Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its Providers Use to Make Mental Health Evaluation Referrals for Servicemembers
Published: 2006-05-11T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Many servicemembers supporting Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have engaged in intense and prolonged combat, which research has shown to be strongly associated with the risk of developing post-traumatic stress disorder (PTSD). GAO, in response to the Ronald W. Reagan National Defense Authorization Act for Fiscal Year 2005, (1) describes DOD's extended health care benefit and VA's health care services for OEF/OIF veterans; (2) analyzes DOD data to determine the number of OEF/OIF servicemembers who may be at risk for PTSD and the number referred for further mental health evaluations; and (3) examines whether DOD can provide reasonable assurance that OEF/OIF servicemembers who need further mental health evaluations receive referrals.
section_title: What GAO Found
paragraphs: DOD offers an extended health care benefit to some OEF/OIF veterans for a specified time period, and VA offers health care services that include specialized PTSD services. DOD's benefit provides health care services, including mental health services, to some OEF/OIF veterans for 180 days following discharge or release from active duty. Additionally, some veterans may purchase extended benefits for up to 18 months. VA also offers health care services to OEF/OIF veterans following their discharge or release from active duty. VA offers health benefits for OEF/OIF veterans at no cost for 2 years following discharge or release from active duty. After their 2-year benefit expires, some OEF/OIF veterans may continue to receive care under VA's eligibility rules. Using data provided by DOD, GAO found that 9,145 or 5 percent of the 178,664 OEF/OIF servicemembers in its review may have been at risk for developing PTSD. DOD uses a questionnaire to identify those who may be at risk for developing PTSD after deployment. DOD providers interview servicemembers after they complete the questionnaire. A joint VA/DOD guideline states that servicemembers who respond positively to three or four of the questions may be at risk for PTSD. Further, we reviewed a retrospective study that found that those individuals who provided three or four positive responses to the four PTSD screening questions were highly likely to have been previously given a diagnosis of PTSD prior to the screening. Of the 5 percent who may have been at risk, GAO found that DOD providers referred 22 percent or 2,029 for further mental health evaluations. DOD cannot provide reasonable assurance that OEF/OIF servicemembers who need referrals receive them. According to DOD officials, not all of the servicemembers with three or four positive responses to the PTSD screening questions will need referrals for further mental health evaluations. DOD relies on providers' clinical judgment to decide who needs a referral. GAO found that DOD health care providers varied in the frequency with which they issued referrals to OEF/OIF servicemembers with three or more positive responses; the Army referred 23 percent, the Marines about 15 percent, the Navy 18 percent, and the Air Force about 23 percent. However, DOD did not identify the factors its providers used in determining which OEF/OIF servicemembers needed referrals. Knowing the factors upon which DOD health care providers based their clinical judgments in issuing referrals could help explain variation in the referral rates and allow DOD to provide reasonable assurance that such judgments are being exercised appropriately.

section_title: Letter
paragraphs: Servicemembers returning from the military conflicts in Afghanistan and  Iraq—Operation Enduring Freedom (OEF) and Operation Iraqi Freedom  (OIF), respectively—have engaged in intense and prolonged combat,  which research has shown to be strongly associated with the risk for  developing PTSD. PTSD can occur after experiencing or witnessing a life- threatening event and is the most prevalent mental health disorder  resulting from combat. Mental health experts state that early identification  and treatment of symptoms through education, peer and family support,  therapy, or medications may lessen the severity of the condition and  improve the overall quality of life for those with PTSD.
The Department of Defense (DOD) uses a questionnaire to screen  OEF/OIF servicemembers after their deployment outside of the United  States has ended. The questionnaire assesses servicemembers’ physical  and mental health and includes four questions that are used to identify  those who may be at risk for developing PTSD. In conjunction with  completion of the questionnaire, each OEF/OIF servicemember is  interviewed by a DOD health care provider who reviews the completed  questionnaire and discusses with the servicemember any deployment- related health concerns, including mental health concerns. From among  those who may be at risk for PTSD or other mental health conditions,  these DOD health care providers then determine which servicemembers  need referrals for a further mental health evaluation. Providers use a  section of the post-deployment screening questionnaire to indicate when a  servicemember needs a referral.
