DOD Health Care: Mental Health and Traumatic Brain Injury Screening Efforts Implemented, but Consistent Pre-Deployment Medical Record Review Policies Needed
Published: 2008-05-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The John Warner National Defense Authorization Act for Fiscal Year 2007 included provisions regarding mental health concerns and traumatic brain injury (TBI). GAO addressed these issues as required by the Act. In this report GAO discusses (1) DOD efforts to implement pre-deployment mental health screening; (2) how post-deployment mental health referrals are tracked; and (3) screening requirements for mild TBI. GAO selected the Army, Marine Corps, and Army National Guard for the review. GAO reviewed documents and interviewed DOD officials and conducted site visits to three military installations where the pre-deployment health assessment was being conducted.
section_title: What GAO Found
paragraphs: DOD has taken positive steps to implement mental health standards for deployment and pre-deployment mental health screening. However, DOD's policies for providers to review medical records are inconsistent. DOD issued minimum mental health standards that servicemembers must meet in order to be deployed to a combat theater and identified the pre-deployment health assessment as a mechanism for ensuring their use in making deployment decisions. DOD's November 2006 policy implementing these deployment standards requires a review of servicemember medical records during the pre-deployment health assessment. However, DOD's August 2006 Instruction on Deployment Health, which implements policy and prescribes procedures for conducting pre-deployment health assessments, is silent on whether such a review is required. Because of this inconsistency, providers determining if Operation Enduring Freedom and Operation Iraqi Freedom servicemembers meet DOD's mental health deployment standards may not have complete medical information. Health care providers at the installations GAO visited where the post-deployment health assessment (PDHA) is conducted manually track whether servicemembers who receive mental health referrals from the PDHA make or complete appointments with mental heath providers. Because health care providers conducting the PDHA and making referrals from the PDHA may not have an ongoing relationship with referred servicemembers, health care providers responsible for tracking referrals at these installations have developed manual systems to track servicemembers to ensure that they made or kept their appointments for evaluations. Tracking is more challenging for Guard and Reserve units because their servicemembers generally receive civilian care. Guard and Reserve units do not know if servicemembers used civilian care to complete their PDHA referrals unless disclosed by the servicemembers, which they may be reluctant to do because of stigma concerns. DOD is addressing the TBI requirement through implementing screening for mild TBI in its PDHA and prior to deployment. DOD has also provided guidance and training for health care providers. DOD in January 2008 added TBI screening to the PDHA, and plans to require screening of all servicemembers for mild TBI prior to deployment beginning in July 2008. The TBI screening questions on the PDHA assess the servicemember's exposure to events that may have increased the risk of a TBI and the servicemember's symptoms. The TBI screening questions to be used prior to deployment are similar to those on the PDHA. Prior to DOD's screening efforts, several installations had been screening servicemembers for mild TBI before or after deployment. An official from the Defense and Veterans Brain Injury Center told GAO that these initiatives would probably be replaced by the DOD-wide screening.

section_title: Letter
paragraphs: Since the initiation of military conflicts in Afghanistan—Operation  Since the initiation of military conflicts in Afghanistan—Operation  Enduring Freedom (OEF)—and Iraq—Operation Iraqi Freedom (OIF)— Enduring Freedom (OEF)—and Iraq—Operation Iraqi Freedom (OIF)— servicemembers have engaged in intense and prolonged combat, placing  servicemembers have engaged in intense and prolonged combat, placing  them at risk for developing post-traumatic stress disorder (PTSD) or other  them at risk for developing post-traumatic stress disorder (PTSD) or other  mental health conditions. Those with PTSD often relive their stressful  mental health conditions. Those with PTSD often relive their stressful  experiences, such as exposure to combat, through nightmares and  experiences, such as exposure to combat, through nightmares and  flashbacks, and may have difficulty sleeping and feel detached or  flashbacks, and may have difficulty sleeping and feel detached or  estranged. A 2006 Army mental health advisory team report found that   estranged. A 2006 Army mental health advisory team report found that   20 percent and 15 percent of Army and Marine Corps OIF servicemembers,  20 percent and 15 percent of Army and Marine Corps OIF servicemembers,  respectively, screened positive for PTSD, depression, or anxiety.  respectively, screened positive for PTSD, depression, or anxiety.  concussion.
Office of the Surgeon, Multinational Force-Iraq and Office of The Surgeon General, United  States Army Medical Command, Mental Health Advisory Team (MHAT) IV Operation  Iraqi Freedom 05-07 Final Report (Nov. 17, 2006). The 2008 MHAT report (MHAT V)  found that 18 percent of male Army enlisted servicemembers in OIF brigade combat teams  screened positive for PTSD, depression, or anxiety. Office of the Surgeon, Multi-National  Force-Iraq, Office of the Command Surgeon, and Office of the Surgeon General, United  States Army Medical Command, Mental Health Advisory Team (MHAT) V Operation Iraqi  Freedom 06-08: Iraq Operation Enduring Freedom 8: Afghanistan (Feb. 14, 2008).
DOD states that these groups may not be representative of all Army and Marine Corps  servicemembers returning from OEF/OIF.
