Effects from Repeated Blast 1 

Auditory, Vestibular, and Cognitive Effects Due to Repeated Blast Exposure on the Warfighter 1 

BANDITS with Modification-assessment of biomarkers of concussion and acute TBI 1 

Basic Training and Mental Fitness Study: Enhancing Performance and Mental Health 1 

Bioluminescence Imaging in Traumatic Brain Injury: Implications for Pharmacotherapy 1 

Biomarkers: Evaluating and Treating Acute and Chronic TBI 1 

Blister Packaging Medication to Increase Treatment for Adherence and Clinical Response: Impact on Suiciderelated Morbidity and Mortality1 

Blockade of Nociceptin Signaling Reduces Biochemical, Structural, and Cognitive Deficits After Traumatic Brain 

Injury

1 

Brain Injury Biomarkers and Behavioral Characterization of mild TBI (mTBI) in Soldiers Following Repeated, 

Low-Level Blast Exposure

2 

Brain Injury Biomarkers and Therapy 1 

Brain Tissue Regeneration After Traumatic Brain Injury 1 
Appendix III: RDT&E-Funded Projects

Page 37 GAO-12-154 Defense Health

Clinical Research and Development (award titles)

Number of projects

funded under title

Brain Vulnerability to Repeated Blast Overpressure and Polytrauma 1 

Battlefield Research Accelerating Virtual Environments for Military Individual Neuro Disorders (BRAVEMIND): 

Advancing the Virtual Iraq/Afghanistan PTSD Exposure Therapy System

1 

Breacher Injury Survey II: Prevalence of the Bio-Effects of Repeated Low-Level Blast Exposure 2 

Brief Cognitive Behavioral Therapy for Military Populations 1 

Catecholamines in Posttraumatic Stress Disorder 1 

Catechol-O-Methyltransferase, Impulsivity, and Substance Abuse Treatment 1 

Cerebrovascular Injury in Blast Loading 1 

Characterizing the Relationship between Blast Exposure and Mild TBI with Dynamic Modeling and Testing in a 

New Mouse Model

1 

Child Adjustment to Parental Combat Deployment: Risk and Resilience Models 1 

Children of Military Fathers with Post Traumatic Stress Disorder 1 

Combat Exposure, PTSD, and Misconduct: Direct and Indirect Behavioral Impacts of War 1 

Combat Operational Stress Stigma Reduction Intervention 1 

Combat Stress Intervention Program (Year 3) 1 

Comprehensive 3-D Model of Shock Wave-Brain Interactions in Blast-Induced Traumatic Brain 1 

Computational Modeling of Causal Mechanisms of Blast Wave-Induced Traumatic Brain Injury: A Potential Tool 

for Injury Prevention

1 

Conditioned Fear Extinction and Generalization in Post-Traumatic Stress Disorder 1 

Conference support for W81XWH-05-2-0094 “Physical and Neuropsychiatric Trauma Wound Healing and 

Tissue Prevention”

1 

Corticosterone Administration to Promote Fear Memory Forgetting in an Animal Model of PTSD 1 

Data Modeling Approaches for Biomarkers in Clinical Traumatic Brain Injury 1 

Deep Brain Stimulation of Treatment of Traumatic Brain Injury 1 

Deployment Family Stress: Child Neglect and Maltreatment in U.S. Army Families 1 

Deployment, PTSD Symptoms, and Comorbid Mental Health Conditions in the Active Force and Reserve 

Components

1 

Deployment-Related Mild Traumatic Brain Injury (mTBI): Incidence, Natural History, and Predictors of Recovery 

in Soldiers Returning from OIF/OEF

1 

Design of Effective Therapeutic Interventions for Mild TBI/PTSD Using Interactive Virtual World Environments 1 

Design of Virtual Reality-Based Therapy to Restore the Whole Body Coordination Deficits Following 

Deployment-Acquired Traumatic Brain Injury

1 

Developing Memory Reconsolidation Blockers as Novel PTSD Treatments 1 

Development of a Novel Lab-on-a-Tube for Multimodal Monitoring in the Injured Warrior 1 

Development of a PTSD Population Registry 2 

Development of a Vision Assistive Device for Veterans with TBI-Associated Visual Dysfunctions 1 

Development of an Intervention for Soldiers and Veterans with Co-Occurring Traumatic Brain Injury and 

Substance Abuse Disorders

1 
Appendix III: RDT&E-Funded Projects

Page 38 GAO-12-154 Defense Health

Clinical Research and Development (award titles)