OEF/OIF servicemembers can obtain mental health evaluations, as well as  any necessary treatment for PTSD, while they are servicemembers—that  is, on active duty—or when they transition to veteran status after being  discharged or released from active duty. DOD provides mental health  evaluations and treatment for PTSD to servicemembers, including  OEF/OIF servicemembers, and the department also provides these mental  health benefits for OEF/OIF veterans through an extended health care  benefit created for this population. The Department of Veterans Affairs  (VA) also provides mental health benefits to OEF/OIF veterans as part of  health care services that it offers to these and other veterans. In this  report, we use the term OEF/OIF servicemembers when we refer to those  returning from the OEF/OIF conflicts who are screened for PTSD and may  receive referrals during active duty. We use the term OEF/OIF veterans  when we refer to those returning from the OEF/OIF conflicts who, after  being discharged or released from active duty, are eligible for DOD and VA  mental health benefits and could access the departments’ services.
The Ronald W. Reagan National Defense Authorization Act for Fiscal Year  2005 (NDAA) directed that we describe the mental health benefits  available for OEF/OIF veterans. NDAA further directed that we examine  the process DOD uses to refer OEF/OIF servicemembers who need further  mental health evaluations. In this report, we (1) describe DOD’s extended  health care benefit for OEF/OIF veterans and VA’s health care services for  OEF/OIF veterans; (2) analyze DOD data to determine the number of  OEF/OIF servicemembers who may be at risk for developing PTSD and the  number of these servicemembers who were referred for further mental  health evaluations; and (3) examine whether DOD can provide reasonable  assurance that OEF/OIF servicemembers who need further mental health  evaluations receive referrals for these evaluations.
To describe DOD’s extended health care benefit and VA’s health care  services for OEF/OIF veterans, we reviewed DOD policies and the  educational materials DOD provides to individuals on its health insurance  benefits, including information on the length of coverage of these benefits.
We also interviewed DOD officials and the military service branches about  these benefits. In addition, we reviewed VA’s policies, directives, and  educational information on its health care services, including the mental  health services that VA has available for OEF/OIF veterans. We reviewed  the types of mental health services available through VA’s health care  system for OEF/OIF veterans. We also interviewed VA headquarters  officials about these services.
To determine the number of OEF/OIF servicemembers who may be at risk  for developing PTSD and the number of these servicemembers referred for  further mental health evaluations, we analyzed DOD computerized data.  We obtained from DOD a list of OEF/OIF servicemembers who (1) were  deployed in support of OEF/OIF from October 1, 2001, through   September 30, 2004; (2) had since been discharged or released from active  duty; (3) completed DOD’s post-deployment screening questionnaire; and  (4) had the record of their completed questionnaire available in a DOD  computerized database. From this list, we identified 178,664 OEF/OIF  servicemembers who answered the four PTSD screening questions on  DOD’s post-deployment screening questionnaire, the DD 2796. To  determine the number of OEF/OIF servicemembers who may have been at  risk for developing PTSD, we reviewed a clinical practice guideline for  PTSD developed jointly by VA and DOD, which indicates that  servicemembers who provide three or four positive responses to the four  PTSD screening questions may be at risk for developing PTSD. We also  reviewed a retrospective study that found that those individuals who  provided three or four positive responses to the four PTSD screening  questions were highly likely to have been previously given a diagnosis of  PTSD prior to the screening. To determine the number of OEF/OIF  servicemembers who received referrals from a DOD health care provider,  we used information from the post-deployment questionnaires of the  178,664 OEF/OIF servicemembers in our review. The questionnaires  indicate whether a DOD health care provider issued a referral for a mental  health or combat/operational stress reaction evaluation. We determined  that DOD’s data were sufficiently reliable for the purposes of the report.
To examine whether DOD can provide reasonable assurance that OEF/OIF  servicemembers who need further mental health evaluations receive  referrals, we reviewed DOD’s policies and guidance, including guidance  for DOD health care providers who use the DD 2796. We reviewed DOD’s  quality assurance program and spoke to a researcher about a DOD study  on PTSD referrals to examine the extent to which DOD studies its  providers’ decisions to issue referrals. We interviewed DOD officials,  including mental health clinicians involved with the DD 2796 and asked  them about DOD’s criteria for issuing referrals to those who may be at risk  for developing PTSD.
NDAA also directed us to determine the number of OEF/OIF veterans who,  because of their DOD provider-issued referrals, accessed DOD or VA  health care services to obtain a further mental health or  combat/operational stress reaction evaluation. However, as discussed with  the committees of jurisdiction, we could not use data from OEF/OIF  veterans’ DD 2796 forms to determine if veterans accessed DOD or VA  health care services because of their mental health referrals. DOD officials  explained that the referral checked on the DD 2796 cannot be linked to a  subsequent health care visit using DOD computerized data. Therefore, we  could not determine how many OEF/OIF veterans accessed DOD or VA  health care services for further mental health evaluations because of their  referrals.