DOD is required by law to have a system to assess the medical condition of  servicemembers before and after deployment to locations outside the  United States. The required elements of this system include the use of pre-  and post-deployment medical examinations. To implement the system,  DOD uses multiple health assessments to screen servicemembers for a  variety of health concerns, including mental health concerns, both before  and after their deployments to combat theaters. These assessments  include the pre-deployment health assessment, the post-deployment health  assessment (PDHA), and the post-deployment health reassessment  (PDHRA). During these assessments, a servicemember completes a form  that includes questions used to screen for mental health concerns. A  health care provider reviews the completed form and may refer the  servicemember for further evaluation if necessary.
Questions have been raised about DOD’s mental health screening of  servicemembers before and after their deployments to OEF/OIF. In 2007 a  DOD Mental Health Task Force reported that DOD faced several  challenges to effective mental health assessments, including eagerness to  deploy or stigma, that may prevent servicemembers from disclosing  mental health concerns on the pre-deployment health assessment or the  PDHA respectively, and recommended that DOD coordinate the mental  health screening questions that are used on the health assessment forms to  ensure accuracy and consistency. In May 2006 we reported that DOD  could not provide reasonable assurance that OEF/OIF servicemembers  who need referrals for mental health following deployments receive them.
There has also been interest in ensuring that servicemembers are screened  for TBI, particularly mild TBI. Mild TBI can be difficult to identify in part  because, unlike with more severe forms of TBI, there may be no  observable head trauma and because some of its symptoms overlap with  other conditions, such as PTSD. In May 2007 an Army TBI Task Force  report identified gaps in TBI screening efforts across all levels of Army  health care, such as few military installations that had been conducting  TBI screening before deployment and a lack of policies requiring TBI  screening after deployment.
The John Warner National Defense Authorization Act for Fiscal Year 2007  (NDAA), enacted on October 17, 2006, included a provision that addressed  DOD’s efforts to screen servicemembers for mental health concerns and  TBI. In particular, the Act required DOD to  issue minimum mental health standards that servicemembers must meet in  order to be deployed and take actions to ensure their utilization;   use the pre-deployment health assessment and PDHA to screen  servicemembers for treatment and medication use for a mental health  condition;   as part of its deployment health quality assurance program, document the  effectiveness of DOD tracking mechanisms used to ensure that  servicemembers who are referred for mental health evaluations from the  PDHA receive them;    document the mental health training received by health care providers  conducting the PDHA, as well as develop guidance for these health care  providers to use in deciding whether to refer a servicemember for a mental  health evaluation; and   screen servicemembers for TBI in the pre- and post-deployment health  assessments, develop guidance, and ensure health care providers  conducting the assessments receive training on TBI.
Furthermore, the 2007 NDAA required us to report on DOD’s  implementation of this provision, and 11 members of Congress also  expressed interest in this work. In this report we discuss (1) DOD efforts  to implement 2007 NDAA requirements related to mental health screening  in the pre-deployment health assessment, including issuing mental health  standards for deployment; (2) how mental health referrals made as a result  of the PDHA are tracked to ensure that referred servicemembers receive  evaluations; (3) the training and guidance on mental health issues received  by health care providers conducting the PDHA; and (4) DOD efforts to  implement 2007 NDAA requirements for TBI screening, including the  guidance and training DOD makes available to health care providers for  identifying mild TBI.
We reviewed DOD efforts involving active duty and reserve components of  the Army and Marine Corps; we also included the Army National Guard in  our review. As of September 2007, these components comprised about   88 percent of all OEF/OIF forces. Although Air Force and Navy personnel  serve in OEF/OIF, Army and Marine Corps servicemembers generally  serve in ground combat roles, and servicemembers involved in combat are  more at risk for exposure to events that can lead to mental health  conditions and physical injuries such as TBI. Our findings related to  mental health and TBI screening that are military service- and component- specific cannot be generalized across other military services or across  DOD.
To discuss DOD efforts to implement 2007 NDAA requirements related to  mental health screening in the pre-deployment health assessment,  including issuing mental health standards for deployment, we reviewed  federal laws, DOD and military service-specific policies and guidance  related to deployment health, deployment standards, and the pre- deployment health assessment. We conducted three site visits to military  installations—one Army unit at Fort Campbell, Kentucky; one Marine  Corps unit at Camp Lejeune, North Carolina; and one Army National  Guard unit at Fort Richardson, Alaska. We selected these installations  based on their deployment schedules in order to observe the pre- deployment screening process. During these site visits, we interviewed  commanders about their role in making determinations of whether a  servicemember may deploy, and DOD health care providers about their  role in conducting the pre-deployment health assessments.
To discuss how mental health referrals made as a result of the PDHA are  tracked to ensure that referred servicemembers receive evaluations, we  defined tracking as the process in which a health care provider or other  official monitors whether an individual servicemember referred from the  PDHA makes or completes his or her appointment for a mental health  evaluation. We reviewed DOD and military service-specific policies and  guidance related to the PDHA. We interviewed DOD and military service  officials about the types of electronic and manual systems that can be used  to track referrals from the PDHA, and health care providers at Fort  Campbell and Camp Lejeune about the electronic and manual systems that  they use to track these referrals.
To discuss the training and guidance on mental health issues received by  health care providers conducting the PDHA, we reviewed DOD and Army,  Navy, and Marine Corps health care provider education and training. We  reviewed DOD clinical practice guidelines (CPG) related to mental health  conditions associated with deployment, and other guidance related to the  PDHA with respect to mental health issues. We also interviewed DOD and  military service officials regarding these issues. We interviewed 4 health  care supervisors and 15 physicians and independent duty corpsmen (IDC)  at Fort Campbell and Camp Lejeune who were available during our visit  about their training and qualifications related to mental health. Finally, we  observed health care provider training at Fort Bragg, North Carolina for an  Army program that trains primary care providers in identifying and  treating servicemembers with depression and PTSD.