Number of projects

funded under title

Development of F-18-Labeled Radiotracers for Positron Emission Tomography (PET) Imaging of Brain Alpha-1 

Noradrenergic Receptors: Potential PTSD Vulnerability and/or Diagnostic Biomarkers

1 

Differentiating the severity of Mild and Moderate Traumatic Brain Injury 1 

Disequilibrium after Traumatic Brain Injury: Vestibular Mechanisms 1 

Do Undetected or Untreated Sleep Disorders Predict PTSD Psychotherapy Outcomes? 1 

Docosahexaenoic Acid (DHA) versus Placebo in a Special Operations Unit with a High Rate of Blast Exposures 1 

Drug Related Overdoses Among a Military Population 1 

Drug-Encapsulated Immunonanoparticles, Neuron-Targeted Delivery System 1 

Early Post-Traumatic Seizures in Military Personnel Result in Long-Term Disability 1 

Effect of a Hypocretin/Orexin Antagonist on Neurocognitive Performance 2 

Effects of Repeated Traumatic Brain Injuries in a Combat Setting 1 

Electrical Stimulation of the Midbrain to Promote Recovery from Traumatic Forebrain Injury 1 

Enduring Effects of Traumatic Stress on Brain Neuropeptide Y (NPY) and Corticotropin-Releasing Factor (CRF) 

Systems: Molecular and Neuropharmacologic Studies

1 

Epidemiological Study of Mild Traumatic Brain Injury Sequelae Caused by Blast Exposure During Operations 

Iraqi Freedom and Enduring Freedom

1 

Epigenetic Patterns of PTSD: Deoxyribonucleic Acid (DNA) Methylation in Serum of OIF/OEF Service Members 1 

Epigenetic Patterns of TBI: DNA Methylation in Serum of OIF/OEF Service Members 1 

Etiology of Sleep Disorders in PTSD: Potential Role of Inflammatory Cytokines 1 

Evaluation of a New Screening Approach to Identify Soldiers at High Risk for Substance Abuse 1 

Evaluation of Prospective Biomarkers for TBI in the Presence of Hemorrhagic Shock 1 

Eye-Tracking Rapid Attention Computation 2 

Fabrication and Testing of a Blast Concussion Burst Sensor 1 

Fear Conditioning Effects on Sensitivity to Drug Reward 1 

Fibrin Matrix-Supported Mesenchymal Stem Cell Treatment for Traumatic Brain Injury 1 

Genetic Screen for PTSD-Prone Soldiers 1 

Glutamate Transmission Enhancement for Treatment of PTSD 1 

Glyburide - Novel Prophylaxis and Effective Treatment for Traumatic Brain Injury 1 

Health Status and Performance of United States Air Force Airmen Following Mild Traumatic Brain Injury 1 

Helmet Integrated Nanosensors, Signal Processing and Wireless Real Time Data Communication for 

Monitoring Blast Exposure to Battlefield Personnel

1 

Helmet Mounted Sensor Recorded Blast Data in Combat 1 

Helmet Sensor- Transfer Function and Model Development 1 

High Resolution Diffusion Tensor Imaging of Cortical-Subcortical White Matter Tracts in TBI 1 

High Risk Suicidal Behavior in Veterans-Assessment of Predictors and Efficacy of Dialectical Behavior Therapy 1 

High-Throughput Screening of Therapeutic Neural Stimulation Targets: Toward Principles of Preventing and 

Treating Post-Traumatic Stress Disorder

1 

Hormonal Regulation of Extinction: Implications for Gender Differences in the Mechanisms of PTSD 1 
Appendix III: RDT&E-Funded Projects

Page 39 GAO-12-154 Defense Health

Clinical Research and Development (award titles)

Number of projects

funded under title

Identification and Validation of Novel Therapeutics Targets for Traumatic Brain Injury 1 

Identification of Gene Expression Patterns in Brain Tissues and Peripheral White Blood Cells of Rat Model of 

Post-Traumatic Stress Disorder 

1 

Identifying Biomarkers that Distinguish Post-Traumatic Stress Disorder and Mild Traumatic Brain Injury Using 

Advanced Magnetic Resonance Spectroscopy

2 

Implantable Microsystems for Anatomical Rewiring of Cortical Circuitry: A New Approach for Brain Repair 1 

Improving Deployment Related Primary Care Provider Assessments of PTSD and Mental Health Conditions 1 

Improving Work Outcomes for Veterans with Traumatic Brain Injury 1 

Incidence of Traumatic Brain Injury, Mild Traumatic Brain Injury, and Postconcussion Syndrome among U.S. 