For a complete discussion of our scope and methodology, see appendix I.  We conducted our work from December 2004 through April 2006 in  accordance with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: PTSD can develop following exposure to combat, natural disasters,  terrorist incidents, serious accidents, or violent personal assaults like rape.  People who experience stressful events often relive the experience  through nightmares and flashbacks, have difficulty sleeping, and feel  detached or estranged. These symptoms may occur within the first 4 days  after exposure to the stressful event or be delayed for months or years.  Symptoms that appear within the first 4 days after exposure to a stressful  event are generally diagnosed as acute stress reaction or combat stress.
Symptoms that persist longer than 4 days are diagnosed as acute stress  disorder. If the symptoms continue for more than 30 days and significantly  disrupt an individual’s daily activities, PTSD is diagnosed. PTSD may  occur with other mental health conditions, such as depression and  substance abuse. Clinicians offer a range of treatments to individuals  diagnosed with PTSD, including individual and group therapy and  medication to manage symptoms. These treatments are usually delivered  in an outpatient setting, but they can include inpatient services if, for  example, individuals are at risk of causing harm to themselves.
subsections: section_title: DOD’s Post-Deployment Process and Screening for PTSD
paragraphs: DOD’s screening for PTSD occurs during its post-deployment process.  During this process, DOD evaluates servicemembers’ current physical and  mental health and identifies any psychosocial issues commonly associated  with deployments, special medications taken during the deployment, and  possible deployment-related occupational/environmental exposures. The  post-deployment process also includes completion by the servicemember  of the post-deployment screening questionnaire, the DD 2796. DOD uses  the DD 2796 to assess health status, including identifying servicemembers  who may be at risk for developing PTSD following deployment. In  addition to questions about demographics and general health, including  questions about general mental health, the DD 2796 includes four  questions used to screen servicemembers for PTSD. The four questions  are:  Have you ever had any experience that was so frightening, horrible, or  upsetting that, in the past month, you    have had any nightmares about it or thought about it when you did not  want to?  tried hard not to think about it or went out of your way to avoid situations  that remind you of it?    were constantly on guard, watchful, or easily startled?  felt numb or detached from others, activities, or your surroundings?
The completed DD 2796 is reviewed by a DOD health care provider who  conducts a face-to-face interview to discuss any deployment-related health  concerns with the servicemember. Health care providers that review the  DD 2796 may include physicians, physician assistants, nurse practitioners,  or independent duty medical technicians—enlisted personnel who receive  advanced training to provide treatment and administer medications. DOD  provides guidance for health care providers using the DD 2796 and  screening servicemembers’ physical and mental health. The guidance gives  background information to health care providers on the purpose of the  various screening questions on the DD 2796 and highlights the importance  of a health care provider’s clinical judgment when interviewing and  discussing responses to the DD 2796.
Health care providers may make a referral for a further mental health or  combat/operational stress reaction evaluation by indicating on the DD  2796 that this evaluation is needed. When a DOD health care provider  refers an OEF/OIF servicemember for a further mental health or  combat/operational stress reaction evaluation, the provider checks the  appropriate evaluation box on the DD 2796 and gives the servicemember  information about PTSD. The provider does not generally arrange for a  mental health evaluation appointment for the servicemember with a  referral. See figure 1 for the portion of the DD 2796 that is used to indicate  that a referral for a further mental health or combat/operational stress  reaction evaluation is needed.
section_title: DOD and VA Health Care Systems
paragraphs: DOD’s health care system, TRICARE, delivers health care services to over  9 million individuals. Health care services, which include mental health  services, are provided by DOD personnel in military treatment facilities or  through civilian health care providers, who may be either network  providers or nonnetwork providers. A military treatment facility is a  military hospital or clinic on or near a military base. Network providers  have a contractual agreement with TRICARE to provide health care  services and are part of the TRICARE network. Nonnetwork providers  may accept TRICARE allowable charges for delivering health care services  or expect the beneficiary to pay the difference between the provider’s fee  and TRICARE’s allowable charge for services.