To discuss DOD efforts to implement 2007 NDAA requirements for TBI  screening, including the guidance and training DOD makes available to  health care providers for identifying mild TBI, we reviewed DOD policies  and guidance, and military service-specific policies and guidance,  including the January 2008 final report of the Army TBI Task Force. We  also interviewed DOD and military service officials, including officials  from the Defense and Veterans Brain Injury Center (DVBIC), on  installation-specific processes used to screen servicemembers for mild TBI  prior to or following deployment as well as DVBIC’s training programs for  health care providers. We discuss DOD’s screening with respect to mild  TBI rather than moderate to severe TBI because in general, mild TBI can  be more difficult to identify than moderate to severe TBI. We conducted  our work from July 2007 through May 2008 in accordance with generally  accepted government auditing standards.
subsections: section_title: Background
paragraphs: Substantial numbers of ground combat Army and Marine Corps  servicemembers are exposed to combat experiences often associated with  an increased risk of developing PTSD or other mental health conditions.  Specifically, according to a 2004 study, more than half of Army or Marine  Corps ground combat units in OEF or OIF report being shot at or receiving  small-arms fire, seeing dead or seriously wounded Americans, or seeing ill  or injured women or children who they were unable to help. More than  half of Marine Corps servicemembers and almost half of Army  servicemembers reported killing an enemy combatant in OIF. In addition  to certain types of experiences, multiple deployments are also associated  with mental health problems. For example, a 2006 Army mental health  advisory team report found that Army servicemembers who had been  deployed more than once were more likely to screen positive for PTSD,  depression, or anxiety than those deployed only once. In a 2008 Army  mental health advisory team report, 27 percent of Army male non- commissioned officers in their third or fourth deployment screened  positive for PTSD, depression, or anxiety (compared to 12 percent of those  on their first deployment).
Servicemembers are also exposed to events such as blasts that increase  their risk of experiencing a TBI. TBI occurs when a sudden trauma causes  damage to the brain and can result in loss of consciousness, confusion,  dizziness, trouble with concentration or memory, and seizures. Of  particular concern are the after-effects of a mild TBI that may not have  resulted in readily apparent symptoms at the time of the injury. A recent  study found that mild TBI was associated with high combat intensity and  multiple exposures to explosions in combat. Identification of mild TBI is  important, as treatment has been shown to mitigate the injury’s effects,  which can include difficulty returning to work or completing routine daily  activities. DVBIC has issued a screening tool called the Military Acute  Concussion Evaluation (MACE), which is based on a screening tool widely  used in sports medicine and is intended to evaluate a servicemember  within 48 hours of the suspected injury. In June 2007, the Army required  health care providers to document a servicemember’s blast exposure in  theater using the MACE. DVBIC also issued in December 2006 a CPG for  the management of mild TBI in theater. The guidance contains a  structured series of questions that include certain “red flags,” such as  worsening headaches or slurred speech, that should trigger further  evaluation for a possible mild TBI. Treatments for mild TBI may include  education, medication, and physical and psychiatric therapy.
subsections: section_title: Deployment Cycles and DOD Health Assessments
paragraphs: There are multiple opportunities during the deployment cycle for  screening and assessing servicemembers’ health status. Specifically, DOD  requires three health assessments during the deployment cycle: the pre- deployment health assessment, the PDHA, and the PDHRA. In addition,  DOD requires an annual periodic health assessment (PHA). These  assessments and their associated forms are described in Table 1.
DOD’s Instruction on Deployment Health, which implements policies and  prescribes procedures for deployment health activities, requires deploying  servicemembers to complete the pre-deployment health assessment form,  the DD 2795, within 60 days prior to the expected deployment date. The  DD 2795 is a brief form for servicemembers to self-report general health  information in order to identify any health concerns that may limit  deployment or need to be addressed prior to deployment, and consists of  eight questions that each servicemember must complete (see fig. 1).
DOD’s Instruction on Deployment Health states that after the  servicemember completes the DD 2795, the form is to be reviewed by a  health care provider, who can be a nurse, medical technician, medic, or  corpsman. If the servicemember indicates a positive, or “yes,” response to  any one of certain questions (2, 3, 4, 7, or 8) the servicemember is to be  referred for an interview by a trained health care provider such as a  physician, physician assistant, nurse practitioner, or advanced practice  nurse. The provider signs the form indicating whether the individual is  medically ready for deployment, and a copy of the DD 2795 is placed in the  servicemember’s deployment health record. The deployment health record  is a summary of the medical record that is to accompany the  servicemember into theater. According to DOD’s Instruction on  Deployment Health, this record should also contain a record of the  servicemember’s blood type, allergies, corrective lens prescription,  immunization record, and a summary sheet listing past and current  medical conditions, screening tests, and prescriptions.
subsections: section_title: Post-Deployment Health Assessment
paragraphs: DOD’s Instruction on Deployment Health requires servicemembers  returning from deployment to complete the post-deployment health  assessment form, the DD 2796, within 30 days of leaving a combat theater  or within 30 days of returning to home or a processing station. The DD  2796 is a form for servicemembers to self-report health concerns  commonly associated with deployments. In January 2008, DOD released a  new version of the DD 2796 that contains screening questions related to  mental health, including questions used to screen for depression, suicidal  thoughts, and PTSD. The screening questions for depression, suicidal  thoughts, and alcohol abuse are more detailed on the new form than on  the previous version of the DD 2796 (See appendix I for a copy of the new  version of the DD 2796). The DD 2796 must be reviewed, completed, and  signed by a health care provider. According to DOD’s Instruction on  Deployment Health, the health care provider conducting the assessment  must be a physician, physician assistant, nurse practitioner, advanced  practice nurse, independent duty medical technician or IDC, or Special  Forces medical sergeant.