Service Members between 1997 and 2007

1 

Innovative Treatment of TBI via Regeneration of Neuronal Microtubules 2 

Interaction of Blast and Head Impact in the Generation of Brain Injuries 1 

Investigation of Prognostic Ability of Novel Imaging Markers for Traumatic Brain Injury 1 

Kaptur Combat Mental Health Initiative: Risk and Resilience Factors for Combat Related Posttraumatic 

Psychopathology and Post Combat Adjustment

1 

Kaptur Combat Mental Health Initiative: Risk and Resilience Factors for Combat Related Posttraumatic 

Psychopathology and Post Combat Adjustment

1 

Ketamine as a Rapid Treatment for Post-Traumatic Stress Disorder 1 

Kevlar Vest Protection against Blast Overpressure Brain Injury: Systemic Contributions to Injury Etiology 1 

Loss of Ceruloplasmin Ferroxidase Activity Contributes to Neuronal Injury After Blast Exposure 1 

Low-Level Light Therapy for Traumatic Brain Injury 1 

Measuring Blast-Related Intracranial Pressure Within the Human Head 1 

Measuring Intracranial Pressure and Correlation with Severity of Blast Traumatic Brain Injury 1 

Mechanisms of Enhanced Fear Response after Diffuse TBI 1 

Medial Prefrontal Cortex and Hypothalamic-Pituitary-Adrenal (HPA) Axis Roles in Generation of PTSD-Like 

Symptoms in Spark Plasma Sintering (SPS) Model

1 

Mental Health and Resilience: Soldiers’ Perceptions about Psychotherapy, Medication, and Barriers to Care in 

the United States Military

1 

Microassay Diagnostic Device for Rapid Assessment of Traumatic Brain Injury 2 

Mild TBI Following Exposure to Explosive Devices: Device Characteristics, Neuropsychological Functioning, 

and Symptoms of Post-Traumatic Stress Disorder

1 

Military Blast-Related Traumatic Brain Injury: A Study of Isolated Shock Waves on Central Nervous System 

Injury

1 

Minocycline and N-Acetylcysteine: A Synergistic Drug Combination to Treat Traumatic Brain Injury 1 

Mission Connect Mild TBI Translational Research Consortium 18

Mission Connect Mild TBI Translational Research Consortium: Subproject 3.5 1 

Molecular Mechanisms Underlying Individual Differences in Response to Stress in a Previously Validated

Animal Model of PTSD

1 

Molecular Signatures and Diagnostic Biomarkers of Cumulative, Blast Graded Mild TBI 1 
Appendix III: RDT&E-Funded Projects

Page 40 GAO-12-154 Defense Health

Clinical Research and Development (award titles)

Number of projects

funded under title

MTBI Effects on Emotion Symptoms, Neurocognitive Performance, and Functional Impairment: A Longitudinal 

Study of Deployed and Non-Deployed Army Soldiers

1 

Multidrug Treatment of Traumatic Brain Injury 1 

Multi-Family Group Intervention for OEF/OIF Traumatic Brain Injury Survivors and their Families 1 

National Capital Consortium TBI Neuroimaging Core Project 1 

Neural and Behavioral Sequelae of Blast-Related Traumatic Brain Injury 2 

Neural Correlates of Early Intervention for PTSD 1 

Neural Mechanisms Linking Mild Traumatic Brain Injury and Anxiety States in an Animal Model 1 

Neural Plasticity and Neurorehabilitation Following Traumatic Brain Injury 1 

Neurobehavioral Effects of Battlemind vs. Mindfulness-Based Military Training in Army Infantry Platoons 1 

Neurobiologic Evaluation of Novel Targets for Therapeutic Intervention in PTSD 1 

Neurobiology of Sleep and Sleep Treatments in PTSD (NOS-STIP) 1 

Neurocognitive and Biomarker Evaluation of Combination mTBI from Blast Overpressure and Traumatic Stress 2 

Neuroimaging of Biomarkers for Combat Relevant Traumatic Brain Injury 1 

Neuroimaging of Brain Injuries and Disorders at Cleveland Clinic 1 

Neuronal Targets Mediating Active Stress Coping 1 

Neuroprotective Strategies after Repetitive Mild Traumatic Brain Injury 1 

Neurosteroids as Critical Modulators of the Stress Response in PTSD 1 

Non-invasive Monitoring of Cerebral Venous Saturation in Patients with Traumatic Brain Injury 1 