VA’s health care system includes medical facilities, community-based  outpatient clinics, and Vet Centers. VA medical facilities offer services  which range from primary care to complex specialty care, such as cardiac  or spinal cord injury. VA’s community-based outpatient clinics are an  extension of VA’s medical facilities and mainly provide primary care  services. Vet Centers offer readjustment and family counseling,  employment services, bereavement counseling, and a range of social  services to assist veterans in readjusting from wartime military service to  civilian life. Vet Centers are also community points of access for many  returning veterans, providing them with information and referrals to VA  medical facilities.
section_title: DOD’s Quality Assurance Program
paragraphs: In January 2004, DOD implemented the Deployment Health Quality  Assurance Program. As part of the program, each military service branch  must implement its own quality assurance program and report quarterly to  DOD on the status and findings of the program. The program requires  military installation site visits by DOD and military service branch officials  to review individual medical records to determine, in part, whether the DD  2796 was completed. The program also requires a monthly report from the  Army Medical Surveillance Activity (AMSA), which maintains a database  of all servicemembers’ completed DD 2796s. DOD uses the information  from the military service branches, site visits, and AMSA to develop an  annual report on its Deployment Health Quality Assurance Program.
section_title: For Veterans, DOD Offers a Benefit for a Specific Period of Time and VA Offers Various Health Care Services
paragraphs: DOD offers an extended health care benefit to some OEF/OIF veterans for  a specific period of time, and VA offers health care services that include  specialized PTSD services. For some OEF/OIF veterans, DOD offers three  health care benefit options through the Transitional Assistance  Management Program (TAMP) under TRICARE, DOD’s health care system.  The three benefit options are offered for 180 days following discharge or  release from active duty. In addition, OEF/OIF veterans may purchase  health care benefits through DOD’s Continued Health Care Benefit  Program (CHCBP) for 18 months. VA also offers health care services to  OEF/OIF veterans following their discharge or release from active duty.  VA’s health benefits include health care services, including specialized  PTSD services, which are delivered by clinicians who have concentrated  their clinical work in the area of PTSD treatment and who work as a team  to coordinate veterans’ treatment.
subsections: section_title: DOD Offers Mental Health Benefits to OEF/OIF Veterans for 180 Days or More
paragraphs: Through TAMP, DOD provides health care benefits that allow some  OEF/OIF veterans to obtain health care services, which include mental  health services, for 180 days following discharge or release from active  duty. This includes services for those who may be at risk for developing  PTSD. These OEF/OIF veterans can choose one of three TRICARE health  care benefit options through TAMP. While the three options have no  premiums, two of the options have deductibles and copayments and allow  access to a larger number of providers. The options are    TRICARE Prime—a managed care option that allows OEF/OIF veterans to  obtain, without a referral, mental health services directly from a mental  health provider in the TRICARE network of providers with no cost for  services.
TRICARE Extra—a preferred provider option that allows OEF/OIF  veterans to obtain, without a referral, mental health services directly from  a mental health provider in the TRICARE network of providers.  Beneficiaries pay a deductible and a share of the cost of services.
TRICARE Standard—a fee-for-service option that allows OEF/OIF  veterans to obtain, without a referral, mental health services directly from  any mental health provider, including those outside the TRICARE network  of providers. Beneficiaries pay a deductible and a larger share of the costs  of services than under the TRICARE Extra option.
See Table 1 for a description of the beneficiary costs associated with each  TRICARE option.
In addition, OEF/OIF veterans may purchase DOD health care benefits  through CHCBP for 18 months. CHCBP began on October 1, 1994, and  like TAMP, the program provides health care benefits, including mental  health services, for veterans making the transition to civilian life. Although  benefits under this plan are similar to those offered under TRICARE  Standard, the program is administered by a TRICARE health care  contractor and is not part of TRICARE. OEF/OIF veterans must purchase  the extended benefit within 60 days after their 180-day TAMP benefit ends.  CHCBP premiums in 2006 were $311 for individual coverage and $665 for  family coverage per month.
Reserve and National Guard OEF/OIF veterans who commit to future  service can extend their health care benefits after their CHCBP or TAMP  benefits expire by purchasing an additional benefit through the TRICARE  Reserve Select (TRS) program. As of January 1, 2006, premiums under  TRS are $81 for individual coverage and $253 for family coverage per  month.
DOD also offers a service, Military OneSource, that provides information  and counseling resources to OEF/OIF veterans for 180 days after discharge  from the military. Military OneSource is a 24-hour, 7-days a week  information and referral service provided by DOD at no cost to veterans.  Military OneSource provides OEF/OIF veterans up to six free counseling  sessions for each topic with a community-based counselor and also  provides referrals to mental health services through TRICARE.
section_title: VA Offers Health Services, Including Specialized PTSD Services, to OEF/OIF Veterans
paragraphs: VA also offers health care services to OEF/OIF veterans, and these  services include mental health services that can be used for evaluation and  treatment of PTSD. VA offers all of its health care services to OEF/OIF  veterans through its health care system at no cost for 2 years following  these veterans’ discharge or release from active duty.21, 22 VA’s mental  health services, which are offered on an outpatient or inpatient basis,  include individual and group counseling, education, and drug therapy.