According to DOD’s Instruction on Deployment Health, the health care  provider review is to take place in a face-to-face interview with the  servicemember. The health care provider is to review the completed DD  2796 to identify any responses that may indicate a need for further medical  evaluation. In addition, the new DD 2796 contains guidance intended to  assist a provider in determining whether to make a referral for some  mental health concerns. For example, the form prompts the provider to  conduct a risk assessment for suicide depending on the servicemember’s  response to the suicide risk questions. Health care providers use a section  of the DD 2796 to indicate when a servicemember needs a referral. The  referral field specifies both the concern for which the servicemember is  being referred, such as depression or PTSD symptoms, and the type of  care or provider to whom the servicemember is being referred, such as  primary care, mental health, specialty care, family support services,  chaplains, or Military OneSource. DOD requires that the DD 2796 be  placed in the servicemember’s medical record.
section_title: Periodic Health Assessment
paragraphs: DOD requires an annual health assessment, the PHA, for all  servicemembers. The PHA is designed to ensure servicemember medical  readiness through monitoring servicemember health status and helps DOD  provide preventive care, information, counseling, or treatment if  necessary. In February 2006, DOD required the military services to begin  administering the PHA, which includes servicemember self-reporting of  health status, conditions, treatments, and medications; provider review of  the medical record and identification of and referral for any health issues.  The PHA also includes efforts to identify and manage preventive needs,  occupational risk and exposure as well as identifying and recommending a  plan to manage risks. DOD requires its providers to record the results of  the PHA in servicemembers’ medical records. DOD has created an online  tool to capture self-reported information from the PHA. A draft of this  form contains several mental health questions, including PTSD and  depression screening questions that are similar to the current PTSD and  depression questions on the DD 2796.
section_title: DOD Electronic Medical Records Systems Used to Make PDHA Referrals
paragraphs: While several DOD information systems contain servicemember medical  information, the Composite Health Care System (CHCS) I and the Armed  Forces Health Longitudinal Technology Application (AHLTA), formerly  known as CHCS II, are the two electronic medical records systems  generally used by DOD health care providers to make PDHA referrals.  Although the military services currently employ both systems, there are  several differences between the two. For example, CHCS I is a localized  system, meaning information contained within CHCS I is only available to  medical facilities on a particular military installation; information is not  available to military treatment facilities (MTFs) on other installations. In  contrast, information in AHLTA is available to medical facilities at  different installations and to providers in theater. Another distinction is  that CHCS I sends health care providers an email alert when a  servicemember they refer makes, completes, or cancels an appointment. If  servicemembers do not make appointments within 30 days, their referral is  terminated from CHCS I and the health care provider is notified by email.  AHLTA does not have this capability. DOD has been expanding AHLTA’s  capabilities and plans on replacing certain CHCS I functions, such as  laboratory tests, with AHLTA.
section_title: DOD Has Taken Steps to Implement Pre- Deployment Mental Health Screening, but Policies for Medical Record Reviews Are Inconsistent
paragraphs: DOD has taken steps to meet the 2007 NDAA requirements for pre- deployment mental health standards and screening. As required by the  2007 NDAA, which was enacted in October 2006, DOD issued minimum  mental health standards that servicemembers must meet in order to be  deployed. In a policy issued in November 2006, DOD identified mental  health disorders that would preclude a servicemember’s deployment,  including conditions such as bipolar disorder. DOD’s policy also identified  psychotropic medications that would limit or preclude deployment if used  by servicemembers—including antipsychotic or anticonvulsant  medications used to control bipolar symptoms and certain types of  tranquilizers and stimulant medications. In addition to identifying the  mental health conditions and medications that would preclude  deployment, DOD’s policy specified the circumstances under which  servicemembers with other mental health conditions can be deployed.  Specifically, according to DOD’s policy, when a servicemember has been  diagnosed with a mental health condition that does not preclude  deployment, the servicemember should be free of “significant” symptoms  associated with this condition for at least three months before he or she  can be deployed. The policy also states that in making a deployability  assessment, health care providers should consider the environmental and  physical stresses of the deployment and whether continued treatment will  be available in theater. Finally, the policy identified the pre-deployment  health assessment as a mechanism for screening servicemembers for  mental health conditions and for ensuring that the standards are utilized in  making deployment determinations.
The 2007 NDAA also required DOD to use the pre-deployment health  assessment to identify those who are under treatment or have taken  psychotropic medications for a mental health condition. The pre- deployment health assessment form, the DD 2795, includes a question  asking servicemembers whether they have sought mental health  counseling or mental health care in the past year. In a July 2007 report to  Congress, DOD cited the pre-deployment health assessment in describing  its implementation of the 2007 NDAA requirements for pre-deployment  screening. The report also identified a medical record review as a  component of the pre-deployment health assessment process to help meet  these mental health screening requirements. According to a senior DOD  official, because servicemembers may be reluctant to disclose symptoms  or treatment that may prevent them from deploying, the provider review of  the medical record should be done to verify the self-reported information  on the DD 2795.