Noninvasive TBI Gravity Assessment Using a Novel Near-Infrared Diffuse Reflectance Imaging Approach 1 

Novel Methods for Identification of Concussion Associated Impairment in Blast Exposure Service Members 1 

Novel Smart Catheter for Multimodal Monitoring of the Head-Injured Warrior 1 

NWHSS: Implement Family Member Assessment Component in the Millennium Cohort Study 2 

Online PTSD Diagnosis and Treatment Training for Primary Care Physicians 2 

Opiate Masking of Stress-Induced Hypervigilance: The Cause of Delayed Symptom Presentation in PTSD 1 

Optimization and enhancement of clinical interface and clinical operations characteristics of the ANAM TBI 

assessment system

1 

Optimizing Screening and Risk Assessment for Suicide Risk in the U.S. Military 1 

Optimizing the Predictive Validity of the Post-Deployment Health Assessment/Post-Deployment Health 

Reassessment (PDHA/PDHRA)

1 

Oxytocin and Social Support as Synergistic Inhibitors of Aversive Fear Conditioning and Fear-Potentiated 

Startle in Male Rats

1 

P11, a Biomarker for Memory Retrieval: A Possible Role in Traumatic Stress 1 

Parental Stress, PTSD, and Infant Health Outcomes in U.S. Military Families 1 

Pathogenesis of Heterotopic Ossification in Traumatic Brain Injury 1 

Pathological Fingerprints, Systems Biology, and Biomarkers of Blast Brain Injury 1 

Pathophysiology of Polytrauma and Novel Treatment Strategies 1 

Personal Monitoring for Ambulatory PTSD Assessment 1 
Appendix III: RDT&E-Funded Projects

Page 41 GAO-12-154 Defense Health

Clinical Research and Development (award titles)

Number of projects

funded under title

Personalized Medicine in Veterans with Traumatic Brain Injuries 1 

Physical and Neuropsychiatric Trauma - Wound Healing and Tissue Preservation 1 

Physical and Neuropsychiatric Trauma Wound Healing and Tissue Prevention 1 

Physical and Psychometric Wound Healing and Tissue Prevention 1 

Post Concussive Rehabilitation, Treatment and Fitness for Return to Duty 2 

Post-Injury Treatment for Traumatic Brain Injury 1 

Post-Stress Combined Administration of Beta-Receptor and Glucocorticoid Antagonists as a Novel Preventive 

Treatment in an Animal Model of PTSD

1 

Post-Traumatic Headache and Psychological Health: Mindfulness Training for Mild Traumatic Brain Injury 1 

Post-Traumatic Stress Disorder and Pain Comorbidity in Veterans 1 

Posttraumatic Stress Disorder Co-Morbidity and the Deployment Cycle 1 

Posttraumatic Stress Disorder, Substance Abuse and Self Harm: Mediating Relationships with Respect to 

Combat Stress 

1 

Prediction, Detection, and Prevention of Post-Traumatic Epilepsy and PTSD in Genetically Susceptible Rats 1 

Progesterone in the Field-Forward Treatment of Traumatic Brain Injury 1 

Prophylactic Neuroprotection for Traumatic Brain Injury 1 

Protein Kinase C-Epsilon in the Amygdala-Prefrontal Cortex Circuit Regulates the Extinction of Conditioned 

Fear

1 

Proteomic Studies of Cerebrospinal Fluid (CSF) and Plasma From Patients With PTSD 1 

PTSD Trajectory, Comorbidity, and Utilization of Mental Health Services Among National Guard Soldiers 1 

PTSD Trajectory, Comorbidity, and Utilization of Mental Health Services among Reserves 1 

Quantitative Tractography and Volumetric MRI in Blast and Blunt Force TBI: Predictors of Neurocognitive and 

Behavioral Outcome

1 

Regional Center of Excellence for PTSD: Phoebe Putney Memorial Hospital 1 

Reintegrating Troops with Mild Traumatic Brain Injury (mTBI) into Their Communities: Understanding the Scope 

and Timeline of Post-Deployment Driving Problems

1 

Research to Improve Emotional Health and Quality of Life Among Service Members with Disabilities 

(RESTORE LIVES)