For those veterans with PTSD whose condition cannot be managed in a  primary care or general mental health setting, VA has specialized PTSD  services at some of its medical facilities. These services are delivered by  clinicians who have concentrated their clinical work in the area of PTSD  treatment. The clinicians work as a team to coordinate veterans’ treatment  and offer expertise in a variety of disciplines, such as psychiatry,  psychology, social work, counseling, and nursing. Like VA’s general mental  health services, VA’s specialized PTSD services are available on both an  outpatient and inpatient basis. Table 2 lists the various outpatient and  inpatient specialized PTSD treatment programs available in VA.
See 38 U.S.C. § 1710(e)(1)(D), 1712A(a)(2)(B) (2000), and VHA Directive 2004-017,  Establishing Combat Veteran Eligibility.
OEF/OIF veterans can receive VA health care services, including mental health services,  without being subject to copayments or other cost for 2 years after discharge or release  from active duty. After the 2-year benefit ends, some OEF/OIF veterans without a service- connected disability or with higher incomes may be subject to a copayment to obtain VA  health care services. VA assigns veterans who apply for hospital and medical services to  one of eight priority groups. Priority is generally determined by a veteran’s degree of  service-connected or other disability or on financial need. VA gives veterans in Priority  Group 1 (50 percent or higher service-connected disabled) the highest preference for  services and gives lowest preference to those in Priority Group 8 (no disability and with  income exceeding VA guidelines).
In addition to the 2-year mental health benefit, VA’s 207 Vet Centers offer  counseling services to all OEF/OIF veterans with combat experience, with  no time limitation or cost to the veteran for the benefit. Vet Centers are  also authorized to provide counseling services to veterans’ family  members to the extent this is necessary for the veteran’s post-war  readjustment to civilian life. VA Vet Center counselors may refer a veteran  to VA mental health services when appropriate.
section_title: Based on DOD Data, About 5 Percent of OEF/OIF Servicemembers May Have Been at Risk for Developing PTSD and Over 20 Percent Received Referrals
paragraphs: Using data provided by DOD from the DD 2796s, we found that about   5 percent of the OEF/OIF servicemembers in our review may have been at  risk for developing PTSD, and over 20 percent received referrals for  further mental health or combat/operational stress reaction evaluations.  About 5 percent of the 178,664 OEF/OIF servicemembers in our review  responded positively to three or four of the four PTSD screening questions  on the DD 2796. According to the clinical practice guideline jointly  developed by VA and DOD, individuals who respond positively to three or  four of the four PTSD screening questions may be at risk for developing  PTSD. Of those OEF/OIF servicemembers who may have been at risk for  PTSD, 22 percent were referred for further mental health or  combat/operational stress reaction evaluations.
subsections: section_title: About 5 Percent of OEF/OIF Servicemembers May Have Been at Risk for Developing PTSD
paragraphs: Of the 178,664 OEF/OIF servicemembers who were deployed in support of  OEF/OIF from October 1, 2001, through September 30, 2004, and were in  our review, 9,145—or about 5 percent—may have been at risk for  developing PTSD. These OEF/OIF servicemembers responded positively to  three or four of the four PTSD screening questions on the DD 2796.  Compared with OEF/OIF servicemembers in other service branches of the  military, more OEF/OIF servicemembers from the Army and Marines  provided positive answers to three or four of the PTSD screening  questions—about 6 percent for the Army and about 4 percent for the  Marines (see fig. 2). The positive response rates for the Army and Marines  are consistent with research that shows that these servicemembers face a  higher risk of developing PTSD because of the intensity of the conflict  they experienced in Afghanistan and Iraq.
We also found that OEF/OIF servicemembers who were members of the  National Guard and Reserves were not more likely to be at risk for  developing PTSD than other OEF/OIF servicemembers. Concerns have  been raised that OEF/OIF servicemembers from the National Guard and  Reserve are at particular risk for developing PTSD because they might be  less prepared for the intensity of the OEF/OIF conflicts. However, the  percentage of OEF/OIF servicemembers in the National Guard and  Reserves who answered positively to three or four PTSD screening  questions was 5.2 percent, compared to 4.9 percent for other OEF/OIF  servicemembers.