While medical records are an important part in making deployment  determinations, DOD’s deployment policies are not consistent with  respect to their review. DOD’s November 2006 policy on minimum mental  health standards for deployment states that the pre-deployment health  assessment includes a medical record review as part of ensuring the  standards are utilized, and DOD officials confirmed that the policy  requires such a review. However, DOD’s August 2006 Instruction on  Deployment Health, which implements policies and prescribes procedures  for deployment health activities, is silent on whether a review of medical  records is required as part of the pre-deployment health assessment. This  Instruction states only that the pre-deployment health assessment form,  DD 2795, must be completed by each deploying servicemember and the  responses reviewed by a health care provider. A health care provider  following DOD’s Instruction may not conduct the medical record review  during the pre-deployment health assessment required by DOD’s policy on  minimum mental health standards for deployment. Because of DOD’s  inconsistent policies, providers determining if OEF and OIF  servicemembers meet DOD’s minimum mental health deployment  standards may not have complete medical information.
During our site visits, we found that practices varied with respect to pre- deployment mental health screening, and medical records were not  routinely reviewed at the time of the pre-deployment health assessment by  the provider reviewing the DD 2795. While a review of medical records can  serve to validate information reported by servicemembers, the health care  providers we spoke with during our site visits were unaware that it was  required as part of the pre-deployment health assessment. At all three  installations we visited, servicemembers completed the DD 2795 form. At  two of the three installations all servicemembers were interviewed by a  health care provider to review their responses on the DD 2795 and discuss  any additional health concerns. At the third installation, providers  interviewed servicemembers if they indicated any concerns on the DD  2795. While the deployment health record was available to providers at all  three installations, the medical record was routinely reviewed by the  provider at only one of the three installations during the pre-deployment  health assessment. At the other two installations, providers told us the  record was reviewed only if servicemembers identified concerns on the  DD 2795 or during the interview.
section_title: Health Care Providers at Installations Visited Manually Track Mental Health Referrals from the PDHA
paragraphs: Health care providers at Fort Campbell and Camp Lejeune manually  track whether servicemembers who receive mental heath referrals from  the PDHA make or keep appointments for evaluations with mental health  providers. DOD does not require that individual referrals from the PDHA  be tracked; however, DOD has a quality assurance program that monitors  the PDHA, including follow-up encounters. In addition, because Guard  and Reserve servicemembers generally receive civilian care, which they do  not have to disclose, and because servicemembers may be reluctant to  disclose mental health encounters due to stigma concerns, Guard and  Reserve referrals are difficult to track.
subsections: section_title: Health Care Providers at Visited Installations Manually Track PDHA Mental Health Referrals
paragraphs: While DOD health care providers generally make PDHA referrals using one  of two DOD information technology systems, AHLTA or CHCS I, health  care providers at military installations we visited have developed different  manual systems to track whether referred servicemembers made or kept  appointments with mental health providers. DOD does not require these  referrals to be tracked. However, a Fort Campbell health care provider we  spoke with said that the health care providers who make referrals from the  PDHA may not have an ongoing relationship with the referred  servicemembers and, therefore, manual systems have been created to  track whether referred servicemembers completed their evaluations.  According to installation health care providers, manually tracking referrals  is labor-intensive and time-consuming, and necessary to ensure that  referred servicemembers receive their evaluations.
We found that health care providers at Fort Campbell and Camp Lejeune  have developed manual tracking systems to ensure that servicemembers  receive evaluations. At Fort Campbell, the installation’s readiness  processing manager, who is the health care provider who tracks PDHA  referrals, created an Access database for this purpose. The manager  checks CHCS I, the information technology system Fort Campbell  healthcare providers use to make PDHA referrals, daily to obtain their  status. Then, this individual manually enters the status of each referral into  the Access database, which allows all PDHA referrals and their status to  be viewed in one list. Servicemembers who fail to make or keep their  appointments are contacted, and if a servicemember does not respond  after two follow-up attempts, the unit commander is informed.
At Camp Lejeune, health care providers track division servicemembers’  PDHA mental health referrals to the division psychiatrist using hard-copy  logbooks. Because the division psychiatrist’s clinic does not have access  to AHLTA or CHCS I, health care providers make referrals by phoning the  division psychiatrist and follow-up with the psychiatrist every two weeks  to track whether servicemembers kept their appointments. Camp Lejeune  officials told us that, unlike the division, the air wing’s and logistics  group’s PDHA mental health referral tracking is facilitated by having  greater access to AHLTA, which allows providers to check the status of  appointments scheduled at the MTF.
section_title: Some Reserves’ PDHA Mental Health Referrals Are Manually Tracked
paragraphs: We found that mental health PDHA referrals for Marine Reserve members  who complete the PDHA at Camp Lejeune are tracked manually. Officials  from the Marine Reserves’ Deployment Support Group (DSG) at Camp  Lejeune inform the home units of Reserve member referrals and track  their status. According to a Fort Campbell health care provider, Army  Reserve members are not processed through Fort Campbell following  deployment and, therefore, do not complete the PDHA at this installation.