1 

Resonance and Spectroscopy of the Human Brain in Gulf War Illness 1 

Resonance and Spectroscopy of the Human Brain in Gulf War Illness 1 

Role of MicroRNAs in the Synaptic Plasticity Dysfunction During Post-Traumatic Stress Disorder 1 

Root Cause of Post-Traumatic and Development Stress Disorders 1 

Scaffold/Neural Stem Cells-Based Tissue Engineering in a Traumatic Brain Injury Model 1 

Sensors to Assess Pressure-Mediated Effects on Blast-Induced TBI 1 

Small Molecule Activators of the TRK Receptors for Neuroprotection 1 

Small Molecule Activators of the Tropomyosin-Receptor-Kinase (Trk) Receptors for Neuroprotection in TBI 3 

Spreading Depressions as Secondary Insults after Traumatic Injury to the Human Brain 1 

Stable Intravenous Fluorohydrocarbon Emulsion with High Oxygen Capacitance Combined with Hyperbaric 

Oxygen for the Acute Salvage of Tissue Injury After TBI

1 
Appendix III: RDT&E-Funded Projects

Page 42 GAO-12-154 Defense Health

Clinical Research and Development (award titles)

Number of projects

funded under title

Stem Cell Therapeutics for Military Relevant Brain Injury Using Amnion-Derived Multipotent Progenitor (AMP) 

Cells

1 

Stimulant Therapy and Memory Strength: Implications for the Emergence and Treatment of PTSD 1 

Suicide Prevention Research 1 

TBI Effects of Marine Corp Breacher Training Program 1 

The Association between Suicide and OEF/OIF Deployment History 1 

The Effects of Hypoxia on Cognitive Function in Aviators and Complex System Operators that Have Had a Mild 

Traumatic Brain Injury

1 

The Effects of Explosive Blast as Compared to Post-Traumatic Stress Disorder on Brain Function and Structure 1 

The Effects of Systemic Hyperoxia and/or Hyperventilation on the Oxidative Injury and Cerebral Perfusion After 

TBI and Hemorrhage

1 

The International Brain Research Foundation (IBRF) Disorders of Consciousness (DOC) Advanced Care 

Protocol (ACP)

1 

The Investigation of Emerging Technologies and Field Expedient Methods for Screening Traumatic Brain Injury 

and Tracking Initial Recovery 

1 

The Role of Early Stress on the Development of PTSD After Blast Injury 1 

The Role of Microglial Subsets in Regulating Traumatic Brain Injury 1 

The Root Cause of Post-traumatic and Developmental Stress Disorders 1 

The Separate and Cumulative Effects of TBI and PTSD on Cognitive Function and Emotional Control 1 

The Soldier Medic Mettle Study 2 

The STRONG STAR Multidisciplinary PTSD Research Consortium 1 

To Support Institute of Creative Technologies (ICT) contract W911NF-04-D-0005 2 

To Support Institute of Creative Technologies (ICT) contract W911NF-04-D-0005 (follow-on fiscal year 2009 

and fiscal year 2010)

1 

Translation of Cognitive Neuroscience to Rehabilitation for Patients with TBI 1 

Traumatic Brain Injury Diffusion Magnetic Resonance Imaging Research Roadmap Development Project 1 

Treatment of TBI and Concomitant Hemorrhage With Ghrelin 1 

Treatment of TBI with Hormonal and Pharmacological Support, Preclinical Validation Using Diffuse and 

Mechanical TBI Animal Models

1 

Treatment of Traumatic Brain Injury by Localized Application of Subatmospheric Pressure to the Site of Cortical 

Impact

1 

Ultrahigh Resolution Retinal Imaging with Adaptive Optics for Early Diagnosis of Traumatic Brain Injury 1 

Understanding Injury Mechanisms of Blast-Induced Neurotrauma: Validation of Human Injury Surrogates 1 

Understanding Psychological Recovery through Resilient Army National Guard Veterans 1 

Understanding Resilience in Wounded Warriors and Their Families 1 

Understanding the Brain Mechanism Underlying Depression in Combat-Related Traumatic Brain Injury 1 

Use of Neural Progenitor Cells and Attractive Proteins to Heal TBI 1 

Vagus Nerve Stimulation (VNS) and Rehabilitation in the Treatment of TBI 1 
Appendix III: RDT&E-Funded Projects

Page 43 GAO-12-154 Defense Health

Clinical Research and Development (award titles)