section_title: Twenty-two Percent Who May Have Been at Risk for Developing PTSD Received Referrals
paragraphs: Of the 9,145 OEF/OIF servicemembers who may have been at risk for  developing PTSD, we found that 2,029 or 22 percent received a referral— that is, had a DD 2796 indicating that they needed a further mental health  or combat/operational stress reaction evaluation. The Army and Air Force  servicemembers had the highest rates of referral—23.0 percent and   22.6 percent, respectively (see fig. 3). Although the Marines had the second  largest percentage of servicemembers who provided three or four positive  responses to the PTSD screening questions (3.8 percent), the Marines had  the lowest referral rate (15.3 percent) among the military service branches.
section_title: DOD Cannot Provide Reasonable Assurance That OEF/OIF Servicemembers Who Need Mental Health Referrals Receive Them
paragraphs: During the post-deployment process, DOD relies on the clinical judgment  of its health care providers to determine which servicemembers should  receive referrals for further mental health or combat/operational stress  reaction evaluations. Following a servicemember’s completion of the   DD 2796, DOD requires its health care providers to interview all  servicemembers. For these interviews, DOD’s guidance for health care  providers using the DD 2796 advises the providers to “pay particular  attention to” servicemembers who provide positive responses to three or  four of the four PTSD screening questions on their DD 2796s. According to  DOD officials, not all of the servicemembers with three or four positive  responses to the PTSD screening questions need referrals for further  evaluations. Instead, DOD instructs health care providers to interview the  servicemembers, review their medical records for past medical history  and, based on this information, determine which servicemembers need  referrals.
DOD expects its health care providers to exercise their clinical judgment  in determining which servicemembers need referrals. DOD’s guidance  suggests that its health care providers consider, when exercising their  clinical judgment, factors such as servicemembers’ behavior, reasons for  positive responses to any of the four PTSD screening questions on the   DD 2796, and answers to other questions on the DD 2796. However, DOD  has not identified whether these factors or other factors are used by its  health care providers in making referral decisions. As a result, DOD  cannot provide reasonable assurance that all OEF/OIF servicemembers  who need referrals for further mental health or combat/operational stress  reaction evaluations receive such referrals.
DOD has a quality assurance program that, in part, monitors the  completion of the DD 2796, but the program is not designed to evaluate  health care providers’ decisions to issue referrals for mental health and  combat/operational stress reaction evaluations. As part of its review, the  Deployment Health Quality Assurance Program requires DOD’s military  service branches to collect information from medical records on, among  other things, the percentage of DD 2796s completed in each military  service branch and whether referrals were made. However, the quality  assurance program does not require the military service branches to link  responses on the four PTSD screening questions to the likelihood of  receiving a referral. Therefore, the program could not provide information  on why some OEF/OIF servicemembers with three or more positive  responses to the PTSD screening questions received referrals while others  did not.
DOD is conducting a study that is intended to evaluate the outcomes and  quality of care provided by DOD’s health care system. This study is part of  DOD’s National Quality Management Program. The study is intended to  track those who responded positively to three or four PTSD screening  questions on the DD 2796 and used the form as well to indicate they had  other mental health issues, such as feeling depressed. One of the  objectives of the study is to determine the percentage of those who were  referred for further mental health or combat/operational stress reaction  evaluations, based on their responses on the DD 2796.
section_title: Conclusions
paragraphs: Many OEF/OIF servicemembers have engaged in the type of intense and  prolonged combat that research has shown to be highly correlated with  the risk for developing PTSD. During DOD’s post-deployment process,  DOD relies on its health care providers to assess the likelihood of  OEF/OIF servicemembers being at risk for developing PTSD. As part of  this effort, providers use their clinical judgment to identify those  servicemembers whose mental health needs further evaluation.
Because DOD entrusts its health care providers with screening OEF/OIF  servicemembers to assess their risk for developing PTSD, the department  should have confidence that these providers are issuing referrals to all  servicemembers who need them. Variation among DOD’s military service  branches in the frequency with which their providers issued referrals to  OEF/OIF servicemembers with identical results from the screening  questionnaire suggests the need for more information about the decision  to issue referrals. Knowing the factors upon which DOD health care  providers based their clinical judgments in issuing referrals could help  explain variation in the referral rates and allow DOD to provide reasonable  assurance that such judgments are being exercised appropriately.  However, DOD has not identified the factors its health care providers used  in determining why some servicemembers received referrals while other  servicemembers with the same number of positive responses to the four  PTSD screening questions did not.
section_title: Recommendation for Executive Action
paragraphs: We recommend that the Secretary of Defense direct the Assistant  Secretary of Defense for Health Affairs to identify the factors that DOD  health care providers use in issuing referrals for further mental health or  combat/operational stress reaction evaluations to explain provider  variation in issuing referrals.
section_title: Agency Comments and Our Evaluation
paragraphs: In commenting on a draft of this report, DOD concurred with our  conclusions and recommendation. DOD’s comments are reprinted in  appendix II. DOD noted that it plans a systematic evaluation of referral  patterns for the post-deployment health assessment through the National  Quality Management Program and that an ongoing validation study of the  post-deployment health assessment and the post-deployment health  reassessment is projected for completion in October 2006. Despite its  planned implementation of our recommendation to identify the factors  that its health care providers use to make referrals, DOD disagreed with  our finding that it has not provided reasonable assurance that OEF/OIF  servicemembers receive referrals for further mental health evaluations  when needed.