According to Guard and Reserve officials, home units rely largely on  servicemembers to disclose whether they receive care from a mental  health provider. Tracking PDHA mental health referrals is challenging for  the Guard and Reserves because their members generally receive civilian  care. Military health care providers would be unaware of civilian care  unless disclosed by the Guard and Reserve member. In addition, Military  OneSource, which is operated by a vendor contracted by DOD, guarantees  that it will not release the identity of servicemembers who receive  counseling unless servicemembers are at risk of harming themselves or  others. As a result, PDHA mental health referral tracking is challenging for  Guard and Reserve units due to their reliance on servicemembers to  disclose mental health encounters with civilian providers, which Guard  and Reserve officials told us they may be reluctant to do because of stigma  concerns.
section_title: Health Care Providers Receive Mental Health Training and Guidance; DOD and the Military Services Are Implementing New Training Initiatives
paragraphs: While DOD policy allows several types of health care providers to conduct  the PDHA, health care providers at Fort Campbell and Camp Lejeune told  us that health care providers actually conducting the assessments are  generally physicians, physician assistants, or, in the case of the Marine  Corps, IDCs. According to installation health care providers, most of the  physicians conducting the assessments have specialties in primary care,  which includes the specialties of family practice and internal medicine.
The health care providers conducting these health assessments receive  varying levels of training in mental health issues based on provider type  during their basic medical education. For example, physician assistants  complete a rotation in psychiatry and may elect an additional psychiatry  rotation, while IDCs receive training in psychiatric disorders as part of a  unit on medical diagnosis and treatment that covers several types of  medical conditions. Physicians receive mental health training in medical  school.
DOD provides several types of guidance for health care providers to help  them conduct mental health assessments and decide whether to make  referrals for further evaluation. DOD maintains a Web site that contains  CPGs and other guidance and training that can be accessed by health care  providers conducting the assessments. For example, DOD provides a set  of reference materials on the Web site that contains information on and  steps to assess servicemembers for PTSD and major depressive disorder.  According to DOD, hard copy versions of these reference materials were  distributed to MTFs beginning in July 2004, and MTFs may order  additional copies.
We found that health care providers conducting the PDHA had varying  familiarity with the CPGs and levels of comfort in conducting assessments.  For example, at Camp Lejeune, some of the physicians and IDCs we  interviewed about DOD’s guidance were not familiar with the CPGs for  depression and PTSD. Some physicians and IDCs cited resource  constraints, in the form of limited access to computers and internet  connectivity, as barriers to accessing these CPGs posted on the Web site.  At Fort Campbell, a brigade surgeon we spoke to who supervises  providers conducting the PDHA said that these providers have varying  knowledge of the CPGs. He stated that the guidance is distributed to email  accounts that some health care providers may not check regularly. In  addition, health care providers varied in their level of comfort in making  mental health assessments. At Camp Lejeune, eight of the 15 physicians  and IDCs we interviewed were comfortable making mental health  assessments, while the remaining seven were less comfortable making  these assessments and expressed interest in receiving more training on  making mental health assessments. At Fort Campbell, the division mental  health providers we spoke with stated that while physician assistants, for  example, could identify a servicemember with mental health concerns,  these providers were generally not comfortable in assessing  servicemembers for mental health issues.
DOD and the military services have implemented and are in the process of  implementing several new mental health training initiatives. DOD created  the Center of Excellence for Psychological Health and Traumatic Brain  Injury in November 2007 that will focus on research, education, and  training related to mental health. According to DOD, the Center will  develop and distribute a core mental health curriculum for health care  providers, as well as implement policies to direct training in the  curriculum across the services. DOD plans to begin training primary care  providers in July 2008. The Army has created a program, RESPECT-MIL,  that trains primary care providers in identifying and treating  servicemembers with depression and PTSD. By the end of 2008, the Army  plans to train providers at 15 installations. The Army also directed all  servicemembers, including health care providers, to participate in a  training program that includes information on PTSD by October 18, 2007.  The training focused on the causes and physical and psychological effects  of PTSD and provided information on how to seek subsequent treatment  for this condition. As of January 31, 2008, 93 percent of Army  servicemembers had received the training. The Army also requires  commanders to include PTSD awareness and response training in pre- and  post-deployment briefings. The Marine Corps has a training program for  non-mental health providers, including those that conduct the PDHA, that  includes training on PTSD. This training began in January 2008 and is  scheduled to train 669 health care providers at 12 sites by August 2008.  The Marine Corps also requires pre- and post-deployment briefings on  identifying and managing combat stress for all Marine Corps  servicemembers and unit leaders.
section_title: DOD Is Implementing Mild TBI Screening for All Servicemembers and Has Provided Guidance and Training for Health Care Providers
paragraphs: In response to the 2007 NDAA, DOD added TBI screening questions to the  PDHA in January 2008 and plans in July 2008 to begin screening all  servicemembers prior to deployment. Prior to these TBI screening efforts  required by DOD, several installations had already implemented efforts to  screen servicemembers before or after their deployments. To help health  care providers screen servicemembers for mild TBI and issue referrals,  DOD has issued guidance and provided various forms of training.
subsections: section_title: DOD Is Implementing Mild TBI Screening in Its PDHA and Prior to Deployment; Several Installation- Specific Mild TBI Screening Initiatives Are in Place
paragraphs: In response to the 2007 NDAA requirement for pre-and post-deployment  screening for TBI, DOD has added TBI screening questions to the PDHA,  and plans to require screening of all servicemembers beginning in July  2008 for mild TBI prior to deployment. These screening questions are  similar to the screening questions on the PDHA. The questions are  included in a cognitive assessment tool that will provide a baseline of  cognitive function in areas such as memory and reaction time. In January  2008, DOD released a new version of the post-deployment health  assessment form, the DD 2796, that contains screening questions for TBI  (See appendix I for a copy of the new version of the DD 2796).