Number of projects

funded under title

Validation of the Single-Photon Emission Computerized Tomography (SPECT) Ligand CLINDE as a Marker of 

Microglial Activation in Baboons

1 

Vascularizing Bone Scaffolds for Craniofacial Reconstruction 1 

Veridical and Adaptive Decision Making 1 

Visual Information Restoration and Rehabilitation via Sensory Substitution Technology 1 

Wearable Flexible Blast Monitor 1 

When Good Memory Mechanisms Go Bad: Toward an Understanding of the Role of Protein Kinase C (PKM)-

Zeta in Post-Traumatic Stress Disorder

1 

Xenon as a Neuroprotectant in Traumatic Brain Injury 1 

Total 397

Source: Army Medical Research and Materiel Command. 
Appendix IV: Examples Provided by the Army 

Medical Research and Materiel Command of 

Ongoing Research That Was Representative of 

Positive Results Achieved to Date

Page 44 GAO-12-154 Defense Health

In providing us with lists of PH and TBI research projects, officials at the 

Army Medical Research and Materiel Command cited three projects, in 

particular, that they indicated were representative of positive results 

achieved to date: the Biomarker Assessment for Neurotrauma Diagnosis 

and Improved Triage System; clinical testing of NNZ-2566, a drug to treat 

patients who experience TBI; and protocols and guidelines for developing 

refined medical imaging that can detect TBI.

The first, the Biomarker Assessment for Neurotrauma Diagnosis and 

Improved Triage System (BANDITS), is an example of a Research and 

Technology Development project. According to information provided by 

the Army, no approved test to objectively diagnose mild TBI exists, and 

the aim of the BANDITS program is to develop a blood test to detect brain 

cell damage. Three systems to measure blood samples are anticipated.

The first would be a bench-top system about the size of a large printer 

and would be deployable only with larger battlefield medical units. The 

second system would be smaller, approximately the size of a loaf of 

bread, and thus more easily deployable. The third system would be a 

hand-held, battery-powered device deployable with individual medics.

Figure 2 depicts one of the systems. According to information provided by 

the Army, in a limited trial of fewer than 100 patients, the BANDITS 

program has achieved levels of accuracy equivalent to those of medical 

tests currently relied on to detect heart damage and prostate cancer. The 

Army is continuing clinical trials for Food and Drug Administration 

licensure and expects to complete them in 2013.

Appendix IV: Examples Provided by the Army 

Medical Research and Materiel Command of 

Ongoing Research That Was Representative of 

Positive Results Achieved to Date
Appendix IV: Examples Provided by the Army 

Medical Research and Materiel Command of 

Ongoing Research That Was Representative of 

Positive Results Achieved to Date

Page 45 GAO-12-154 Defense Health

Figure 2: System Anticipated from the Army’s Biomarker Assessment

The second project entails clinical testing of a potential drug treatment for 

TBI and is an example of a Clinical Research and Development project.

According to information provided by the Army, no approved drug yet 

exists to treat TBI, and the aim of the project is to develop NNZ-2566, a 

drug candidate that could reduce death and disability from moderate to 

severe TBI and speed recovery from mild TBI. An intravenous form of the 

drug has been developed for moderate to severe TBI patients, and an 

oral formulation will be developed for mild TBI patients. NNZ-2566 was 

found to be safe in humans in its initial clinical trial and is currently 

undergoing a larger intermediate trial to see if it will reduce the effects of 

TBI damage. If that trial is successful, a final large trial will be completed 
Appendix IV: Examples Provided by the Army 

Medical Research and Materiel Command of 

Ongoing Research That Was Representative of 

Positive Results Achieved to Date

Page 46 GAO-12-154 Defense Health

with the hope of approval by the Food and Drug Administration by 2016.

Figure 3 depicts the difference between a brain with penetrating brain 

injury that receives no treatment and a brain that does receive treatment 

with NNZ-2256.

Figure 3: Brain Imagery Demonstrating the Impact of Treatment with NNZ-2256

The third RDT&E project that Army Medical Research and Materiel 

Command officials cited entails protocols and guidelines for developing 

refined medical imaging that can detect TBI. According to the Army, no 

approved test exists that can objectively diagnose TBI. Currently, the 

diagnosis of TBI is made by assessing symptoms, such as fatigue, 

headaches, visual disturbances, memory loss, poor 

attention/concentration, sleep disturbances, and the loss of balance.