To support its position, DOD identified several factors in its comments  that it stated may explain why some OEF/OIF servicemembers with the  same number of positive responses to the four PTSD screening questions  are referred while others are not. For example, DOD health care providers  may employ watchful waiting instead of a referral for a further evaluation  for servicemembers with three or four positive responses to the PTSD  screening questions. Additionally, DOD stated in its technical comments  that providers may use the referral category of “other” rather than place a  mental health label on a referral by checking the further evaluation  categories of mental health or combat/operational stress reaction. DOD  also stated in its technical comments that health care providers may not  place equal value on the four PTSD screening questions and may only refer  servicemembers who indicate positive responses to certain questions.  Although DOD identified several factors that may explain why some  servicemembers are referred while others are not, DOD did not provide  data on the extent to which these factors affect health care providers’  clinical judgments on whether to refer OEF/OIF servicemembers with  three or four positive responses to the four PTSD screening questions.
Until DOD has better information on how its health care providers use  these factors when applying their clinical judgment, DOD cannot  reasonably assure that servicemembers who need referrals receive them.  DOD’s plans to develop this information should lead to reasonable  assurance that servicemembers who need referrals receive them.
DOD also described in its written comments its philosophy of clinical  intervention for combat and operational stress reactions that could lead to  PTSD. Central to its approach is the belief that attempting to diagnose  normal reactions to combat and assigning too much significance to  symptoms when not warranted may do more harm to a servicemember  than good. While we agree that PTSD is a complex disorder that requires  DOD health care providers to make difficult clinical decisions, issues  relating to diagnosis and treatment are not germane to the referral issues  we reviewed and were beyond the scope of our work. Instead, our work  focused on the referral of servicemembers who may be at risk for PTSD  because they answered three or four of the four PTSD screening questions  positively, not whether they should be diagnosed and treated.
Further, DOD implied that our position is that servicemembers must have  a referral to access mental health care, but there are other avenues of care  for servicemembers where a referral is not needed. We do not assume that  servicemembers must have a referral in order to access these health care  services. Rather, in this report we identify the health care services  available to OEF/OIF servicemembers who have been discharged or  released from active duty and focus on how decisions are made by DOD  providers regarding referrals for servicemembers who may be at risk for  PTSD. DOD also provided technical comments, which we incorporated as  appropriate.
VA provided comments on a draft of this report by e-mail. VA concurred  with the facts in the draft report that related to VA.
We are sending copies of this report to the Secretary of Veterans Affairs;  the Secretary of Defense; the Secretaries of the Army, the Air Force, and  the Navy; the Commandant of the Marine Corps; and appropriate  congressional committees. We will also provide copies to others upon  request. In addition, the report is available at no charge on the GAO Web  site at http://www.gao.gov.
If you or your staff members have any questions regarding this report,  please contact me at (202) 512-7101 or bascettac@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs may be found  on the last page of this report. GAO staff members who made major  contributions to this report are listed in appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: To describe the mental health benefits available to veterans who served in  military conflicts in Afghanistan and Iraq—Operation Enduring Freedom  (OEF) and Operation Iraqi Freedom (OIF), we reviewed the Department of  Defense (DOD) health care benefits and Department of Veterans Affairs  (VA) mental health services available for these veterans. We reviewed the  policies, procedures, and guidance issued by DOD’s TRICARE and VA’s  health care systems and interviewed DOD and VA officials about the  benefits and services available for post-traumatic stress disorder (PTSD).  We defined an OEF/OIF veteran as a servicemember who was deployed in  support of OEF or OIF from October 1, 2001, through September 30, 2004,  and had since been discharged or released from active duty status. We  classified National Guard and Reserve members as veterans if they had  been released from active duty status after their deployment in support of  OEF/OIF.