The TBI screening questions added to the PDHA are designed to be  completed by the servicemember in four series. The sequence of  questions specifically assesses (a) events that may have increased the risk  of a TBI, (b) immediate symptoms following the event, (c) new or  worsening symptoms following the event, and (d) current symptoms. (See  appendix I.) If there is a positive response to any question in the first  series, the servicemember completes the second and third series; if there  is a positive response to any question in the third series, the  servicemember completes the fourth series about current symptoms. The  DD 2796 directs the health care provider to refer the servicemember based  on the servicemember’s current symptoms. See figure 2 for a description  of these screening questions.
DOD is planning to require screening of all servicemembers for mild TBI  prior to deployment using questions similar to those on the PDHA. This  screening is planned to begin in July 2008 and these screening questions  are included in a cognitive assessment, the Automated Neuropsychological  Assessment Metrics (ANAM). The ANAM will provide a baseline  assessment of cognitive function in areas such as memory and reaction  time, which may be affected by a mild TBI. If a servicemember  experiences an event in theater, the ANAM can be administered again and  the differences in function assessed. Because the ANAM does not  distinguish between impairments in cognitive function caused by events  such as blasts and those caused by other factors such as fatigue, the  ANAM needs to be used with screening questions to identify the event that  may have caused a TBI. However, the ANAM can be used to identify  changes in baseline cognitive function that may warrant further  evaluation. According to an Army official, since August 2007 about 50,000  Army servicemembers have been assessed using the ANAM.
Prior to DOD’s plans to screen all servicemembers on the PDHA and prior  to deployment, several installations had implemented, as early as 2000,  initiatives for mild TBI screening to be used before or after units from  those locations deployed. Generally, servicemembers participating in  these initiatives are screened using a three-question screen developed by  the DVBIC called the Brief Traumatic Brain Injury Screen (BTBIS). The  BTBIS is designed to identify servicemembers who may have had a mild  TBI, and includes questions about events and symptoms that are similar to  those used on DOD’s PDHA. The first of these initiatives began at Fort  Bragg, North Carolina in 2000. Since then, Fort Carson, Colorado; Fort  Irwin, California; Fort McCoy, Wisconsin and Camp Pendleton, California  have initiated screening for mild TBI either pre-deployment, post- deployment, or both. A DVBIC official told us that these initiatives would  probably be replaced by the DOD-wide screening.
section_title: DOD Has Issued Guidance on Identification of Mild TBI and Trained Some Health Care Providers on Identifying Mild TBI
paragraphs: DOD issued guidance for health care providers on the identification of  mild TBI, trained some health care providers on identifying mild TBI, and  plans additional health care provider training initiatives. In October 2007  DOD released guidance on identifying mild TBI for providers screening,  assessing, and treating servicemembers outside the combat theater. The  guidance contains information to help health care providers conducting  the PDHA, including follow-up questions that the provider can ask a  servicemember based on the servicemember’s responses to the TBI  screening questions on the PDHA. The guidance contains structured series  of questions that include certain “red flags,” such as double vision or  confusion, that suggest a need for referral for further evaluation for a  possible mild TBI. The guidance recommends assessments and treatments  for servicemembers with symptoms such as irritability and includes  screening tools to help health care providers assess the severity of these  symptoms. According to a DOD official, DOD also plans to provide the  military services with guidance on using the new TBI screening questions  on the PDHA.
In addition to issuing guidance, DOD and the military services also trained  health care providers on identifying possible mild TBI. In September 2007  DOD held a tri-service conference in which more than 800 health care  providers were trained. According to DVBIC officials, DVBIC staff provide  training through workshops for health care providers at its 14 sites and  travel to other installations to train health care providers. In addition,  DOD’s planned Defense Center of Excellence for Psychological Health and  Traumatic Brain Injury, which began initial operations on November 30,  2007, and is expected to be fully functional by October 2009, will develop a  national collaborative network to advance and disseminate TBI  knowledge, enhance clinical and management approaches, and facilitate  services for those dealing with TBI, according to DOD. According to Army  officials, the Army is also initiating several health care provider training  efforts for the summer of 2008 designed to train primary care providers on  mild TBI. According to these officials, primary care providers are generally  uncomfortable with treating mild TBI, preferring instead to refer these  cases to specialty care. The Marine Corps’ training program for non-mental  health care providers, including those conducting the PDHA, also includes  material on diagnosing mild TBI. With respect to the ANAM, DVBIC  officials told us that wherever this assessment tool is used, DVBIC officials  and officials responsible for the implementation of the ANAM train health  care providers in its use.
section_title: Conclusions
paragraphs: DOD has taken positive steps to implement provisions of the 2007 NDAA  related to screening servicemembers for TBI and mental health. For  example, DOD has added mild TBI screening to its PDHA and will require  screening prior to deployment. With respect to mental health, we found  that health care providers’ familiarity with DOD’s CPGs and comfort in  making mental health assessments varied. However, DOD and the military  services have implemented or are implementing training initiatives, some  of which are specifically aimed at the primary care providers who  generally conduct the PDHA. Furthermore, the installations we visited had  developed manual systems for tracking those servicemembers who were  referred from the PDHA to ensure that they made or completed their  appointments. Referral tracking is difficult for the Guard and Reserves  because their servicemembers generally receive civilian care.