Using a high-powered magnetic resonance imaging (MRI) machine, Army 

researchers have developed an advanced imaging protocol that produces 

41,000 images of the brain; standard MRIs of the brain produce 350 

images. The added images are computer enhanced to show brain lesions 

undetectable with standard medical imaging approaches. Going forward, 

the effort is intended to develop a new standardized imaging protocol that 

can be achieved on existing medical imaging machines routinely found in 

medical centers. Using the new protocol, 64 percent of patients with 

normal computer tomography (CT) and MRI scans were shown to have 

MRI findings of trauma. Figure 4 displays the differences among CT, 

routine MRI, and advanced protocol MRI scans.
Appendix IV: Examples Provided by the Army 

Medical Research and Materiel Command of 

Ongoing Research That Was Representative of 

Positive Results Achieved to Date

Page 47 GAO-12-154 Defense Health

Figure 4: Differences among CT, Routine MRI, and Advanced Protocol MRI Scans
Appendix V: Comments from the Department 

of Defense

Page 48 GAO-12-154 Defense Health

Appendix V: Comments from the Department 

of Defense
Appendix V: Comments from the Department 

of Defense

Page 49 GAO-12-154 Defense Health
Appendix V: Comments from the Department 

of Defense

Page 50 GAO-12-154 Defense Health
Appendix VI: GAO Contact and Staff 

Acknowledgments

Page 51 GAO-12-154 Defense Health

Brenda S. Farrell, Director, (202) 512-3604 or farrellb@gao.gov

In addition to the contact named above, Revae Moran, Acting Director; 

David E. Moser and Marilyn Wasleski, Assistant Directors; Geraldine 

Beard; Karen Nicole Harms; Travis Hill; LaToya Jeanita King; Felicia 

Lopez; Grant Mallie; Charles Perdue; Beverly C. Schladt; Michael Silver; 

Amie Steele; Cheryl A. Weissman; and Ricardo A. Marquez made key 

contributions to this report.

Appendix VI: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 
Related GAO Products

Page 52 GAO-12-154 Defense Health

VA Mental Health: Number of Veterans Receiving Care, Barriers Faced, 

and Efforts to Increase Access. GAO-12-12. Washington, DC: 

Oct. 14, 2011.

DOD and VA Health Care: Action Needed to Strengthen Integration 

across Care Coordination and Case Management Programs. 

GAO-12-129T. Washington, DC: Oct. 6, 2011.

Defense Centers of Excellence: Limited Budget and Performance 

Information on the Center for Psychological Health and Traumatic Brain 

Injury. GAO-11-611. Washington, DC: June 30, 2011.

DOD and VA Health Care: Federal Recovery Coordination Program 

Continues to Expand but Faces Significant Challenges. GAO-11-250. 

Washington, DC: Mar. 23. 2011.

Defense Health: Management Weaknesses at Defense Centers of 

Excellence for Psychological Health and Traumatic Brain Injury Require 

Attention. GAO-11-219. Washington, DC: Feb. 28, 2011.

VA Health Care: Progress and Challenges in Conducting the National 

Vietnam Veterans Longitudinal Study. GAO-10-658T. Washington, DC:

May 5, 2010.

VA Health Care: Status of VA’s Approach in Conducting the National 

Vietnam Veterans Longitudinal Study. GAO-10-578R. Washington, DC:

May 5, 2010.

VA Health Care: Preliminary Findings on VA’s Provision of Health Care 

Services to Women Veterans. GAO-09-899T. Washington, DC: July 16, 

2009

DOD and VA Health Care: Challenges Encountered by Injured 

Servicemembers during Their Recovery Process. GAO-07-589T. 

Washington, DC: March 5, 2007.

VA Health Care: Spending for Mental Health Strategic Plan Initiatives 

Was Substantially Less Than Planned. GAO-07-66. Washington, DC:

November 21, 2006.

VA Health Care: Preliminary Information on Resources Allocated for 

Mental Health Strategic Plan Initiatives. GAO-06-1119T. Washington, DC: 

September 28, 2006.

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Page 53 GAO-12-154 Defense Health

VA Health Care: VA Should Expedite the Implementation of 

Recommendations Needed to Improve Post-Traumatic Stress Disorder 

Services. GAO-05-287. Washington, DC: February 14, 2005.

VA and Defense Health Care: More Information Needed to Determine If 

VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder 

Services. GAO-04-1069. Washington, DC: September 20, 2004.

(351513)
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