We interviewed officials in DOD’s Office of Health Affairs about health  care benefits, including length of coverage, offered to OEF/OIF veterans  who are members of the National Guard and Reserves and have left active  duty status. We attended an Air Force Reserve and National Guard training  seminar in Atlanta, Georgia, for mental health providers, social workers,  and clergy to obtain information on PTSD mental health services offered  to National Guard and Reserve members returning from deployment. To  obtain information on DOD’s Military OneSource, we interviewed DOD  officials and the manager of the Military OneSource contract about the  services available and the procedures for referring OEF/OIF veterans for  mental health services. We interviewed representatives from the Army, Air  Force, Marines, and Navy about their use of Military OneSource.
We interviewed VA headquarters officials, including mental health experts,  to obtain information about VA’s specialized PTSD services. We reviewed  applicable statutes and policies and interviewed officials to identify the  services offered by VA’s Vet Centers for OEF/OIF veterans. In addition, to  inform our understanding of the issues related to DOD’s post-deployment  process, we interviewed veterans’ service organization representatives  from The American Legion, Disabled American Veterans, and Vietnam  Veterans of America.
To determine the number of OEF/OIF servicemembers who may be at risk  for developing PTSD and the number of these servicemembers who were  referred for further mental health evaluations, we analyzed computerized  DOD data. We worked with officials at DOD’s Defense Manpower Data  Center to identify the population of OEF/OIF servicemembers from the  Contingency Tracking System deployment and activation data files. We  then worked with officials from DOD’s Army Medical Surveillance Activity  (AMSA) to identify which OEF/OIF servicemembers had responded  positively to one, two, three, or four of the four PTSD screening questions  on the DD 2796 questionnaire. AMSA maintains a database of all  servicemembers’ completed DD 2796s. The DD 2796 is a questionnaire that  DOD uses to identify servicemembers who may be at risk for developing  PTSD after their deployment and contains the four PTSD screening  questions that may identify these servicemembers. The four questions are:  Have you ever had any experience that was so frightening, horrible, or  upsetting that, in the past month, you    have had any nightmares about it or thought about it when you did not  want to?  tried hard not to think about it or went out of your way to avoid situations  that remind you of it?    were constantly on guard, watchful, or easily startled?  felt numb or detached from others, activities, or your surroundings?
Because a servicemember may have been deployed more than once, some  servicemembers’ records at AMSA included more than one completed   DD 2796. We obtained information from the DD 2796 that was completed  following the servicemembers’ most recent deployment in support of  OEF/OIF. We removed from our review servicemembers who either did  not have a DD 2796 on file at AMSA or completed a DD 2796 prior to DOD  adding the four PTSD screening questions to the questionnaire in   April 2003. In all, we reviewed DD 2796’s completed by 178,664 OEF/OIF  servicemembers. To determine the criteria we would use to identify  OEF/OIF servicemembers who may have been at risk for developing  PTSD, we reviewed the clinical practice guideline for PTSD developed  jointly by VA and DOD, which states that three or more positive responses  to the four questions indicate a risk for developing PTSD. Further, we  reviewed a retrospective study that found that those individuals who  provided three or four positive responses to the four PTSD screening  questions were highly likely to have been previously given a diagnosis of  PTSD prior to the screening. To determine the number of OEF/OIF  servicemembers who may be at risk for developing PTSD and were  referred for further mental health evaluations, we asked AMSA to identify  OEF/OIF servicemembers whose DD 2796 forms indicated that they were  referred for further mental health or combat/operational stress reaction  evaluations by a DOD health care provider.
To examine whether DOD has reasonable assurance that OEF/OIF  veterans who needed further mental health evaluations received referrals,  we reviewed DOD’s policies and guidance, as well as policies and  guidance for each of the military service branches (Army, Navy, Air Force,  and Marines). Based on electronic testing of logical elements and our  previous work on the completeness and accuracy of AMSA’s centralized  database, we concluded that the data were sufficiently reliable for the  purposes of this report.
NDAA also directed us to determine the number of OEF/OIF veterans who,  because of their referrals, accessed DOD or VA health care services to  obtain a further mental health or combat/operational stress reaction  evaluation. However, as discussed with the committees of jurisdiction, we  could not use data from OEF/OIF veterans’ DD 2796 forms to determine if  veterans accessed DOD or VA health care services because of their mental  health referrals. DOD officials explained that the referral checked on the  DD 2796 cannot be linked to a subsequent health care visit using DOD  computerized data. Therefore, we could not determine how many  OEF/OIF veterans accessed DOD or VA health care services for further  mental health evaluations because of their referrals. We conducted our  work from December 2004 through April 2006 in accordance with  generally accepted government auditing standards.
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, key contributors to this report  were Marcia A. Mann, Assistant Director; Mary Ann Curran, Martha A.  Fisher, Krister Friday, Lori Fritz, and Martha Kelly.