DOD has taken steps to meet 2007 NDAA requirements related to mental  health standards and screening, including issuing a policy on minimum  mental health standards for deployment. A key component of DOD’s  efforts to meet these requirements is a review of medical records, and we  agree that this should be done to verify information in a screening process  that depends on self-reported information. Unfortunately, DOD’s policies  for reviewing medical records during the pre-deployment health  assessment are inconsistent. During our site visits we found that health  care providers were unaware a medical record review was required and  that medical records were not always reviewed by providers conducting  the pre-deployment health assessment. A health care provider following  DOD’s Instruction on Deployment Health, which is silent on whether  medical record review is required during the pre-deployment health  assessment, may not conduct the medical record review required by  DOD’s policy on minimum mental health standards for deployment. Until  DOD resolves the inconsistency between its policies, its health care  providers may not have complete mental health information when  screening servicemembers prior to deployment.
section_title: Recommendation for Executive Action
paragraphs: In order to address the inconsistency in DOD’s policies related to the  review of medical record information and to assure that health care  providers have reviewed the medical record when screening  servicemembers prior to deployment, we recommend that the Secretary of  Defense direct the Under Secretary of Defense for Personnel and  Readiness to revise DOD’s Instruction on Deployment Health to require a  review of medical records as part of the pre-deployment health  assessment.
section_title: Agency Comments and Our Evaluation
paragraphs: In commenting on a draft of this report, DOD stated that our concerns  regarding provider review of medical records are well-taken and that an  assessment is only complete when it includes a medical record review.  While DOD concurred with our recommendation and said that it will  update its Instruction on Deployment Health to require a medical record  review at the time of the pre-deployment health assessment, DOD is  limiting this medical record review requirement to servicemembers who  have a significant change in health status since their most recent periodic  health assessment. According to a senior DOD health official, it is  anticipated that the updated Instruction will be published in one year.  However, DOD does not explain how providers will be able to identify the  subset of servicemembers who have had a significant change in health  status. As a result, its response does not fully eliminate the inconsistency  between its policy and current Instruction. To fully eliminate the  inconsistency, as we recommended, DOD should require a medical record  review for all servicemembers as part of the pre-deployment health  assessment in its updated Instruction. We also encourage DOD to update  its Instruction as quickly as possible so that providers have the complete  information that we and DOD agree they need to make pre-deployment  decisions.  DOD also provided technical comments, which we  incorporated as appropriate.
We are sending copies of this report to the Secretary of Defense; the  Secretaries of the Army, the Air Force, and the Navy; the Commandant of  the Marine Corps; and appropriate congressional committees and  addressees. We will also provide copies to others upon request. In  addition, the report is available at no charge on the GAO Web site at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact me  at (202) 512-7114 or bascettac@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix III.
section_title: Appendix I: New Post-Deployment Health Assessment (DD 2796), January 2008
section_title: Appendix II: Comments from the Department of Defense
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Marcia Mann, Assistant Director;  Eric Anderson; Krister Friday; Lori Fritz; Adrienne Griffin; Amanda Pusey;  and Jessica Cobert Smith made key contributions to this report.
section_title: Related GAO Products
paragraphs: VA Health Care: Mild Traumatic Brain Injury Screening and  Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain.  GAO-08-276. Washington, D.C.: February 8, 2008.
VA and DOD Health Care: Administration of DOD’s Post-Deployment  Health Reassessment to National Guard and Reserve Servicemembers  and VA’s Interaction with DOD. GAO-08-181R. Washington, D.C.:   January 25, 2008.
Defense Health Care: Comprehensive Oversight Framework Needed to  Help Ensure Effective Implementation of a Deployment Health Quality  Assurance Program. GAO-07-831. Washington, D.C.: June 22, 2007.
Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its  Providers Use to Make Mental Health Evaluation Referrals for  Servicemembers. GAO-06-397. Washington, D.C.: May 11, 2006.
Military Personnel: Top Management Attention Is Needed to Address  Long-standing Problems with Determining Medical and Physical  Fitness of the Reserve Force. GAO-06-105. Washington, D.C.:   October 27, 2005.
Defense Health Care: Occupational and Environmental Health  Surveillance Conducted during Deployments Needs Improvement.   GAO-05-903T. Washington, D.C.: July 19, 2005.
Defense Health Care: Improvements Needed in Occupational and  Environmental Health Surveillance during Deployments to Address  Immediate and Long-term Health Issues. GAO-05-632. Washington, D.C.:  July 14, 2005.
VA Health Care: VA Should Expedite the Implementation of  Recommendations Needed to Improve Post-Traumatic Stress Disorder  Services. GAO-05-287. Washington, D.C.: February 14, 2005.
Defense Health Care: Force Health Protection and Surveillance Policy  Compliance Was Mixed, but Appears Better for Recent Deployments.  GAO-05-120. Washington, D.C.: November 12, 2004.
VA and Defense Health Care: More Information Needed to Determine If  VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder  Services. GAO-04-1069. Washington, D.C.: September 20, 2004.